Inspection on 02/05/07 for Redcotts

This inspection was carried out on 2nd May 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Redcotts 24/02/10

Redcotts 21/01/10

Redcotts 19/11/09

Redcotts 26/02/09

Redcotts 09/09/08

Redcotts 24/04/08

Redcotts 16/05/06

Redcotts 24/11/05

Redcotts 07/04/05

Redcotts 03/11/04

Redcotts 14/07/04

Redcotts 14/01/04

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 Redcotts 96 Wensleydale Road Hampton Middlesex TW12 2LY Lead Inspector Simon Smith Unannounced Inspection 2nd May 2007 12:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Redcotts DS0000017388.V339168.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. Redcotts DS0000017388.V339168.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Redcotts Address 96 Wensleydale Road Hampton Middlesex TW12 2LY 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 8979 5477 020 8979 5491 Mr Sajjad Hassan Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Redcotts DS0000017388.V339168.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Redcotts is a privately owned residential care home registered for up to 18 older people. The owner visits the home on a regular basis and a manager is employed to oversee the day-to-day operation of the home. The home is situated in a residential road in Hampton, close to local shops, community facilities and public transport networks. Communal rooms include a lounge and separate dining room. The home has a large rear garden. Residents’ rooms are on the ground and first floor of the home. The home is staffed 24 hours a day. Information about the home is available in a Service User Guide, which includes information on the aims and objectives of the service. The home’s charges range from £499 to £520 per week. Redcotts DS0000017388.V339168.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector used evidence from a range of sources when making judgements about the home. These included visiting the home twice and talking to residents, staff and the manager. Surveys were given to residents, relatives and staff. Three residents, two relatives and four members of staff returned surveys to the CSCI. A sample of records was examined, including staff and residents’ files. The inspector was made welcome during the visits and wishes to thank residents, staff and all those who gave their views about the home. The home met 20 of 32 National Minimum Standards assessed at this visit. Eleven Standards were almost met and one Standard was not met. Some Requirements made at the last inspection had not been met by the home and are reinstated in this report. The home had four vacancies at the time of inspection and one resident was in hospital. Some improvements have been made to the home since the last inspection but more work is needed to ensure that all parts of the building and grounds are suitable for residents’ use. The rear garden is inaccessible to most residents, which is unfortunate as this could be a valuable resource. There are steep steps leading from the house to the garden, which have no handrail. The path around the garden is uneven and there are few flowers or shrubs. Activities at the home have improved but residents still have little to do during the day and few opportunities to go out. This was highlighted by residents and staff spoken to during the inspection. A new manager has recently been appointed. The manager is clearly working hard to improve the service and some of the changes already introduced have realised benefits for residents. Whilst many of the developments introduced by the manager have led to improvements, there is evidence to suggest that some staff have found the changes difficult to accept. Four staff have left the home in recent months and five new staff have been employed. As a result one of the challenges currently facing the home is to create a new team willing to work together to improve the service provided to residents. Establishing good systems of communication and providing all staff with opportunities to contribute to the development of the home will be key to this process. In addition the owner should ensure that the manager is supported in her efforts to drive improvements to the service. What the service does well: Redcotts DS0000017388.V339168.R01.S.doc Version 5.2 Page 6 Residents are able to have visitors whenever they please and relatives feel that staff welcome them when they visit. Residents usually enjoy the food provided by the home and can have alternatives if they do not like the advertised menu. The cook knows residents’ likes and dislikes well. The home has a committed manager who is working hard to improve the service provided to residents. What has improved since the last inspection? What they could do better: Redcotts DS0000017388.V339168.R01.S.doc Version 5.2 Page 7 Arrange a moving and handling assessment for all residents to identify their needs in relation to mobility. Obtain any specialist moving and handling equipment identified through the assessment process. Record and respect residents’ preferences with regard to personal care. Improve information about residents’ personal history, interests and preferred activities. Provide a wider range of activities and outings to residents. Ensure all areas of the home and gardens are safe and accessible to residents. Ensure that accessible bath and shower facilities are available to residents. Paint the radiator covers to improve their appearance. Replace the worktops and flooring in the kitchen. The owner must forward the manager’s application for registration to the CSCI. The manager should have access to regular, professional support and supervision. Obtain all appropriate documents for staff, including Criminal Records Bureau disclosures, proof of identity and references. Ensure all staff have received training in First Aid, food hygiene, health and safety and fire safety. Support staff to undertake and achieve National Vocational Qualifications. Review staffing levels at the home to identify and address any ‘thin’ periods. Improve records of fire drills and fire risk assessments. 