Inspection on 13/12/05 for Redclyffe

This inspection was carried out on 13th December 2005.

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

Redclyffe 20/04/07

Redclyffe 14/06/06

Redclyffe 23/06/05

Redclyffe 28/01/05

Redclyffe 26/04/04

Redclyffe 22/12/03

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Redclyffe 6/8 Aldrington Road London SW16 1TP Lead Inspector Davina McLaverty Unannounced Inspection 13th December 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Redclyffe DS0000010220.V272541.R01.S.doc Version 5.0 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. Redclyffe DS0000010220.V272541.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Redclyffe Address 6/8 Aldrington Road London SW16 1TP Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020-8769 6200 020 8769 6200 yvonne.wallace2@btinternet.com Richard Cusden Homes Ms Yvonne Wallace Care Home 22 Category(ies) of Dementia (6), Old age, not falling within any registration, with number other category (22) of places Redclyffe DS0000010220.V272541.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd June 05 Brief Description of the Service: Redclyffe, is a residential care home for older people that is owned and operated by the voluntary organisation, Richard Cusden Homes (non profit provider) and is located in a leafy, residential area of Streatham. The property comprises of two attached, but formally detached, large Victorian houses in their own grounds. A small car park is available. Public transport and local shops are nearby. The home is registered for twenty-two service users, six of whom may suffer with dementia. Sixteen of the bedrooms have en-suite facilities. The atmosphere is homely and relatives are encouraged to visit and take part in the life of the home. Redclyffe DS0000010220.V272541.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over the course of a single day and involved discussion with residents, the manager, members of the staff team and one visiting relative. Records relating to three residents chosen at random were examined, as well as four staff files, medication and health and safety records. A tour of the communal areas of the premises was also undertaken. What the service does well: What has improved since the last inspection? What they could do better: Monthly reviews of residents are still not consistently taking place and risk assessments still require updating. Staff supervision although improved from the previous inspection still does not meet the standard. Redclyffe DS0000010220.V272541.R01.S.doc Version 5.0 Page 6 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. Redclyffe DS0000010220.V272541.R01.S.doc Version 5.0 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 Redclyffe DS0000010220.V272541.R01.S.doc Version 5.0 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&6 Prospective residents and their relatives/advocates have the information they need to make an informed choice regarding the suitability of the home to meet their needs. EVIDENCE: The home has a Statement of Purpose and Service User Guide, which contain relevant information about the home and its operation. All new residents receive a copy of the resident’s guide. A copy of the Statement of Purpose is displayed in the entrance hall of the home. The home does not provide intermediate care. Redclyffe DS0000010220.V272541.R01.S.doc Version 5.0 Page 9 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 Residents care plans require further detail to show how resident’s needs are being met. Care plans must be updated monthly. The health needs of residents are adequately met and there is evidence of multi-disciplinary working with health care professionals. The home has appropriate systems in place for the ordering and recording of medication. EVIDENCE: Three care plans were examined. Monthly reviews were not taking place regularly and one care plan was not fully completed. Care plans for residents with dementia were no different from those of frail elderly residents. Care plans must be more person centred and reviewed monthly to reflect residents changing needs. Feedback from individual residents regarding the care provided was positive. Typical comments were made as follows “ I am well looked after” and the “staff do a good job and are all very caring”. Redclyffe DS0000010220.V272541.R01.S.doc Version 5.0 Page 10 The health care needs of residents was seen to be monitored and evidence was seen in residents files of other health professionals involvement e.g. GP, dentist, optician and occupational therapists. Boots Chemist who provides training and advice to the home supplies medication. The homes uses a monitored dosage system where each prescribed medication is individually blister packed. Medication administration sheets examined were found to be appropriately stored. However the temperature of the fridge where medication is stored was found not to have been taken since September 05. The inspector was informed that some staff have been trained to administer insulin injections to a resident but written evidence of this was not available in the home. Redclyffe DS0000010220.V272541.R01.S.doc Version 5.0 Page 11 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 Residents reported that their preferred life style is accommodated within the home and they can exercise choice about how they wish to live. EVIDENCE: Residents reported