Inspection on 07/04/05 for Redcotts

This inspection was carried out on 7th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 24/11/05

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 07 April 2005 09.50am 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 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 Version 1.10 Page 3 SERVICE INFORMATION Name of service Redcotts Address 96 Wensleydale Road, Hampton, Middlesex TW12 2LY Telephone number Fax number Email 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 Ms Amanda Draper Care Home (PC) 18 Category(ies) of 18 OP registration, with number of places REDCOTTS Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 03/11/04 Brief Description of the Service: Redcotts is a residential care home registered for up to eighteen people. Fifteen service users resided at the home at the time of the inspection. The home is privately owned. The Owner visits the home on a regular basis. 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 Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 7th April 2005 at 9.50am and was unannounced. The Inspection Team consisted of a Regulation (Lead) Inspector and a Pharmacy Inspector. The findings of the Pharmacy Inspector are recorded in the section Health and Personal Care (Standard 9). The Inspection Team met with the Registered Manager, Registered Provider, service users and staff on duty. They were made welcome by all. The Inspection Team were concerned that none of the requirements made at the last inspection had been met. There was limited evidence to suggest that work had taken place with regards to one requirement. There was no evidence that any action had been taken to address any of the other sixteen requirements or two good practice recommendations. Fourteen requirements made at the inspection in November had been made previously at the announced inspection of the home in July 2004. In addition, further areas of concern were identified at this inspection visit. The Inspection Team is concerned that the service does not adequately protect the service users from the risk of harm or abuse. Twenty-nine standards were assessed at this inspection visit. The home met four standards. Ten standards had minor short falls (partly met) and fifteen standards had major shortfalls (not met). Thirty statutory requirements have been made. Three immediate requirements were made at this inspection. Seventeen service users were living at the home at the time of the inspection. What the service does well: What has improved since the last inspection? There have been no improvements to the service since the last inspection. None of the seventeen requirements made in November 2004 have been met and further areas of concern have been highlighted at this inspection visit. This is a serious concern for the Commission for Social Care Inspection. REDCOTTS Version 1.10 Page 6 The Registered Provider was invited to a meeting with the Commission for Social Care Inspection on 12th April 2005, where these concerns were discussed. The Registered Provider must produce an action plan, which clearly identifies how the requirements made at this inspection will be met. Failure to take appropriate action will lead to the Commission for Social Care Inspection taking enforcement action. What they could do better: The home fails to meet twenty-five of the twenty-nine standards that were assessed. There is limited evidence of pre admission assessments for service users. Information recorded is basic and has not been appropriately translated into service user plans. Service user plans and risk assessments are either not in place or have not been subject to regular review, resulting in some information being out of date. The Inspection Team observed and were told about practices at the home which are unacceptable and impinge on service users’ rights to privacy, dignity and respect. Medication records were, in some cases, inaccurate. There is no planned activity programme and no evidence that ad hoc activities meet the needs of service users. Service users are not consulted about the running of the home and are not able to make informed choices about food or activities. Menus on display were inaccurate and service users reported that they were not accessible. One complaint has been made since the last inspection. There was no report of the complaint, investigation or feedback to the complaint. Limited action has been taken to reduce the risk of reoccurrence of the event leading to the complaint. One service user reported that they were not able to vote at elections. Staff have not been referred for criminal record checks. Insufficient pre employment checks have been made on staff. Staff have not received sufficient information or any training on recognising and reporting abuse. The Registered Person has not taken steps to address outstanding maintenance problems and service users have been placed at risk from outstanding requirements to ensure their health and safety. Recruitment and selection procedures are unsafe, and training and support for staff is inadequate. Staff are not given appropriate instruction, supervision or support to undertake their duties. The service is not appropriately managed and risks to health and safety are not appropriately identified or reduced. REDCOTTS Version 1.10 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. REDCOTTS Version 1.10 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 Standards Statutory Requirements Identified During the Inspection REDCOTTS Version 1.10 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 standard(s) 3 & 4 There are major shortfalls in both standards assessed. There is limited information on individual needs and some of this information is out of date. Staff are not given appropriate induction, training, supervision or support to ensure that they are effectively meeting the needs of service users. Service users are at risk or harm and abuse. EVIDENCE: Standard 6 is not applicable – the home does not provide intermediate care. The procedure for assessments indicates that the Manager or senior staff conducts an assessment of need prior to a service users admission to the home. Assessments are also undertaken by placing authorities, where applicable. The Lead Inspector examined records relating to six service users. There was no service user plan in place for three service users, who had been admitted to the home over the past twelve months. In one file, there was a detailed assessment