Inspection on 26/04/06 for Redclyffe Residential Care Home

This inspection was carried out on 26th April 2006.

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

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

Other inspections for this house

Redclyffe Residential Care Home 17/09/09

Redclyffe Residential Care Home 30/08/07

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Redclyffe Residential Care Home 1 Pightles Terrace Rushden Northants NN10 0LN Lead Inspector Mrs Pat Harte Unannounced Inspection 26th April 2006 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 Residential Care Home DS0000066208.V289146.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Redclyffe Residential Care Home DS0000066208.V289146.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Redclyffe Residential Care Home Address 1 Pightles Terrace Rushden Northants NN10 0LN 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) 01933 314645 01933 359420 BPS Care Homes Limited Position Vacant Care Home 24 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (24) of places Redclyffe Residential Care Home DS0000066208.V289146.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No person falling within the category Older People (OP) can be admitted when there are already 24 persons of category OP in the home. No person falling within the category Dementia over 65 years of age DE (E) may be admitted to the home when there are already 14 persons in the category DE (E) in the home. Additional Inspection following Registration 23/11/05 Date of last inspection Brief Description of the Service: Redclyffe is a care home providing personal care for up to a total of 24 Older People of which up to 14 places are for Residents with Dementia care needs. The Home is owned by the Company BPS Care Homes Limited. Currently there is no Registered Manager although a new proposed Manager has been appointed and an application for Registration is to be submitted shortly to the Commission. In the interim the management of the Home is overseen, as agreed with the Commission, by the Company’s Responsible Individual Mr. T. Balendra and a Manager from one of the Company’s nearby Home. The Home is a well established older character building located in a residential area of Rushden within reasonable travelling distance of the town centre and local amenities. The premises include a new extension and accomodation is provided over two floors with the majorityof bedrooms devoted to single occupancy but double rooms are also available. Eleven bedrooms have en suite facilities. Some of the rooms do not meet current space Standards although they remain registered as this home was running prior to The Care Standards Act 2000. Communal space includes homely dining and lounge areas. The Home has a lift enabling Residents to access the first floor except for two bedrooms in the extension where Residents must be able to access stairs. The Home has a garden area and there are plans to make alterations to provide fencing so that Residents with Dementia needs can access the gardens freely. The fees charged are £370 to £390. Extra charges include Chiropody, hairdressing, newspapers and toiletries. Redclyffe Residential Care Home DS0000066208.V289146.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for Service Users and their views of the service provided. Inspection planning took half a day and consisted of a review of the requirements made in an additional inspection carried out to monitor the progress made since registration, the Homes service history record including notifications of accidents and events and incidents and contact and correspondence between the Commission and the Home. The information was collated and analysed to form the plan of inspection focusing on the outcomes for Residents. It is important to note that this is the first Statutory Inspection conducted at the Home since the registration of the Company BPS Care Homes Limited in December 2005. The primary method of inspection used was ‘case tracking’ which involved selecting three Residents and tracking the care they receive through review of their records, talking with them and the care staff. In addition 9 Residents, 5 staff were spoken with and care practices were observed. A tour of the premises took place and a selection of records was inspected. Discussions were held with the Company’s Responsible Individual and the proposed Manager. The Inspection took place during the morning and afternoon over a period of 6 hours and was carried out on an unannounced basis What the service does well: The Home has a stable staff group who demonstrated their commitment to the well being of their Residents. Residents spoke very highly of the staff commenting that they were very caring, helpful and on hand to quickly respond to their needs. Residents commented on and observations confirmed that relationships between themselves and the staff group were very good. The Home’s assessment process ensures that all prospective Residents are visited and a thorough assessment carried out to that the needs of anyone admitted to the Home can be met. Redclyffe Residential Care Home DS0000066208.V289146.R01.S.doc Version 5.1 Page 6 Residents’ Health care needs are carefully monitored and they are enabled to see their relevant medical professionals promptly and in private. Residents confirmed that they are aware of the home’s complaints procedure