Inspection on 24/11/05 for Redcotts

This inspection was carried out on 24th November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

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 02/05/07

Redcotts 16/05/06

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 Sandy Patrick Unannounced Inspection 24th November 2005 09:30 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.V260138.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Redcotts DS0000017388.V260138.R01.S.doc Version 5.0 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 02089795491 Mr Sajjad Hassan Ms Amanda Draper Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Redcotts DS0000017388.V260138.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th April 2005 Brief Description of the Service: Redcotts is a residential care home registered for up to eighteen people. The home is privately owned. A Manager is employed to oversee the day-to-day operations of the home. The home is situated in a residential road in Hampton, close to local shops, facilities and public transport routes. Accommodation is provided on two floors, accessed by a stairway and passenger lift. The home is staffed twenty-four hours a day. The Registered Persons have produced a Service User Guide, which includes information on the aims and objectives of the service. Redcotts DS0000017388.V260138.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days, 24th and 28th November 2005. The Inspection Team included a Pharmacy Inspector. The report of his findings is recorded within Section 2 (Standard 9) of this report. The Inspectors met with service users and staff on duty during the first day of the inspection and the Lead Inspector met with the Manager on the second day of the inspection. They were made welcome by all. The atmosphere at the home was relaxed and service users appeared happy and comfortable. Staff were seen to treat service users with kindness. Service users who spoke to the Inspectors said that they were happy living at the home. One service user said that the home was ‘wonderful’. Several service users said that they lived the food. One service user said that they would like more things to do. The Lead Inspector met with two visiting health care professionals. They told the Inspector that things at the home had improved and that communication from staff was much better than in the past. What the service does well: What has improved since the last inspection? Twenty-nine National Minimum Standards were assessed at the last inspection visit on 7th April 2005. The home failed to meet twenty-five of these and thirty requirements were made. Following this the Owner was invited to meet with the CSCI to discuss these serious concerns and how he intended to meet the requirements made. The Inspection Team have also visited the home on 2nd June 2005, 29th June 2005, 15th August 2005, 1st September 2005 and 6th October 2005 to monitor compliance with requirements. A new Manager was recruited in June 2005. Redcotts DS0000017388.V260138.R01.S.doc Version 5.0 Page 6 Since the last inspection visit improvements have been noted in some areas. These include improved pre-admission assessments, care planning, risk assessments, communication with health care professionals, activities, staff training and checks on health and safety. The new Manager has worked with the staff team to improve standards throughout the home and make the quality of life better for service users. The Manager has experienced some resistance to change from some of the staff team. It is natural that people find change difficult, however standards at the home were previously unacceptable and service users were put at serious risks, the staff team must work towards implementing positive changes and improvements in all areas must continue. 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. Redcotts DS0000017388.V260138.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Redcotts DS0000017388.V260138.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 There is an appropriate procedure for assessments and the Manager has conducted thorough assessments of need on prospective service users. Service users whose needs have changed must be reassessed. EVIDENCE: Three service users have moved to the home since the last inspection. The Manager has completed thorough assessments, which include the service user spending time at the home prior to making a decision about moving. Copies of pre admission assessments were seen. These incorporated information from the placing authorities and health care professionals. The Manager told the Inspector that she recognises the importance of thorough assessments to make sure the home can meet the needs of individuals. The Manager reported that the needs of some service users have changed and she has requested reassessments of need from placing authorities and health care professionals. One service user’s needs have changed significantly and the Manager organised for a nursing needs assessment. The home has not yet had a copy of this assessment. It is important that this assessment is obtained Redcotts DS0000017388.V260138.R01.S.doc Version 5.0 Page 9 and a review of this person’s needs is held. The home does not have the equipment necessary to meet this person’s needs and this must be considered as part of the review. Redcotts DS0000017388.V260138.