that some activities are provided and described the music and movement session, reminiscence and piano playing. The manager said that these activities are fixed and occur weekly. Staff will carry out other activities either in a small group or on an individual basis depending on interests. A record is kept of these activities. The mobile library also visits and the home has been loaned a number of large print books which one resident said she enjoys. Several residents said that they were satisfied with the level of activities offered whereas at least two said that they would like more to be organised. A family member visiting a resident reported how satisfied they were with the home and the care provided by the staff that he had nothing but praise for them. The manager stated that contact with the local church had been resurrected and that the new vicar very much wanted to support residents in their worship and in the church community as much as they are able. A “father” from the Catholic Church also visits to give communion to two of the residents. Redclyffe DS0000010220.V272541.R01.S.doc Version 5.0 Page 12 Residents who smoke can do so in a part of the dining room away from where food is served or go outside in the summer. Residents clearly exercise choice and a degree of control over their own lives. Redclyffe DS0000010220.V272541.R01.S.doc Version 5.0 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): 16 & 18 A complaints procedure is in place, which is accessible to residents. Organisational policies and procedures are available to protect residents from abuse. EVIDENCE: Systems are in place for recording any complaints. No complaint has been received by the home or by CSCI since the previous inspection, which took place on the 23rd June 2005. Residents spoken with expressed confidence in the home to deal with any concerns or complaint they might have. Residents were clear that they would speak to the manager if they were unhappy or if they had a complaint. None of the residents spoken to had any concerns at the time of the inspection. Information on what action needs to be taken should there be an allegation or suspicion of abuse is in place. However, only the manager had received training in this area. All staff should receive training in the Protection of Vulnerable adults. Redclyffe DS0000010220.V272541.R01.S.doc Version 5.0 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, 21 & 26 Redecorating to the lounge and the replacement of the hallway carpets have substantially enhanced the environment resulting in the home being more “homely” and “welcoming”. The standard of cleanliness was satisfactory on the day of the inspection. EVIDENCE: As stated above the redecorating in the lounge enhances the environment. Residents spoke of their delight in having it done and being involved in choosing the colours of the walls. New curtains had also been put up and the room had been transformed. New carpet on the ground floor hallway has brightened up the area, but the replacement ensures residents safety as many use zimmer frames/walking sticks to get around the building. The manager stated that fundraising continues, although it was proving difficult, as relatives did not really want to get heavily involved in fundraising. The organisation has appointed a new finance manager who is currently looking at the organisations spending. The home still requires decorating in the hallways on all floors as well as needing to consider replacing carpets on Redclyffe DS0000010220.V272541.R01.S.doc Version 5.0 Page 15 staircases as they are badly stained and dirty in appearance. The office also requires decorating although the staff team had tidied it, which had a very positive impact. At the last inspection a refurbishment action plan was submitted. In discussion with the manager it was noted that several of the dates had slipped and require updating. In respect of bathing and washing facilities the home has one assisted bath and shower in the home. Although sixteen of the bedrooms have en suite facilities the majority of the baths are unsuitable for the residents use. There are five communal toilets, two with disabled access. The home is currently exploring the possibility of purchasing an additional hoist as there can be a delay in being able to support someone to have a bath when they request. Other support aids e.g. grab rails, raised toilet seats are available in the home. On the day of the inspection the home was seen to be tidy and free from offensive smells. Redclyffe DS0000010220.V272541.R01.S.doc Version 5.0 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): 29 & 30 The Recruitment practices in the home still require further input to ensure that residents are not being put at risk by the employment of unsuitable staff. Resident’s benefit from a committed and experienced team of staff at the home. EVIDENCE: Residents made positive comments regarding the staff team describing them as “kind” and “helpful”. The majority of staff have worked in the home for a number of years and continue to show a strong loyalty for the home and demonstrated a conscientious approach to the residents. Shifts are busy and the home aims to have at least four staff on duty in the mornings and three in the afternoon/late shift with two waking night staff. The manager is supernumerary and ancillary staff and a cook are employed. On the day of the