and are confident to raise any issues or concerns with staff or the Manager. There have been no complaints since the last inspection. Routines were relaxed and flexible and Residents had choice in how and where they wished to spend their time. Residents’ comments included that their rising and going to bed times were respected, that they had freedom of movement within the Home and could spend their time where they wished and that they were given choice in whether they wished to join in activities. Observations confirmed that staff took care to protect Residents’ dignity and privacy by ensuring personal care tasks were carried out in private. Residents commented that staff took care to ease any embarrassment and make them comfortable when intimate tasks such as bathing were carried out. Residents’ comments on the food provision were very positive. They felt that they were provided with a good range of meals, choices were available and the catering staff were fully aware of their dietary needs and likes and dislikes. The serving of the midday meal was efficient and Residents were given help by staff where necessary to eat their meals. Records showed that weight is monitored to ensure any problems are quickly identified. Residents’ religious persuasions are respected and arrangements are made for them to receive visits from their relevant clergy in order that they may fulfil their religious observances. Residents are provided with a safe and comfortable environment. What has improved since the last inspection? This inspection was the first statutory inspection since the Home’s registration however issues identified on an additional visit made in November 2005 have been addressed as follows. Records relating to Residents are now held securely to ensure maintenance of confidentiality and data protection. Due attention is paid to keeping fire exits clear to ensure appropriate fire safety. A new Cook has been employed with relevant qualifications and experience in order to ensure that Residents diets are catered for. Redclyffe Residential Care Home DS0000066208.V289146.R01.S.doc Version 5.1 Page 7 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. Redclyffe Residential Care Home DS0000066208.V289146.R01.S.doc Version 5.1 Page 8 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 Residential Care Home DS0000066208.V289146.R01.S.doc Version 5.1 Page 9 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, 2, 3, 4 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective Residents are provided with information to enable them to make informed choices regarding their placements. The pre-admission assessment is thorough and effective in ensuring that the needs of people admitted to the home can be met. EVIDENCE: We looked at the assessment and admission processes for new Residents to see that they were thorough in identifying Peoples needs and to ensure the Home only admitted Residents where their needs could be met. Discussions with Residents confirmed that they had been supplied with information on the Home and its services and facilities prior to admission. They stated they felt the information accurately reflected the services and was of assistance to them in making decisions about a possible placement. Redclyffe Residential Care Home DS0000066208.V289146.R01.S.doc Version 5.1 Page 10 The admission process ensures that all prospective Residents are visited and assessed by senior staff from the Home to identify their individual needs and ensure that these can be met. The records of a new Resident were viewed and showed that the process of assessment was thorough. Recognised risk assessment tools were used to determine areas of risk, such as nutritional needs, the potential for falls and the need to prevent pressure ulcers, in order that strategies could be put in place to reduce the level of risk. The assessment process also pays attention to determining Dementia care needs. Records showed that the Home pays particular attention to gathering life history information to aid the staffs’ understanding and enable them to support Residents in their confusion and assist them to be less anxious or frustrated. Residents and their relatives have opportunities to visit the Home prior to their admission to discuss their needs, view the accommodation and talk with other Residents and staff. Staff spoken with felt that they were given good information on their Residents needs, routines and wishes in readiness for their admission. Records showed that Residents are provided with written contracts of the terms and conditions with copies maintained in their records. Redclyffe Residential Care Home DS0000066208.V289146.R01.S.doc Version 5.1 Page 11 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 adequate. This judgement has been made using available evidence including a visit to this service. The development of Residents care plans showed a good approach but not all the areas of need were documented and instruction for staff needs to be broadened to give clear guidance on how the care and support is to be carried through especially for Residents with Dementia care needs. EVIDENCE: We looked at the Home’s care planning processes to ensure that staff were given instruction and guidance on meeting Residents needs in accordance with their wishes. Since the Home changed ownership considerable work has been undertaken to review, update and develop the care plans