Inspection on 17/10/07 for Redclyffe

This inspection was carried out on 17th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Redclyffe 30/10/06

Redclyffe 10/02/06

Redclyffe 07/06/05

Redclyffe 31/01/05

Redclyffe 05/07/04

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

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

CARE HOME ADULTS 18-65 Redclyffe 21 Salisbury Avenue Harpenden Hertfordshire AL5 2QF Lead Inspector Pat House Unannounced Inspection 17th October 2007 11:00 Redclyffe DS0000019506.V353229.R01.S.doc Version 5.2 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 DS0000019506.V353229.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 Adults 18-65. 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 DS0000019506.V353229.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Redclyffe Address 21 Salisbury Avenue Harpenden Hertfordshire AL5 2QF 01582 620000 01582 620001 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) www.scope.org.uk SCOPE Mr Hon Ching Ng (Barney) Care Home 20 Category(ies) of Learning disability (20), Physical disability (20), registration, with number Physical disability over 65 years of age (20) of places Redclyffe DS0000019506.V353229.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th October 2006 Brief Description of the Service: Redclyffe is registered to provide care and accommodation for up to 20 adults with a learning disability and/or a physical disability, all of whom can be over the age of 65.The home is owned and managed by Scope and is a large period house in a quiet residential area, close to the town centre of Harpenden. The building has three ground floor accommodation areas, which include kitchen, lounges and bathrooms with WCs, including assisted bathrooms. The ground floor also includes office facilities, the main kitchen, dining room and laundry. A passenger lift gives access to the first floor, which includes two further accommodation areas with lounge and WCs. To the front of the building is a large garage used for storage and re-charging electric wheelchairs and the home also has a single storey annexe, which can be used for training, meetings and as a quiet area for service users. The home has the use of three specially adapted vehicles to help with the transport needs of residents. The home’s Statement of Purpose is kept in the office and is available on request. Current fees for the home, which include the cost of transport, are £35000 per annum. Redclyffe DS0000019506.V353229.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day with one inspector. The manager was present and some residents and staff were spoken with. All areas of the home were visited briefly and a selection of records was examined. The manager had returned an annual quality assurance assessment to the Commission prior to the inspection, and information from this document (the AQAA) has been referred to in this report. The Commission has sent out questionnaires to a selection of residents, relatives and staff and, at the time of completing this report, five have been returned from residents and two from relatives. Comments from these questionnaires are included in this report. What the service does well: Staff at the home ensure that the wishes of the residents are what guide the care provided. Residents are consulted on all aspects of care and of the running of the home. Staff support residents to make choices about how they spend their days and provide support where these choices involve risks. Residents spoken with, and comments in the questionnaires received from residents and relatives, all say that people living at Redclyffe enjoy their daily lives and are pleased with all aspects of the care provided. Comments in the questionnaire sent from one relative include that they are “ very pleased with all aspects of the home, their relative is very happy living there” and another relative says “ I can’t think of any improvements I would make.” Residents are fully aware of how to make a complaint and there are several complaints recorded, all from residents. These complaints were generally about the behaviour of other residents, and show that concerns are taken seriously and that residents feel free to express their views. Residents and staff spoken with felt the home is well managed. The home gives a high priority to staff training and more than 50 of support staff have achieved NVQ level 3 training. Senior staff have either finished or are completing NVQ level 4 training. Redclyffe DS0000019506.V353229.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. Redclyffe DS0000019506.V353229.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Redclyffe DS0000019506.V353229.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides all prospective residents with detailed written information about services and full assessments are completed on all applicants. This ensures that all parties can be sure that individual needs can be met and that the home is the right place for the prospective resident. EVIDENCE: The home has a written Statement of Purpose and Service User’s guide, which contain up to date details about services provided at the home. Copies are given to all new service users and relatives. The manager will ensure that details about fees for the home comply with the amended Care Homes Regulations. There have been no new service users admitted to the home since the last inspection, but spot checks of records showed that full needs assessments are completed for anyone wishing to enter the home to ensure that individual needs can be met. Redclyffe DS0000019506.V353229.