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. Redcotts DS0000017388.V339168.R01.S.doc Version 5.2 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 Redcotts DS0000017388.V339168.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2, 3, 5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence, including two visits to the service. Residents have a contract that outlines the terms and conditions of residence. Residents’ needs are assessed prior to admission. Prospective residents are able to visit the home before moving in to establish its suitability. EVIDENCE: The manager reported that she has put in place contracts for all residents that outline the terms and conditions of residence. Where residents are unable to sign their contracts the manager said that she would obtain signature from their next of kin. Redcotts DS0000017388.V339168.R01.S.doc Version 5.2 Page 10 The manager said that she meets all prospective residents before they move in to carry out an assessment. This assessment is used to determine whether or not the home can meet the resident’s needs. The manager said that she aims to improve the information gathered by the home at the time of each resident’s admission, including details of residents’ personal history, medical history and preferred activities. People thinking of moving to the home are able to visit with their families before doing so. Admissions are made initially on a six-week trial basis. A review is held at the end of this period. The home does not admit residents for intermediate care. Redcotts DS0000017388.V339168.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence, including two visits to the service. The recording of healthcare appointments, treatment and other medical interventions has improved. The recording of accidents and falls has improved. All residents must have a moving and handling assessment to identify their needs in relation to mobility. The home must obtain any specialist moving and handling equipment identified through the assessment process. The home has appropriate arrangements for the handling, storage and administration of medication. Residents’ preferences with regard to personal care must be respected. Redcotts DS0000017388.V339168.R01.S.doc Version 5.2 Page 12 EVIDENCE: Each resident has a plan of care, which records their individual needs and strengths. The manager said that she is aiming to improve the information held about residents on their care plans, including residents’ personal history, important events and preferences regarding activities. The manager has developed a standard format for this purpose, which will be updated monthly. There have been significant improvements in the recording of healthcare appointments, treatment and other medical interventions since the last inspection. The recording of accidents and falls has also improved. The last key inspection of the home in August 2006 noted that some residents have poor mobility but that the home has no equipment to assist with lifting or transferring. The report of the August 2006 inspection made a Requirement that all residents must have a moving and handling assessment to identify their needs in relation to mobility and that the home obtain any specialist equipment identified through this process. There is no evidence that the home has taken action to meet this Requirement and it is reinstated in the Environment section of this report. (See Requirement 1). One relative’s survey said that her mother prefers to receive personal care from female staff but that this does not always happen. The home should ensure that residents’ preferences regarding personal care are respected. (See Requirement 2). The manager has tightened up procedures around the administration of medication and carries out a weekly medication audit. All medication was stored securely at the time of inspection. Most medication is administered using a monitored dosage system. Inspection of medication records for four residents revealed no omissions or errors. The manager said that staff will attend medication training with the home’s pharmacist in June 2007. One resident self medicates. There is a risk assessment in place to address this. Redcotts DS0000017388.V339168.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence, including two visits to the service. Activities at the home have improved but residents still have little to do during the day and few opportunities to go out. This affects the quality rating for this section of the report. Residents are able to have visitors whenever they please and relatives feel that staff welcome them when they visit. Residents usually enjoy the food provided by the home and can have alternatives if they do not like the advertised menu. The cook knows residents’ likes and dislikes and caters for specific dietary needs. EVIDENCE: Residents and staff spoken to during the inspection said that there is not much for residents to do during the day. In addition, there are few opportunities for Redcotts DS0000017388.V339168.R01.S.doc Version 5.2 Page 14 residents to leave the home for outings. This is an area identified for improvement at the last key inspection of the home. (See Requirement 3). The manager advised that the home is seeking to improve this area. An Activities Co-ordinator has