compiled by the placing authority. Assessment information recorded by the home was minimal in all three cases, giving basic information. REDCOTTS Version 1.10 Page 10 In one case the only information on a service user’s needs was a standard checklist recording very basic general needs, which had been ticked where there was a perceived need. There was no evidence that service users or their representatives had been consulted during the assessment process. There is no information for staff on how to meet the needs of these individuals. Service user plans have not been reviewed monthly. Changes in need have not been recorded. In one case a service user plan indicated that a service user was much more independent than they actually are. Only one of the six files examined had a risk assessment in place and this was dated 2001 and had not been reviewed. Only one service user plan seen had been signed by the service user as a record of their agreement in 2001. There was no evidence that the service user had been consulted about their plan since this time. There has been no formal staff induction, training, meetings or supervision organised. The Manager reported that informal discussions took place. These were not recorded. The Inspection Team saw no evidence to suggest that staff were offered appropriate support, supervision, written information or practical guidance on how to meet service users needs or ensure their health and well being. Refer to Requirements 1, 2, 3, 8, 9 REDCOTTS Version 1.10 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 standard(s) 7, 8, 9 & 10 One standard is met, two standards have minor shortfalls, and one standard has major shortfalls. There is insufficient information on meetings service users needs. Some of the information is inaccurate and has not been subject to regular review. Service users are not appropriately consulted about the care. The lack of even basic information in respect of some service users puts their health and welfare at risk. Service users have access to health care professionals and staff respond appropriately to accidents. However risk assessments are either not in place or are old and do not reflect current needs. This places service users at risk of harm. The Inspectors were informed of and witnessed practices that did not show due respect to the privacy, dignity and respect of service users. The home has arrangements for the safe ordering, storage and administration of medication and has access to a pharmacist for advice. The majority of service users are administered their medication correctly. Omissions in recording of medication and in assessment and reviews of service users who are self-medicating were found that made it difficult to audit the use of medication and potentially putting service users health and welfare at risk. REDCOTTS Version 1.10 Page 12 EVIDENCE: The Lead Inspector examined six records relating to service users. No service user plan was in place for three of these service users. Two service user plans had been written in 2001. One of these had been reviewed in July 2002 but not since. National Minimum Standards state that service user plans must be reviewed monthly. Two of the three service user plans seen had not been checked since October 2004. Changes in need are not recorded and one service user plan indicated that a service user was more independent and able to care for them self much than they actually are. Only one service user plan had been signed by the service user and this was in 2001. There was no evidence of consultation with them about their plan since this time. Service user plans did not contain photographs of service users. There was no evidence of accurate and up to date information on how to meet these service user’s individual needs. Only one of the files examined contained a risk assessment and this was dated 2001 and had not been reviewed. Daily care notes made by staff were very basic. In one service user file the notes each day only referred to the personal care given to that service user. In another file daily notes only stated that the service user was ‘fine’ or ‘ok’. Service user plans examined indicated that service users did have regular access to health care professionals, and there was a record of medical consultation, including recent dental and chiropody appointments for all six service users. There is a record of accidents at the home. These indicate that staff have taken appropriate action following accidents and injuries, including the involvement of medical services when required. A hairdresser visits the home each week. The Inspectors were told that the hairdresser based herself in one service user’s bedroom. This practice is unacceptable and service users’ bedrooms must not be used by other service users. The Inspection Team recognises that space is at a premium in the home, however, alternative arrangements must be made to ensure that service user’s privacy and dignity are maintained. The Inspection Team observed a member of staff using a vacuum cleaner in a room where a service user was eating their midday meal. This practice is unacceptable and must cease. REDCOTTS Version 1.10 Page 13 All medications in the office and in two service users’ rooms along with the records relating to receipt, storage, administration and disposal of medication were examined. The Manager and two service users were interviewed. All medication was stored securely and under the correct storage conditions. Arrangements were seen to record the receipt, administration and disposal of medication. Three service users were self-medicating on the day of inspection. No detailed assessments or reviews are in place for service users self-administering their medication. One service user who is self-medicating is registered blind and unable to read the medication labels. The service user plan did not detail any special consideration regarding self-medication for this person. The allergy section on the administration record was only completed for one service user. The dosage directions on hand-written entries on the administration record were not written fully in words for one service user. Three service users did not have the actual quantity of medication given recorded for items prescribed with a variable dose. The quantity of medication in stock did not match with the record of receipt and administration for three service users with items not supplied in the monitored dosage system. The Manager stated that this was due to medication being