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home support service users to make decisions about their daily lives and to take appropriate risks so that everyone remains as independent as possible. All residents have frequent reviews, which are documented, so that they know their own wishes are being supported. EVIDENCE: A selection of residents’ care plans was checked, and some were those of residents spoken with during the inspection. Records were detailed and contained information about visits from and to Health professionals, individual risk assessments, weight checks and daily monitoring. Separate written details for staff showing what was happening that day, included a dental appointment arranged for one resident. Evidence was seen of monthly reviews taking place and the manager had stated in the completed AQAA record that every resident has an annual multi disciplinary review and an additional six monthly review with the appropriate key worker and team leader from the home. Some residents spoken with confirmed that staff support them to take responsible Redclyffe DS0000019506.V353229.R01.S.doc Version 5.2 Page 10 risks and make decisions about their daily lives, but the care plans seen did not have evidence of service user involvement in their care planning. It is acknowledged that not all residents will wish to take part in written plans, but the process for involving them does need to be developed. The manager is currently researching staff training courses, which include Person Centred Planning guidance and the Mental Capacity Act and plans to develop the care plan recording when this training has taken place. Redclyffe DS0000019506.V353229.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home support residents to take part in a variety of activities and courses and promote continuing contact with families and the wider community. This helps residents to continue feeling part of the community. The well-balanced and enjoyable meals provided help to maintain the health of all residents in the home. EVIDENCE: Information provided by the manager in the AQAA report shows that all residents have an individual activity plan, which is reviewed at least annually. The report states that residents attend a variety of clubs and educational classes and make trips out to the cinema, restaurant and pubs. Details of the clubs and classes available were seen on the home’s notice board during the inspection. One resident spoken with said they were “doing history” at college at present and another said she had been to the theatre several times lately. The home has three vehicles for the use of residents and most of the staff have a licence to drive these. There is a computer for the use of the residents in the dining room and all lounges in the home have their own television. Many Redclyffe DS0000019506.V353229.R01.S.doc Version 5.2 Page 12 of the service users have their own music and television equipment in their bedrooms. Questionnaires returned from relative’s state that staff at the home keep families informed and help residents to keep in touch with them. Residents spoken with confirmed that care staff always treat them with respect and they could get up and go to bed when they chose. Weekly menus were seen displayed in the dining room and staff confirmed that residents could choose alternative meals if they wished. Food is cooked as the residents wish and during the inspection one resident had their choice of lunch prepared while, at the same time, another had a late breakfast. Residents sign a daily record showing if they are in or out of the home for meals that day and the menus seen were varied and well balanced. There was a large tray of fruit available for residents to take during the visit and coffee and cake is also served between meals for those who want this. The kitchen was clean and stocks of food were at good levels in the stores. Daily fridge and freezer temperature checks were seen recorded. Redclyffe DS0000019506.V353229.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures followed in the home ensure that residents have their health needs met in a way they prefer and that the system for administering medication is sound and helps to protect all service users. EVIDENCE: Service users spoken with said that they chose how staff assisted them with any personal care and that they chose how they would dress. One service user chose to get up late on the day of the inspection and records showed that a variety of health professionals were involved with the residents and their care. Medication was being stored appropriately and amounts tallied when tablets and records were spot-checked. Staff spoken with confirmed they had received training in the Administration of Medication and the home has a medication fridge. Medication, which was not pre-packed, had dates of opening recorded, to ensure audits could take place easily. It was just recommended that any hand written information is endorsed by two staff members to ensure accuracy and safety. Redclyffe DS0000019506.V353229.R01.S.doc Version 5.2 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures followed in the home ensure that all residents feel able to voice any concerns they might have and are all protected from abuse. EVIDENCE: The home has written policies on making a complaint, Safeguarding Adults and Whistle Blowing. In the AQAA report the manager confirmed that residents are encouraged to make concerns known and that all staff had received training in Adult Protection. The questionnaires returned form relatives and service users show that they are all aware of the complaints procedures in the home. The complaints’ file was examined during the visit and all issues recorded were from residents, often about other residents. Clearly, residents in the home feel able and know how to voice their concerns. The manager and staff were aware of the reporting procedures for Safeguarding Adults but there had been no incidents at the home since that last inspection. Redclyffe DS0000019506.V353229.