for all Residents although it is acknowledged that the development work is on going. The plans showed a good level of instruction for staff on the physical care needs but not all areas were covered and timings for routines were not always Redclyffe Residential Care Home DS0000066208.V289146.R01.S.doc Version 5.1 Page 12 stated. For example the timings for toileting programmes and nail care were generalised and more specific guidance should be provided for staff. Residents Dementia care needs were recognised but more reference should be made to guide staff in the level of support to be given taking account of how Residents are to be helped through their confusion, anxieties and frustrations brought about by their conditions. Records showed that the care plans are reviewed on a monthly basis but it was not clear from the records how much each Resident was involved in the planning and reviewing processes although Residents confirmed that they were consulted and involved in decisions about their care. The Home has introduced a Key Worker system with a member of staff dedicated specifically to work with individual Residents. This gives consistency and continuity of care particularly for Residents with Dementia and enables them to become familiar with their carers. Records showed that a good approach is taken to health care with prompt referrals made to the relevant Medical Professionals including Opticians, Dentist and Chiropodists. Residents confirmed that consultations were carried out in private. It was clear from observations that staff responded to their Residents needs promptly. They were on hand to sensitively guide and reassure Residents with memory loss. Observations confirmed that staff ensure the protection of Residents privacy and dignity when carrying through personal care tasks. The Home’s Medication system was generally well maintained with the appropriate procedures in place. Medications profiles are maintained for all Residents. Care must be taken to ensure that all incoming medication is signed for as checked, some signatures were missing. Administration records were well maintained although some prescriptions needed referring back to General Practitioners for changes where the medication was no longer needed at the prescribed frequencies. Advise was given to ensure protocols for “as required” sedation medication are put in place to give staff clear guidelines on the circumstances under which the medication is to be given. A disposal record is maintained and all medication is disposed of through the contracted Pharmacist. In one instance the stock of a sedation medication was not available for three days. The proposed Manager showed that this had not been the fault of the Redclyffe Residential Care Home DS0000066208.V289146.R01.S.doc Version 5.1 Page 13 Home but a failure to supply by the Pharmacist and that every effort had been made to obtain the medication. Stock rotation was carefully managed. Medication storage was secure although the facility for storage of controlled drugs, if necessary, was limited. However steps are being taken to obtain a medication trolley to improve the arrangements. The proposed Manager was advised and agreed to obtain a Controlled Drugs Register, currently the required controlled drugs records are maintained on loose-leaf formats. A medication fridge is provided. Redclyffe Residential Care Home DS0000066208.V289146.R01.S.doc Version 5.1 Page 14 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 visit to this service. Residents are enabled to maintain their independence as much as possible and exercise control and choice in the way they wish to lead their lives. EVIDENCE: We looked at routines, activities, visiting arrangements and the food provision to ensure that Residents are enabled to lead fulfilled lives, keep in contact with their families and can exercise choice. Residents stated and observations confirmed that routines were relaxed and flexible. They commented that they were free to decide on how and where they wished to spend their time and their preferred rising and going to bed times were respected. The care plans showed and Residents confirmed that they were encouraged to maintain their independence by doing things for themselves as much as is possible. Records showed that attention is given to identifying Residents religious persuasions and arrangements are made for visiting clergy in order that they may pursue their observances if they wish. Redclyffe Residential Care Home DS0000066208.V289146.R01.S.doc Version 5.1 Page 15 Residents were satisfied with the Home’s activity programme and praised the designated activities co-ordinator highly for the enjoyable range of activities provided on both a group and individual basis. These include games, craftwork, sing-alongs, reading of novels and quizzes. Outside entertainment is also bought in. Special events are celebrated for example Residents birthdays. Residents commented and observations confirmed that staff spend time talking with them both on a group and individual basis. The development of meaningful activity programmes for Residents with Dementia is ongoing and advice was given to creatively develop individual programmes using the information gathered and taking account of Residents needs, behaviours and abilities. The Home has an open visiting policy. Residents confirmed that they were enabled to receive their visitors in private if