carried over from the previous month. No documentary evidence was seen to substantiate this. No records were seen when extra medication had been used from the monitored dosage system for two service users. Refer to Requirements 2 – 6. REDCOTTS Version 1.10 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 standard(s) 12, 14 & 15 One standard had a major shortfall and two standards had minor shortfalls. There are very limited planned activities and no evidence that ad hoc activities are sufficient. There was an almost total lack of interactions between staff and service users. This is a serious concern and the Inspectors feel that service users are not given appropriate support and stimulation to meet their social, emotion and leisure needs. Food is generally well prepared and tasty. However, service users are not given a choice at meal times and are not aware of the menu choices that are reportedly available. There is no fresh fruit available for service users to help themselves. The service is denying service users their basic right to make choices about the food that they eat and the activities they participate in. Service users are not consulted about the running of the home. EVIDENCE: There is no Activities Officer at the home and there is no planned programme of activities. A weekly keep fit class is organised. There are no other planned activities. The Manager reported that activities do take place however records of activities are periodic and vague. Records of activities from December to REDCOTTS Version 1.10 Page 15 April were examined and only one specific activity, a sherry afternoon, was recorded. There was reference to occasional quizzes, a singing session and conversations. However, these records did not indicate the date, time, duration, who attended and the enjoyment of any of these events. Throughout the inspection, service users spent their time either in their rooms or the main lounge. Staff did not spend time with service users and the Inspection Team did not see any activity provision or any conversations between staff and service users. On a number of occasions, during this and previous inspections, the Inspection Team observed long periods of time where several members of staff were together in areas of the house away from service users. Whilst the Inspection Team acknowledges that staff should be able to socialise with each other during their breaks, should they wish, they should prioritise supporting service users. The lack of interactions between staff and service users was a serious concern and the Inspectors feel that service users are not given appropriate support and stimulation to meet their social, emotion and leisure needs. One service user told the Inspection Team that there had been no planned activities over Christmas apart from Christmas Dinner. No activities have been recorded. There are no service user meetings, there is no quality assurance procedure in place and there is no evidence that service users are consulted about any aspect of the home, whether this be the quality of service delivery or the planning and participation of the day to day running of the home. Service users are not given sufficient information on the service, including activities, food and staffing. There is a three week rolling menu. Service users reported that food was generally well prepared and tasty. However, one concern raised at the announced inspection in July 2004 was that fresh fruit was not made available to service users. This was discussed with the Manager at the time and a requirement made. Service users reported that this situation has not changed and fruit is still not available. The menu on display in the dining room showed the wrong week. This menu is handwritten and service users reported that they find it difficult to read, unclear and positioned wrongly. The menu indicated that a choice was available at each meal. The Cook reported that only the first choice was generally made but that service users could request the second choice or it was made if it was known that they did not like the first choice. However, as the menu on display was inaccurate, and service users find it difficult to read, the reality of this choice is questionable. In addition, the Cook reported that the actual dish being prepared for lunch was being made from beef instead of chicken as the menu indicated, because chicken was not available. Service users had not been made aware of this change and therefore could not make REDCOTTS Version 1.10 Page 16 an informed choice about whether they wanted this. The Lead Inspector met one service user who was going to the dining room for their lunch and asked them what they were having for lunch. They replied that they did not know and never knew what they would be having. Refer to Requirements 7 – 11. REDCOTTS Version 1.10 Page 17 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 standard(s) 16, 17 & 18 One standard had a minor shortfall, two standards had major shortfalls. Complaints are not adequately investigated and action to minimise the risks of reoccurrence of the events leading to a recent complaint was inadequate. Service users do not have access to advocacy services and may have been denied their right to vote at elections. The service does not adequately protect service users from harm or abuse. Appropriate checks have not been made on staff and they have not received information or training on recognising and reporting abuse. EVIDENCE: There is an appropriate complaints procedure. One complaint has been made since the last inspection. The Manager had not produced a report on the complaint, investigations or findings. There was no evidence of any investigation or interviews made in relation to the complaint. The complaint relates to the financial abuse of a service user. There was no evidence that appropriate action had been taken to minimise the risks of reoccurrence, apart from the advice to relatives of service users to remove items of value. One service user who had lived at the home for several years reported that they had never been given their polling card at elections. The Manager and Registered Person reported that all service users were registered to vote. It is REDCOTTS Version 1.10 Page 18 the responsibility of the Registered Persons to ensure that all service users who are eligible to vote are included on the electoral register and are given their polling cards as soon as the home is in receipt of these. Any person responsible for preventing a