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 There has been significant improvements to care planning and to support of service users to meet personal and health care needs. Some practices at the home do not adequately respect privacy. Although the home has arrangements for the ordering, storage and recording of medication and has access to a pharmacist for advice serious errors in administration of medication and errors and omissions in recording were found that question whether these arrangements protect the health and welfare of residents. EVIDENCE: Over the past six months the Manager has put a lot of work into developing service user plans so that they clearly identify needs and how these can be met. The plans are now much more detailed and person centred than they were previously. Individual needs are described in more detail. There was evidence that service user plans have been reviewed monthly. The daily care notes made by staff have improved and are more detailed than in the past. Redcotts DS0000017388.V260138.R01.S.doc Version 5.0 Page 11 The senior staff member showed the Inspector some of the improvements introduced to help monitor health and personal care needs. Staff at previous visits to the home have spoken about how changes introduced by the new Manager to support service users with personal care have been very positive and service users are now treated with more respect. On the first day of the inspection, information relating to one service user’s personal care needs was pinned to the office door. This was later removed by staff. Information relating to service users’ needs must not be put on display and must be stored within service user plans. One service user’s need have changed and a nursing needs assessment has been organised. The Manager reported that she has not yet heard the outcome of this assessment. The Manager must obtain a copy of the assessment and hold a review to look at whether this person’s needs can be safely met within the home. At one point during the inspection, a service user was supported to take a bath. The service user was left alone during their bath (in accordance with their care plan). During this time the bathroom door was left open. The staff on duty reported that this was normal practice and that a curtain was drawn around the bath to preserve their privacy. This practice is unacceptable and must cease. Bathroom doors must be closed whilst service users are taking bath. The Manager reported that staff are working more closely with health care professionals and communicating service user’s health needs and seeking advice. Two visiting health care professionals confirmed that communication had improved and that staff worked better with them than in the past. Health care needs are more clearly recorded in service user plans and there is a record of all medical consultations. All medications in the office along with the records relating to receipt, storage, administration, self-administration by residents and disposal of medication were examined. The person in charge was interviewed, and all medication not supplied in the monitored dosage system was counted and compared to the receipt and administration records. From these observations and discussions residents are encouraged to maintain control of their medication in a safe manner, all staff administering medication have received training in safe handling of medication from a pharmacist and arrangements were seen to record the receipt, administration and disposal of medication. The review date for the assessment of the resident self-medicating was September 2005. No review had been done on this date or since then. Redcotts DS0000017388.V260138.R01.S.doc Version 5.0 Page 12 Two residents did not have the receipt of the current medication recorded. When medication that is not in the Monitored dosage system comes in the quantity and date it was checked is written on the container enabling the audit of use of current medication only. One resident had been signed as being given their medication when it was clear the medication had not been given. One resident had been signed as being given their medication when there was none in stock. One other resident had missing entries on the medication administration record. One item requiring storage in the fridge was not stored securely. In seven instances the amount of medication in stock did not agree with the amount there should be from the records of receipt and administration for medication that was not supplied in the monitored dosage system. In two of these cases the records and amounts of medication indicated that double the dose had been given on two days. The person in charge could not describe the method of supply of medication to residents on leave from the home. The home does not have a controlled drug cupboard. Redcotts DS0000017388.V260138.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 & 15 The organisation and variety of activities at the home has improved. Further developments have been planned. There is an appropriate visitors procedure. Service users are able to choose from a varied menu. Some practices around mealtimes should be improved to offer better support and more choice. EVIDENCE: Staff on duty reported that activities are organised every afternoon. These include a regular keep fit class, quizzes, singing groups and games. The number and variety of activities offered to service users has improved, as has the staff commitment to facilitating these. Staff are also spending more time with service users, chatting and offering individual support. This is positive and must continue. A wider variety of activities and more opportunities for service users to take trips out of the home should be considered. The Manager reported that a new member of staff has been employed to organise and facilitate activities once a week. She said that this person plans to speak with all service users about their individual interests and life histories. Redcotts DS0000017388.V260138.R01.S.doc Version 5.0 Page 14 The Manager said that she will organised activities around these identified needs with a focus on individual support. Staff on duty reported that a singing session was planned for the afternoon on the day of the inspection. They said that service users enjoyed this. A hairdresser visits the home weekly. Visitors are welcome at the home at any time. The Manager reported that the staff’s communication with families had improved. A Christmas party was being planned for December, where families and friends would be invited. A qualified Aromatherapist has recently started offering service users massages at a small cost. The staff on duty reported that this was well received. The Manager must make sure that this person has had a recent criminal record check. There is a choice of meals available on the menu. Service users reported that the cook asked them in advance which meal they would like. The menu is displayed in the dining room. Fresh fruit was available in the dining room for service users to help themselves. Service users said that they liked the food at the home. One service user who was supported by staff at the mealtime. The staff member was standing next to this service user. It is important that staff sit with service users who they are supporting. The main lunchtime meal was served ready plated from the kitchen. Consideration should be given to the provision of vegetable dishes so that service users can help themselves to these. Redcotts DS0000017388.V260138.