they wished. They may also keep in contact by using the Home’s telephone. Residents were satisfied with the food provision. They felt that staff respected their dietary needs and individual likes and dislikes and they stated that they were provided with a good range of choice. Observations of the mid day meal confirmed that the meal was nicely presented, efficiently served and that staff were on hand to assist Residents where necessary. Discussions with the new Cook showed that she had a good understanding of nutritional needs and was able to cater for special dietary needs. The menu planning showed a commitment to providing fresh foods and good home cooking. Nutritional assessments are undertaken and records showed that Residents’ weight and daily intake is carefully monitored to identify any problem areas. Systems are in place to record food and fluid intake, where necessary, and food supplements can be obtained through the medical service should this be necessary. Redclyffe Residential Care Home DS0000066208.V289146.R01.S.doc Version 5.1 Page 16 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 good. This judgement has been made using available evidence including a visit to this service. The Home’s Complaints and Adult Protection procedures ensure that any complaints are listened to, investigated and acted upon and Residents are protected from abuse. EVIDENCE: We looked at the systems in place to ensure that any concerns or complaints are taken seriously and that any allegations or suspicions of abuse are reported in order to protect Residents. Residents confirmed that they had been given the Home’s complaints procedure. Those spoken with felt confident and able to raise any issues or concerns with staff. A complaints/compliments record is maintained. Procedures are in place to ensure that any complaint is investigated with action taken to improve the service where necessary. No complaints have been made to the Home or to the Commission since the Home’s registration. Records showed Relatives compliments on the care provided to their Residents. Staff demonstrated, through discussions, their understanding of the procedures for the Protection of Vulnerable Adults. They were fully aware of the areas constituted as abuse. Advice was given to the proposed Manager to regularly update training in this area and to ensure that staff, who would Redclyffe Residential Care Home DS0000066208.V289146.R01.S.doc Version 5.1 Page 17 normally report any instances or allegations to him, are provided with information on the contact numbers for the relevant Authorities to whom they must report if the allegation or suspicion are about the Manager or Company officials. Redclyffe Residential Care Home DS0000066208.V289146.R01.S.doc Version 5.1 Page 18 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, 20, 21, 22, 23, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a well-maintained, clean, warm, safe, comfortable and homely environment that is suitable for their needs. EVIDENCE: We looked at the environment to ensure that it was well maintained and suitable for the Residents needs. A full tour of the premises was carried out and the premises were in good order and well maintained. Since the Company took over the running of the Home many improvements to the décor of the premises and the replacement of carpeting and furniture have been carried out and a new extension has been completed. The Company has a maintenance plan in place to address areas remaining in need of refurbishment. Redclyffe Residential Care Home DS0000066208.V289146.R01.S.doc Version 5.1 Page 19 There are plans in place to fence off garden areas so that Residents with Dementia can use then freely and safely whenever they wish. Residents confirmed their satisfaction with the facilities stating that the communal accommodation was comfortable and homely. They were also satisfied that their rooms were comfortable and suitable for their needs. Observations and Residents’ comments confirmed that they are enabled to personalise their rooms as they wish and have their furnishings and belongings about them Residents’ bathrooms are fitted with appropriate hoists to enable easy and safe access to baths and there is a new walk in shower room, fitted to a very good standard for those Residents who prefer a shower. Standards of domestic and hygiene maintenance were good and the Home was warm, clean and comfortable. Observations confirmed that Toilet and Bathroom areas were hygienically maintained. Observations and discussions with staff showed that appropriate equipment and aids are obtained to assist Residents with mobility problems. Redclyffe Residential Care Home DS0000066208.V289146.R01.S.doc Version 5.1 Page 20 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 visit to this service. Recruitment procedures are not robust and therefore the protection of Residents is compromised. EVIDENCE: We looked at staff recruitment procedures, staffing levels and the training and competency of staff to ensure Residents were in safe hands. Residents spoken with said that the all the staff, including ancillary staff, were very kind and caring. They felt that staff understood their needs and were committed to their well-being. Rotas showed that currently three care staff are deployed on the early shift 7.30 am to 3pm dropping to two on the late shift 3pm to 10pm. There are proposals to increase the number of