service user who wishes to vote from doing so is committing an offence and is denying that person one of their basic rights of citizenship. The service does not liaise with any advocacy groups and service users are not given information on how to access local advocacy services. Information on the service user notice board is old and out of date. The home has adopted that London Borough of Richmond Protection of Vulnerable Adults Procedure and has its own procedures on abuse and whistle blowing. There is no evidence that these procedures have been discussed with staff. Staff have not had training on recognising and reporting abuse. The Registered Person reported that one member of staff had a current criminal record check (CRB) and that four staff had been referred for these checks. Evidence to support this was not seen. No other staff have been referred for these checks. Two staff have been employed since the last inspection without sufficient reference or criminal record checks. Refer to Requirements 12 - 15. REDCOTTS Version 1.10 Page 19 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 standard(s) 19, 20, 21, 23, 24, 25 & 26 Two standards were met, four standards had minor shortfalls and one standard had major shortfalls. The building meets National Minimum Standards size requirements and the layout is appropriate for its purpose. However, the Registered Person has shown no regard the maintenance needs of the home. Requirements made at previous inspections and assurances by the Registered Person regarding maintenance work have not been met and no action has been taken to address even minor repair needs since the last inspection. Service users are not provided with a safe, comfortable environment. EVIDENCE: REDCOTTS Version 1.10 Page 20 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. Areas of maintenance identified at the last two inspections have not been attended to. In particular areas of paintwork and woodwork throughout the home are showing wear and tear, uneven paving in the garden presented a risk to health and safety and paint and putty splattered on window pains, which had been painted some time ago had not been removed. The flooring in one bathroom was damaged and presented a risk to those using the room. In addition the carpets in corridors and the stairs are worn and some furniture in communal areas required replacement. The front path to the home is uneven and presents a risk to service users. In January, one service user fell because the light cord pull that they were using broke away from the socket. The light fitting was clearly faulty and the service user was put at unnecessary risk. The Lead Inspector found that the light cord pull which had caused the fall was still lying on the bathroom floor and the light was permanently illuminated, four months after the accident happened. In July 2004, one service user raised concerns that their curtains had not been cleaned in several years and that they were bulky and in need of repair. This was discussed with the Manager at the time and again in November 2004. Requirements were made at both inspections. The service user raised this concern with the Registered Person when he visited the home on the 18th February 2005. The Registered Person wrote in his report of that visit that he had ‘assured’ the service user that the curtains would be replaced in two weeks. The curtains remained at this inspection visit and no action had been taken to either clean or replace them. The bath in one bathroom, which is reportedly not used, was stained and encrusted dirt, soap and hair were seen around the plughole. Another bathroom cannot be used because of the uneven and damaged floor. There were no paper towels in two of the WCs. Radiators and pipe work at the home are temperatures. The Registered Person must in respect of this and take appropriate minimised. Recorded checks on hot water and must be reinstated. exposed and are not low surface produce a written risk assessment action to ensure that risks are temperatures ceased in July 2004 REDCOTTS Version 1.10 Page 21 There is a large lounge and a separate dining room at the home available for service users. These are appropriately furnished and equipped. Current arrangements are that service users who smoke may do so in the hallway. Staff are allocated a room in which they can smoke. The smoke from service users smoking in the hallway drifts through the home into all areas. No action has been taken to offer an alternative place for service users to smoke despite this issue being raised at two previous inspection visits. The Manager must consider alternative arrangements to accommodate service users who smoke so that smoke is not free to drift throughout the non-smoking areas of the home. In July 2004, two service users raised a concern that staff smoked in the kitchen. This was discussed with the Manager who assured the Inspector that such practice was not permissible and action would be taken against staff member who did this. When the Registered Person visited the home on 18th February 2004 service users again raised this concern with him. His report of the conversation does not indicate what action he proposed to take or even that he found the practice unacceptable. This blatant disregard for the health and well-being of service users by staff and by the Registered Persons who have both been made aware of this practice is a serious concern. Immediate action must be taken to ensure that staff do not smoke in the kitchen. Refer to Requirements 16 – 20. REDCOTTS Version 1.10 Page 22 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30 One standard was met. Three standards had major shortfalls. Service users are put at risk by unsafe recruitment and selection procedures, and inadequate training and support for staff. Staff are not given appropriate instruction, supervision or support to undertake their duties. EVIDENCE: Staff are employed in sufficient number and there is a large team of full and part time workers. Two staff have been recruited since the last inspection. The records for these staff were examined. Both job application forms were basic and did not give sufficient information regarding the staff member’s ability to perform the role. One staff member had not signed their application form. There was no record of interviews and no evidence to suggest how these staff were found to be suitable for the post which they have both been appointed to. One application form did not give any named referees. There