recently been employed and now visits the home for two days each week. The manager said that some in house events have been planned, such as a garden party in August, and that residents will be given opportunities to go on occasional outings. In addition the home is aiming to identify and cater for residents’ individual likes and interests. For example one resident enjoys chess and staff plan to arrange opportunities for him to play. Residents are able to have visitors at any time and relatives said that they are made welcome by staff when they visit. One resident said, “You can have your relatives come and visit you whenever you like”. Some residents had visitors during the inspection and chose to spend time with them in the home’s garden. The manager said that staff encourage residents to make decisions about their lives. Residents are able to bring personal items with them when they move in and to personalise their private space. Residents are able to access the information held about them by the home should they wish to do so. The manager said that she has changed the catering suppliers used by the home and that this had resulted in improved quality of produce. The cook was planning a new menu at the time of inspection and said that she asks residents what they would like to see on the menu. . The cook demonstrated a good knowledge of residents’ individual likes and dislikes. The cook said that the home is able to cater for specific dietary needs and provides diabetic, celiac and soft food diets. There was evidence that the home seeks the input of appropriate professionals in developing residents’ diets where necessary. For example one resident’s diet was developed by a Speech and Language Therapist. Residents spoken to during the inspection said that they usually enjoy the food provided by the home and that they can have alternatives if they do not like the advertised menu. Surveys returned by relatives also reported that food at the home is usually good but did make some suggestions for improvement. One relative said, “Lunch is of a good standard but breakfast could be more varied to include a cooked breakfast 2 or 3 times a week”. Redcotts DS0000017388.V339168.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence, including two visits to the service. The home has an appropriate Complaints procedure. Staff receive training in the protection of vulnerable adults. EVIDENCE: The home has a Complaints procedure, which is available to residents and relatives if required. The manager said that there had been no complaints about the home since the last inspection. Residents who completed surveys said that they knew who to speak to if they were unhappy with their care. The home works within the London Borough of Richmond Protection of Vulnerable Adults (POVA) procedures. POVA training has been provided for the staff team. The manager said that new staff receive training in this area during their induction. Redcotts DS0000017388.V339168.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21, 22, 23, 24 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence, including two visits to the service. Some improvements have been made to the home since the last inspection but more work is needed to ensure that all parts of the building and grounds are accessible to residents. The gardens are not safe for use by residents. Bath and shower facilities are not accessible to all residents. The home has insufficient equipment to enable staff to work safely with residents who require lifting. The standard of cleanliness has improved. EVIDENCE: Redcotts DS0000017388.V339168.R01.S.doc Version 5.2 Page 17 The home is a converted two-storey house. There is a stair lift between the ground and first floor. There is a large lounge and separate dining room. All residents have single rooms and are able to personalise their own space as they wish. There have been some improvements to the home since the last inspection. Some of the communal areas have been repainted and the hall has been recarpeted. Radiator covers have been installed but would benefit from painting. There have also been some improvements to the gardens. The front garden has been cleared and the footpath improved, although there is still no handrail. However the large rear garden is largely inaccessible to residents, which is unfortunate as this could be a valuable resource for residents. There are steep steps leading from the house to the garden, which have no handrail. The path around the garden is uneven and therefore not safe for residents to use. Removing the dilapidated shed and planting shrubs and flowers would improve the appearance of the garden. (See Requirement 4). A new cooker and fridge have been bought for the kitchen. However the worktops and flooring in the kitchen are worn and should be replaced. The manager said that essential work on the electrical wiring system has been completed. The last inspection report recommended that the home install a shower facility that is accessible to residents. This has yet to take place but the manager said that she is in the process of obtaining quotes for this work from local contractors. (See Requirement 5). As highlighted in the Health and Personal Care section of this report, the last inspection report expressed concern that the home has no equipment to enable staff to work safely with residents who require lifting. This should be addressed through assessments of residents’ individual needs and the provision of any equipment. The manager said that improving the standard of cleanliness in the home was one of her first priorities when she took up her post. The home now employs cleaners, whereas in the past care staff had to combine cleaning duties with their role as carers. A housekeeper has also been employed to manage the laundry system, which has reduced the number of items going missing. Redcotts DS0000017388.V339168.