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a home, which is quite well maintained and is clean and hygienic. EVIDENCE: Most areas of the home were visited during the inspection and all areas were clean and quite well maintained. Those residents’ bedrooms seen were well decorated and the dining rooms were bright and attractive. However some areas were in need of redecoration and some repairs, especially some bathrooms and some areas on the stairs and first floor. The home has a continual programme of decoration and maintenance and the manager hopes to address the redecoration needs soon. The manager reported in the AQAA document that he has asked the owning company to approve the refitting of kitchens in the home to make them more accessible to residents, some of whom need lower height surfaces. Information in the AQAA also lists recent improvements to the home, which included repairing windows, replacing parts in the hot water system and the purchase of two new washing machines and a tumble dryer. Quotes are also being sought for a new “Nurse call system” for the home. Redclyffe DS0000019506.V353229.R01.S.doc Version 5.2 Page 16 Bathrooms seen all contained paper towels and liquid soap, as advised in current guidelines for infection control. Redclyffe DS0000019506.V353229.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34 and 35. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Procedures followed in the home ensure that residents are supported by qualified staff who are themselves well supervised. The system for staff recruitment is thorough and ensures that residents are protected from abuse. EVIDENCE: During the visit there were 6 support workers, a team leader and the manager on duty. Service users spoken with praised the care staff in the home and said there were usually adequate numbers on duty. Staff rotas are displayed on the home’s notice board so that everyone concerned can see who is on duty at any time. Questionnaires returned from residents and relatives also said all staff members were well trained and had the skills required to perform all their duties. The home provides high levels of training for staff and more than 50 are trained to NVQ level 2 or above. One team leader has completed NVQ level 4 and a second team leader is currently doing this training. Since the last inspection, the manager has produced a training overview, which is kept up to date. A copy was seen and showed that staff training was up to date and updates were planned on a rolling programme. Redclyffe DS0000019506.V353229.R01.S.doc Version 5.2 Page 18 All staff at the home also attend Diversity training and in the AQAA document the manager states that the home has reached its target of filling 20 of the staff team with individuals who have a registered disability The manager has completed annual staff appraisals for half the home’s staff and will soon complete the remaining half. All staff in the home also have formal, individual supervision. This is planned to take place every two months, or as near as possible. The recruitment files of two of the newer staff were checked. These files contained evidence of all appropriate checks being in place before the members of staff started work. Redclyffe DS0000019506.V353229.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents at Redclyffe live in a well run home where their views affect the daily running of the home and where procedures followed ensure that the welfare of both residents and staff are protected. EVIDENCE: Staff and service users spoken with praised the home’s management and said they were always listened to and supported to express their views. In the returned AQAA document the manager confirmed that the home’s policies and procedures were up to date and that staff use the Scope Quality system to secure the views of service users and other stakeholders. There is an annual meeting held where residents and staff discuss and plan activities and there are regular Residents’ Forums at the home. One result of such meetings is that residents are part of the interviewing panel for new staff. Returned Redclyffe DS0000019506.V353229.R01.S.doc Version 5.2 Page 20 questionnaires from service users and relatives also confirm that residents are consulted on all aspects of the running of the home. There have been far reaching changes to the management structure of the owning company. As a result, the manager of Redclyffe has been overseeing the management of another home, where there is no current manager in post. Residents and staff were asked during the inspection, if this situation had caused any problems. All those spoken with said that the home was still being managed well and there were enough staff on duty when the manager was absent. However, the role of a manger of any care home is taxing and it could be detrimental to Redclyffe if the current situation continues for much longer. It is hoped that the manager is able to return to full time spent in one home very soon. During the inspection appropriate insurance certificates were seen displayed and the accident records were all in order. Residents spoken with confirmed that fire alarms were tested regularly and the daily log showed when fire testing takes place. Fire hydrants were marked that they had been tested in July this year. No hazardous substances were seen left accessible to residents during the visit and the manager said that health and safety issues were always discussed at staff meetings. The home has a detailed, written Health and Safety Statement, which is available to all staff and also has a named Health and Safety Coordinator. Redclyffe DS0000019506.V353229.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 4 33 x 34 3 35 4 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Redclyffe DS0000019506.V353229.R01.S.doc Version 5.2 Page 22 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Redclyffe DS0000019506.V353229.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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. 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