staff on the late shift to three shortly. Two waking night carers provide night care. Discussions were held with staff and the proposed Manager on the adequacy of the levels taking account of the number of vacancies and Residents current dependency levels. Advice was given to ensure close monitoring of the dependency levels as the number of Residents increased particularly in the area of Dementia care as the Home has the capacity to take up to fourteen Residents in this category and must ensure good levels of monitoring and supervision. Redclyffe Residential Care Home DS0000066208.V289146.R01.S.doc Version 5.1 Page 21 Observations confirmed that staff responded quickly to the needs of their Residents and relationships and interaction were viewed as good. In addition to the care staff, domestic and catering staff are employed together with a Handyman. The ancillary staff provision ensures that care staff are not diverted from their care duties. Two staff members’ records were inspected, one showed that the required clearances had been undertaken and both contained two references. The second staff member had previously worked at the home and had returned to employment there but the record did not show a new Criminal Records Bureau Clearance or POVA First check although it was stated that this had been applied for. The third staff member’s record requested was not available at the home as the staff member concerned was in the process of transferring from the Company’s other Home where her records were currently held. The need for records to be fully maintained including up to date clearances was discussed with the Responsible Individual who demonstrated he was in the process of reviewing all staff records to ensure that they met the required Regulations. Records of staff induction, foundation and ongoing training and updates are maintained. Records indicated that staff had received training in the core areas and in Dementia care since the Company’s registration. Approximately 80 of the care staff group have attained a relevant National Vocational Qualification. Discussions with staff showed that they had knowledge and understanding of the conditions relating to Elderly People. Staff stated that morale had improved greatly since the Company had taken over the Home. It was clear that the staff group now work as a team and relationships between them and the proposed Manager and Responsible Individual were observed to be very good. A carer commented that the senior staff, the proposed Manager and Responsible Individual work alongside them and help out wherever necessary. Redclyffe Residential Care Home DS0000066208.V289146.R01.S.doc Version 5.1 Page 22 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, 32, 33, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home does not currently have a Registered Manager however the Provider has ensured that the management is effective and in the best interests of the Residents. EVIDENCE: We looked at the Management of the Home to ensure Residents have a voice, staff are supported and guided and that the Home is run in the best interests of the Residents. A proposed Manager has been recently appointed and an application for Registration is to be submitted following the completion of his induction period. Redclyffe Residential Care Home DS0000066208.V289146.R01.S.doc Version 5.1 Page 23 In the interim and as agreed with the Commission the Company’s Responsible Individual and a Manager from another of the Company’s Homes oversee the day to day running of the Home with the Deputy Manager. As stated in the body of this report the management arrangements are effective, many improvements have been noted to the record systems, the premises and the general running of the Home. This is demonstrated in the fact that only one requirement has been made in this report. Residents meetings have been introduced to ensure that they have a voice in the running of the Home and other quality assurance systems are being developed, such as surveys, to further gain opinions of the service. The Responsible Individual has ensured that staff are provided with guidance and leadership and is available to both them and the Residents on almost a daily basis. Staff spoken with felt that he and senior staff were easily accessible to discuss any issues or concerns and that good back up systems were in place for contact out of office hours should this be necessary. Formal systems for staff supervision and appraisal are yet to be developed. The approach to general health and safety was assessed as good and staff have received training in this area. Redclyffe Residential Care Home DS0000066208.V289146.R01.S.doc Version 5.1 Page 24 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X X 2 X 3 Redclyffe Residential Care Home DS0000066208.V289146.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP29 Regulation 19 Requirement POVA first and Criminal Record checks must be obtained as appropriate for all staff with records maintained in the Home. Timescale for action 15/06/06 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 Residential Care Home DS0000066208.V289146.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB 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 Residential Care Home DS0000066208.V289146.R01.S.doc Version 5.1 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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