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence, including two visits to the service. Staffing levels are adequate but there are sometimes ‘thin’ periods at weekends. The turnover of staff since the last inspection has been high. The organisation and content of staff files has improved greatly since the last inspection. Some staff records still lack evidence of identity and Criminal Records Bureau disclosures. The home has arranged some relevant training since the last inspection but some staff still need to attend elements of core training. EVIDENCE: The manager reported that she has introduced changes to the staff rota to ensure that staff are on duty at times when they are most needed. The manager reported that there are still times when staff numbers are low given Redcotts DS0000017388.V339168.R01.S.doc Version 5.2 Page 19 residents’ needs, principally at weekends, and that she plans to address these ‘thin’ periods. The manager has introduced a number of positive changes to management systems since her arrival in post. For example the last inspection report noted that staff files were disorganised and poorly maintained. These files are now better organised and contain important information that was previously lacking, such as up to date job descriptions and contracts of employment. Staff files also contained a supervision contract and evidence of supervision. Whilst many of the developments introduced by the manager have led to improvements, evidence (such as staff surveys) indicates that the staff team have found some of the changes difficult to accept. As a result one of the challenges currently facing the home is the establishment of a new team willing to work together as part of a new regime to improve the service provided to residents. Without doubt establishing good systems of communication and providing all staff with opportunities to contribute to the development of the home will be key to this process. The turnover of staff has also been affected by this change in the dynamics of the service. Four staff have left the home in recent months and five new staff have been employed in this period. Two more had recently been appointed and were awaiting start dates at the time of inspection. New staff spoken to during the inspection said that they attended an interview and had an induction to the home when they started work. New staff also confirmed that they had been asked to produce a Criminal Records Bureau (CRB) disclosure and proof of identity. The manager is exploring any gaps in staff checks and records, including references and Criminal Records Bureau disclosures. The manager advised that four staff have yet to obtain a Criminal Records Bureau disclosure and that one of these has not produced appropriate proof identity or references. (See Requirement 7). The manager confirmed that staff do not work unsupervised with residents until a Criminal Records Bureau (CRB) disclosure has been received by the home. The last inspection report made a Requirement that staff must attend all areas of core training, including First Aid, food hygiene, health and safety and fire safety. The report also stated that staff should attend training in specific conditions that affect residents, such as dementia and epilepsy. The manager said that training in dementia and epilepsy had taken place but that not all staff had yet attended all aspects of core training. This Requirement is therefore reinstated. (See Requirement 8). The last report also required that all staff should be given the opportunity to work towards National Vocational Qualifications. This has yet to be achieved, Redcotts DS0000017388.V339168.R01.S.doc Version 5.2 Page 20 although the manager is exploring options of the provision of NVQ training, and the Requirement is reinstated. (See Requirement 6). Redcotts DS0000017388.V339168.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 34, 35, 36, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence, including two visits to the service. The manager is committed to improving the service and is working hard to achieve this. Whilst it is important that staff have opportunities to give their views on how the changes affect them, the owner should also ensure that the manager is supported in making improvements to the service. The manager needs to register with the CSCI and to complete the Registered Managers’ Award. The home is considering ways to improve residents’ involvement in making decisions about their lives. The organisation of the home’s policies and procedures has improved. Redcotts DS0000017388.V339168.R01.S.doc Version 5.2 Page 22 The accounting systems for residents’ monies have improved. Establishing an operational budget has increased opportunities for financial planning. Records of fire drills and risk assessments are poor and must be improved. EVIDENCE: The manager is very committed to improving the service and is working hard to achieve this. These efforts have included the implementation of new systems and ways of working. Almost inevitably given the wholesale changes in many areas, there has been a range of reactions from the staff team. Whilst it is important that staff have opportunities to give their views on how the changes affect them, the owner should also ensure that the manager is supported in making improvements to the service. (See Requirement 11). The last inspection report noted that “there have been times when the situation at the home has been very stressful and the manager has