inspection one of the staff called in sick and it was not possible to get an agency staff for the shift and the shift operated with three staff. However it was extremely busy and one staff who was due to work a long day was very tired at the end of her first shift. In discussion with the inspector she stated that the majority of shifts were busy and she did not feel that there was sufficient time to sit and talk to residents. The manager acknowledged this but maintained that the afternoon shifts are quieter and staff are expected to sit with residents and talk. Staffing levels must continue to be kept under review to ensure that the residents needs can be met adequately. Redclyffe DS0000010220.V272541.R01.S.doc Version 5.0 Page 17 Staff files were examined and some improvement were noted in respect of staff training. Food Hygiene training had recently been carried out for eleven staff members, with Health and safety planned for the January. Four staff files were examined and none were found to contain all the required information. This remains a cause for concern, as recruitment practices do not evidence that they protect resident’s welfare and continues not to meet the Care Home Regulations 2001. In discussion with the manager she stated that all CRB checks had been sent for but evidence of this was not clearly recorded on the staff files. Redclyffe DS0000010220.V272541.R01.S.doc Version 5.0 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): 33,35,36 & 38 The manager continues to communicate a clear sense of direction and leadership in the home. The home is run in the best interests of the residents who are regularly consulted. Resident’s health and welfare is protected by policies and practices within the home. Supervision however was found not to be taking place regularly, which compromised staff professional development. EVIDENCE: The interests of residents are promoted through the home with individuals being encouraged to make their own decisions. Residents are given choices as to how they spend their time. Care staff were found not to be receiving regular supervision although the frequency of staff meetings has improved. Staff stated that they worked as a `team and communicated well together. Redclyffe DS0000010220.V272541.R01.S.doc Version 5.0 Page 19 Records of weekly hot water temperature checks are carried out. Records of any accident/significant event are kept but the home must make sure that these are notified to the CSCI as required by law. The home is registered under the Hazardous Waste Regulations. Tests for legionella were carried out in October and found to be satisfactory. Fire alarm tests are carried out weekly and a fire drill was carried out on the 17/11/05. Fire awareness training took place on the day of the inspection. Finances within the home are addressed with senior staff. Receipts are kept of any thing purchased by care staff on resident’s behalf. Redclyffe DS0000010220.V272541.R01.S.doc Version 5.0 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 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 3 17 X 18 2 2 2 X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 2 X 2 Redclyffe DS0000010220.V272541.R01.S.doc Version 5.0 Page 21 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 OP7 Regulation 15(2) (b) Requirement The Registered Person must ensure that all care plans are reviewed on a monthly basis. Previous timescale of the 30/06/05 not fully met. The Registered Person must ensure that written evidence is available confirming staff who administer insulin injection have been appropriately trained and assessed as fit to carry out. The Registered Person must ensure that the fridge temperatures were medication required for cold storage is taken daily and the record maintained. The Registered Persons must ensure that all staff receive training in adult protection. Previous timescale of the 30/10/05 not met. The Registered Person must submit the programme of works to the Commission and provide dates as to when the works identified will be addressed. The Registered Persons must ensure that staff files contain all the information as set out in DS0000010220.V272541.R01.S.doc Timescale for action 28/02/06 2 OP 9 13(1) (2) 28/02/06 3 OP 9 13(2) (4) 13/12/05 4. OP18 18 (1) (a) 30/10/06 5. OP19 18( 1) 28/02/06 6. OP29 19 Sch 2 28/02/06 Redclyffe Version 5.0 Page 22 7 OP 36 18(2) 8 OP 38 37(1)(2) Schedule 2 of the Care Homes Regulations. Previous timescale of 30/08/ 05 not fully met. The Registered Person must ensure that care staff receives formal supervision at least six times a year. Previous timescale of the 23/06/05 not fully met. The Registered Persons must ensure that written notifications are made to the CSCI as required by Regulations 37 of the care homes Regulations. 28/02/06 13/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP1 OP21 Good Practice Recommendations The Registered Person should give consideration to producing the Service user Guide in different formats to meet service users individual needs. The Registered Person should give consideration to purchasing a second hoist for the home following advice from an occupational therapist. Redclyffe DS0000010220.V272541.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Redclyffe DS0000010220.V272541.R01.S.doc Version 5.0 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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