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 & 18 There are appropriate procedures regarding complaints and protection of vulnerable adults. The staff team have recently been trained in protection of vulnerable adults. EVIDENCE: There is an appropriate complaints procedure. Copies of the complaints procedure on display should be updated as some of the information on these is out of date. There has been one complaint since the last inspection. The Inspector saw evidence that this had been investigated, that the complainant had been informed of the outcome and that action had been taken to address concerns. The home has adopted the London Borough of Richmond protection of vulnerable adults procedure. Staff on duty reported that they had all recently undertaken training in protection of vulnerable adults and that this had been useful and informative. The Manager reported that all service users were registered to vote. Redcotts DS0000017388.V260138.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 & 26 The building meets National Minimum Standards size requirements and the layout is appropriate for its purpose. Some maintenance and decorative work has taken place after repeated requirements however much work remains outstanding. There has been improvements to the general cleanliness of the home. EVIDENCE: All rooms are for single occupancy and meet National Minimum Standards size requirements. Service users are able to bring their personal belongings to furnish and equip their rooms. Some of the maintenance needs identified at previous inspections remain outstanding and must be attended to. Since the last inspection, the lounge and one service user’s room has been equipped with a new carpet and window frames have been painted. Bathrooms on the ground and first floor continue to require work, the garden path is uneven and the extractor fan in the ground floor bathroom does not work. This work and other work identified at previous Redcotts DS0000017388.V260138.R01.S.doc Version 5.0 Page 17 inspections and by the Manager must be attended to. There must be a planned programme of renovation to meet the needs of the home. There is no light in the corridor outside one service user’s room and also no light outside the kitchen. This is a risk for people using these corridors. There is only one bathroom with an electric bath chair to support those with mobility needs. The extractor fan in this room is not working and there is no window. Staff report the room becomes unpleasantly hot and steamy. The Manager must make sure staff and service users are not put at risk from unsafe manual handling due to lack of equipment. The Manager reported that some service users have requested a shower. The changes in need for some service users has meant that they find accessing the bath difficult. The Registered Person should consider the installation of a walk in shower which would be easier for service users to access. A heater in a downstairs WC was connected to a hot water pipe by an electrical wire. This posed a serious risk to health and safety. The Manager has reported that this heater has been removed since the inspection visit. There is no hoist at the home. Some of the service users require a hoist so that they can be safely moved. The equipment needs of service users must be met. The Manager reported that a Housekeeper has been newly employed to work three days a week. Their role includes general cleaning, ironing and laundry. The cleanliness at the home has improved and the Manager said that all service users curtains had been cleaned. Redcotts DS0000017388.V260138.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Additional senior staff must be employed to support the care staff in their roles. Training opportunities for staff have improved. Further training need must be met. Recruitment practice at the home have improved. Formal systems to offer staff support and supervision must be implemented. EVIDENCE: The senior member of staff reported that work at the home was more structured and organised than in the past. She said that individual service user needs are more clearly identified and met through a structured schedule of work each day. The Manager said that she felt staff now had a better awareness of their role. Since the last inspection an additional waking night staff post has been created so that the home now has two waking night staff each night. At the time of the inspection there was only one senior member of staff employed in addition to the Manager. The Deputy Manager had reduced their hours to one day a week and had then gone on extended leave at short notice, Redcotts DS0000017388.V260138.R01.S.doc Version 5.0 Page 19 effectively leaving the home without a Deputy Manager. The Manager was not aware of the Deputy Manager’s plans to continue working. With the changes being implemented and the high number of managerial and supervision tasks that need to be completed, it is important that there is a strong and committed team of senior staff working with the Manager. The Registered Person must make sure the Manager is supported by a senior staff team. Since the last inspection, the Manager has organised a range of training for staff. This must continue as some training needs remain