been faced with a series of challenges”. The report recommended that the owner provide the manager with access to professional support and supervision. This recommendation is reinstated. The score of 2 against the management Standard reflects that the manager has not yet achieved registration with the CSCI or completed the NVQ 4/ Registered Managers’ Award. The Requirements made regarding registration in the last inspection report are reinstated. (See Requirements 9 and 10). The manager said that she plans to arrange relatives meetings every three or four months and will consider distributing surveys to residents, relatives and other stakeholders annually. The manager also said that the home is considering ways in which to improve residents’ involvement in making decisions about their lives. The manager has begun work on organising the home’s operational policies and procedures. The manager said that an introduction to the policies and procedures of the service now forms part of the induction for new staff. The last inspection report required that the owner supply the CSCI with a business plan, although this was never provided. However the manager said that problems with the non-payment of suppliers have stopped and that all the home’s suppliers have been paid up to date. The manager also said that she has established the operational budget for the home with the owner and that this has improved financial planning. Redcotts DS0000017388.V339168.R01.S.doc Version 5.2 Page 23 The manager has improved the accounting systems for residents’ monies. Residents are now issued with receipts for expenditure, all transactions are recorded and individual monthly statements are produced. There was no evidence of a fire risk assessment for the home or a fire book to record drills and equipment checks. (See Requirement 12). The manager said that she was to meet the Fire Officer in the week following inspection to discuss ways in which the home’s fire precautions could be improved. Redcotts DS0000017388.V339168.R01.S.doc Version 5.2 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 X 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 1 3 3 X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 3 3 2 3 2 Redcotts DS0000017388.V339168.R01.S.doc Version 5.2 Page 25 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 OP8 OP22 Regulation 12 13 Timescale for action The Registered Person must 30/06/07 arrange for the manual handling needs of the residents to be assessed by an appropriately qualified health care professional. The assessment should identify what type of equipment could be used safely within the home. The Registered Person must make sure that any equipment identified through this process is provided. This Requirement has been made at a previous inspection. The Registered Person must make sure that residents’ preferences regarding personal care are respected. The Registered Person must ensure that: • Detailed information on social needs and interests is in place for all residents. A wider range of activities and outings is available to Version 5.2 Page 26 Requirement 2 OP10 12(2) 30/05/07 3 OP12 16(m) 30/06/07 • Redcotts DS0000017388.V339168.R01.S.doc residents. • Staff encourage and support residents to meet their social and leisure needs throughout the day. Residents who have a disability have opportunities to participate in activities of their choice. • 4 OP19 23(2) This Requirement has been made at a previous inspection. The Registered Person must make sure the gardens and pathways are safe and accessible to residents. This Requirement has been made at a previous inspection. The Registered Person must ensure that accessible bath and shower facilities are available to residents. This Requirement has been made at a previous inspection. The Registered Person must support staff to undertake and achieve NVQ Level 2 or above. This Requirement has been made at a previous inspection. The Registered Person must make sure that the home obtains appropriate documents for all staff, including Criminal Records Bureau disclosures specifically for this post, proof of identity and references. The Registered Person must make sure all staff have received training in First Aid, food hygiene, health and safety and fire safety. This Requirement has been 30/06/07 5 OP21 23(2) 30/06/07 6 OP28 18(1) 30/07/07 7 OP29 19 30/06/07 8 OP30 18(1) 30/07/07 Redcotts DS0000017388.V339168.R01.S.doc Version 5.2 Page 27 9 OP31 9 made at a previous inspection. The Registered Person must make sure the Manager’s application for registration is forwarded to the CSCI. This Requirement has been made at a previous inspection. The Manager must commence NVQ Level 4/the Registered Managers Award. This Requirement has been made at a previous inspection. The Registered Person must make sure the manager has access to regular, professional support and supervision. This made The make • • Requirement has been at a previous inspection. Registered Person must sure that: Fire drills and checks on fire equipment are recorded. Fire procedures are clear and well known by staff. 30/06/07 10 OP31 10(3) 30/08/07 11 OP36 12(5) 18(2) 30/07/07 12 OP38 23(4) 30/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP19 OP19 OP27 Good Practice Recommendations Paint the radiator covers to improve their appearance. Replace the worktops and flooring in the kitchen. Review staffing levels at the home to identify and address any ‘thin’ periods. Redcotts DS0000017388.V339168.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Redcotts DS0000017388.V339168.R01.S.doc Version 5.2 Page 29 - 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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