unmet. Two members of staff have undertaken a thirteen week course in essential care skills and had almost completed this at the time of the inspection. The Manager reported that she hoped these staff would undertake NVQ training starting in 2006. Three members of staff have undertaken training in computer skills. In house training in diabetes and death and dying has taken place. Staff on duty reported that they had recently received training in protection of vulnerable adults and that this had been useful and informative. The senior staff member reported that she spent time with the Manager each week planning the development of the service and changes which need to be implemented. The Manager showed the Inspector staff files for the two most recently recruited members of staff. There was evidence of pre employment checks including criminal record checks and references. The Manager stated that criminal record checks had now been made on all staff, with the exception of the Aromatherapist. The Manager has reported that some of the staff members have felt that changing practices and procedures at the home is not necessary and this has caused some tensions and disagreements. It is important that the Manager communicates changes and information to the staff team appropriately. Since the last inspection there have been three team meetings and limited individual supervision sessions. The Manager should consider holding more frequent team meetings as these are a good forum for information sharing and for staff to discuss their feelings. Individual supervision meetings must be held regularly and at least six times a year. Given the changes at the home and the staff feelings around these it would be useful to have these more frequently. Any concerns about staff practice or attitude must be addressed through supervision and using the homes disciplinary procedures. Redcotts DS0000017388.V260138.R01.S.doc Version 5.0 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 36, 37, 38 The Manager is suitably experienced but must make an application to be registered with the CSCI. Improvements to office facilities are needed so that the business can be effectively managed. Serious concerns regarding health and safety have been identified at repeated inspection visits. Action must be taken to address these. EVIDENCE: The Registered Manager left the home in May 2005. The new Manager started shortly after this. She is experienced in the care field and has started to undertake her NVQ Level 4 since her employment at Redcotts. The new Manager has not yet applied for registration and must do so. Redcotts DS0000017388.V260138.R01.S.doc Version 5.0 Page 21 The Manager has demonstrated a commitment to improving the service and to looking at how the lives of service users can be improved. Over the past few months the Manager and Lead Inspector have spoken about the needs of the service and individuals. The Manager has a good awareness of individual care needs of all the service users and has put in place practices and procedures designed to meet these. Some of the changes that the Manager has introduced have been hard to implement and she has faced resistance from some staff. However, she has worked hard to implement positive changes and has communicated effectively with the CSCI about the service. The Owner is required to conduct monthly unannounced visits and make a record of these visits. Since the last inspection there have only been three such visits. These visits must take place at least monthly and copies of the reports sent to the Commission for Social Care Inspection. The requirement made at the last three inspections is restated. There is no photocopier or Internet access at the home. These are necessary for the effective management of the business. The Manager is not involved with budget setting or monitoring, and was not able to give information on the home’s financial position. A copy of the home’s budget and business plan must be forwarded to the Commission for Social Care Inspection. Electric power points in the office area were overloaded and posed a risk to health and safety. The Manager rearranged the electrical appliances so that sockets were not overloaded. A full check of electrical sockets throughout the home must be made to make sure that electrical appliances are appropriately connected to the power supply. Staff and service users have raised concerns about the electrical wiring in the home. This has not been checked for over five years and staff report problems with lights blowing and the power supply failing. The Owner reported that he would arrange for an electrician to make a full check of the wiring. This remains outstanding and the requirement made at the previous three inspections is unmet. Failure to meet the requirement of this report within the timescale will lead to enforcement action being taken. Windows throughout the home are not equipped with restricting devices. The Owner told the Lead Inspector that all windows will be suitably equipped by the 31st December 2005. Failure to comply with this will lead to enforcement action. The requirement has been made at the previous three inspection visits. Radiators throughout the home are uncovered and do not have low surface temperatures. Service users are at risk from scalding. A requirement to equip these radiators with suitable covers has been made at the previous three Redcotts DS0000017388.V260138.R01.S.doc Version 5.0 Page 22 inspection visits. The Owner reported that this work would be complete by 31st December 2005. Failure to comply may lead to enforcement action being taken by the Commission for Social Care Inspection. Fire resistant doors throughout the home, including the dining room door and bedroom doors were wedged open. These doors can be heavy and shut doors can restrict movement around the home. However, the practice of wedging these doors open creates a risk and the Registered Person must find alternative methods of holding doors safely open. The requirement made at the previous three inspections is restated. Redcotts DS0000017388.V260138.R01.S.doc Version 5.0 Page 23 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 2 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 2 X 2 3 1 Redcotts DS0000017388.V260138.R01.S.doc Version 5.0 Page 24 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 Regulation 12 14 Requirement Timescale for action The Registered Person must 31/01/06 obtain a copy of the nursing needs assessment which has been made on one service user. A review meeting should be arranged to decide whether the home can continue to meet this person’s needs. The Registered Person must make sure: 1. The amount of medication not supplied in the monitored dosage system is counted ad recorded and that audit arrangements are introduced to monitor the use of these items. 25th November 2005. 2. The administration/nonadministration of all medication is recorded accurately. 25th November 2005. 3. Sufficient supplies of Version 5.0 Page 25 2. OP9 13(2) 23/12/05 Redcotts DS0000017388.V260138.R01.S.doc medication are in stock. 25th November 2005. 4. Secure storage arrangements are in place for items requiring storage in a fridge. 23rd December 2005. 5. The receipt of all medication is recorded rd accurately. 23 December 2005. 6. Residents who are selfmedicating are reviewed appropriately. 23rd December 2005. 7. All staff are aware of all the policies covering medication management. 23rd December 2005. 3. OP10 12 The Registered Person must 31/12/05 make sure bathroom doors are closed whilst service users are bathing to protect their privacy. The Registered Person must 31/12/05 make sure that a criminal record check has been made on the member of staff providing aromatherapy massage. The Registered Person must 31/12/05 make sure that staff supporting service users at mealtimes sit next to them and do not stand over them. The Registered make Person must 28/02/06 sure: 4. OP29 13(4) (6) 18(1)(a) 5. OP15 12 6. OP19 13(4) (6) 23(2)(b) Redcotts DS0000017388.V260138.R01.S.doc Version 5.0 Page 26 (d) 1. All maintenance needs identified at this and previous inspections are attended to. 2. Regular checks on the condition of the building and gardens are made and needs attended to as required. (Previous requirement made 14/07/04, 03/11/04 & 07/04/05) 7. OP19 13(4) (6) 23(2) 12 13 23(2) The Registered Person must 28/02/06 make sure that all corridors are adequately lit. The Registered Person must 31/01/06 make sure that equipment needed to support the safe moving and handling of service users is in place. The Registered Person must 31/01/06 make sure that sufficient senior staff are employed. The Registered Person must 28/02/06 support staff to undertake and achieve NVQ Level 2 or above. (Previous requirement made 07/04/05) 8. OP22 9. OP27 18(1)(a) 10. OP28 18(1)(a) 11. OP30 18(1)(a) & (c) The Registered Person must 28/02/06 make sure all staff are appropriately trained in first aid, food hygiene, health and safety and fire safety. (Previous requirement made 14/07/04 & 03/11/04 & 07/04/06) 12. Redcotts OP36 12(5)(a) The Registered Person must 31/12/05 Version 5.0 Page 27 DS0000017388.V260138.R01.S.doc 18(2) make sure: 1. All staff receive regular, planned and recorded supervision from their line Manager. 2. Regular, planned and recorded team meetings are held. (Previous requirement made 14/07/04 & 03/11/04 & 07/04/05) 13. OP31 9 The Registered Person must 15/01/06 make sure the Manager applies to be registered with the CSCI. The Registered Person must visit 31/12/05 the home monthly, conduct a quality inspection and produce a written report, which is available at the home and a copy sent to the Commission for Social Care Inspection. (Previous requirement made 14/07/04 & 03/11/04 & 07/04/05) 14. OP33 26 15. OP34 25 The Registered Person must 31/01/06 forward a copy of the home’s budget and business plan to the CSCI. The Registered Person must 31/12/05 arrange for a full check of electrical sockets throughout the home must be made to make sure that electrical appliances are appropriately connected to the power supply. The Registered Person must 31/12/05 make sure fire doors are not DS0000017388.V260138.R01.S.doc Version 5.0 Page 28 16. OP38 13(4) (6) 17. Redcotts OP38 13(4) (6) 23(4) wedged open. Consult with the Fire Officer about fire safety at the home. (Previous requirement made 14/07/04 & 03/11/04 & 07/04/05) 18. OP38 13(4) (6) The Registered Person must 31/12/05 make sure the electrical wiring is appropriately checked and actions from this check are implemented. (Previous requirement made 14/07/04 & 03/11/04 & 07/04/05) 19. OP38 13(4) (6) The Registered Person must 31/12/05 make sure all radiators are appropriately covered to protect service users. (Previous requirement made 14/07/04 & 03/11/04 & 07/04/05) 20. OP38 13(4) (6) The Registered Person must 31/12/05 make sure all windows above the ground floor are equipped with restricting devices. (Previous requirement made 14/07/04 & 03/11/04 & 07/04/05) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Redcotts DS0000017388.V260138.R01.S.doc Version 5.0 Page 29 No. 1. Refer to Standard OP9 Good Practice Recommendations It is recommended that a controlled drug be available for the storage of controlled drugs. The Registered Person should consult with service users giving consideration to the provision of vegetable dishes so that service users can help themselves at mealtimes rather than have their food ready plated by kitchen staff. The Registered Person should make sure that the complaints procedure has been reviewed and updated and that copies of the complaints procedure on display give accurate and up to date information. The Registered Person should consider the installation of a shower which would meet the needs of service users. The Registered Person should arrange for internet access and for a photocopier to be purchased. 2. OP15 3. OP16 4. OP21 5. OP37 Redcotts DS0000017388.V260138.R01.S.doc Version 5.0 Page 30 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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