was one written reference in place for one member of staff, written by their friend. The references for the other member of staff were standard references supplied ‘to whom it may concern’ and had not been specifically requested by the home in respect of the post applied for. There were no photographs of the staff. There was no proof of identification for either staff member. No application for criminal record checks had been made for either staff member. REDCOTTS Version 1.10 Page 23 One member of staff is undertaking NVQ Level 2. No members of staff have achieved this qualification and there were no plans to support staff to undertake the qualification in the near future. There is no system for formal supervision or appraisal of staff and individual supervision meetings do not take place. There are no formal staff meetings. The Manager reported that there is a good system of informal support. No discussions around policy or procedures take place. There was no evidence that staff had undertaken any formal induction to their roles. Staff on duty reported that there had been no training organised since the last inspection. There were no training records. The Manager reported that fire training had been organised for some staff shortly after the inspection. Refer to Requirements 21 - 23 REDCOTTS Version 1.10 Page 24 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 35, 36, 37, 38 Five standards have major shortfalls and one standard has minor shortfalls. The service is not managed in a way which ensures the health and well being of service users. Staff are not appropriately trained and supported to undertake their duties. Records required by Regulation are not in place nor are they appropriately maintained and updated where they do exist. Service users are not consulted with and concerns that they raise are not acted upon. Appropriate checks and assessments of risk have not been made on the environment. EVIDENCE: The Manager reported that she has resigned from her post and is due to leave in May 2005. The Registered Person confirmed this. The position of Manager must be recruited to. Arrangements must be made to ensure that the home is managed effectively until this time. The Registered Person must write to the REDCOTTS Version 1.10 Page 25 Commission for Social Care Inspection outlining the arrangements for the management of the home. The Registered Person is required by Regulation 26 to conduct unannounced inspections of the service on a monthly basis and produce a report of his findings. Copies of these reports must be forwarded to the Commission for Social Care Inspection. The Manager told the Lead Inspector that two reports had been made, one for December 2004 and one for February 2005. Neither of these reports was forwarded to the Commission for Social Care Inspection. The Lead Inspector was able to examine both reports at the inspection. The content of the report is insufficient to demonstrate that a quality inspection of the service took place. When he met with the Commission for Social Care Inspection, the Registered Person claimed that he was not aware that the service had so many outstanding requirements. It is his legal responsibility to be aware of and take action to remedy concerns raised by the Commission for Social Care Inspection. Moreover, if he had been conducting the monthly inspections appropriately he would have been fully aware that there are serious areas of concern about practices and procedures at the home. The report from his visit in February 2005, outlines concerns raised by a service user about staff smoking in the kitchen and also about faulty curtains. No action has been taken to remedy either concern. His report on the inspection of the premise, does not refer to the condition of the building, but states that service users were sitting in the lounge. Comments regarding discussions with staff are not in respect of their support, training, supervision or about their role. In one report his only comments on staffing are that one member of staff said that they liked most of the other staff, all of the service users and the food. Neither report refers to an examination of any records, observations of practice, checks of medication, health and safety or the environment. Had his inspections done this would have been aware that there were deficits in the service. There is no quality assurance policy in place and service users have no forum for consultation. One service user told the Inspector that they were not able to speak with Management and that when they did raise concerns no action was taken. An example of this was clearly evidenced from the discussions that one service user had with the Registered Person during his visit in February 2005. Small amounts of money are held on behalf of service users if they require this service. This money is used for small purchases and hairdressing. The Inspector examined records relating to these. The Manager reported that the balance for one service user’s money was incorrect. This was rectified by the Manager during the inspection. However, the Inspector found that another balance was also incorrect. In addition records did not accurately reflect what had happened to service users’ money when they had left the service. In REDCOTTS Version 1.10 Page 26 some cases indicating that the home still held money for service users who no longer lived at the home. Portable electric heaters were seen in bedrooms. No risk assessments have been made in respect of these, despite discussions about this with the Manager at previous inspections. No window restricting devices are in place in the home. No risk assessments have been made in respect of this. This issue and the potential dangers for service users have been discussed at the previous two inspections. Fire doors were seen to be wedged open in a manner which would prevent them from closing in a fire. The Inspector recognises that heavy fire doors can be difficult for some service users to operate. However, these doors could be equipped with devices that can hold them safely open. This has been discussed at the previous two inspections. A record of all accidents is maintained. However, the Commission for Social Care Inspection has not been notified of accidents in accordance with Regulation 37. This has been discussed at previous inspections. There has been no recorded checks on hot water delivery temperatures since July 2004. Staff have not made any checks on fire equipment since October 2004. There have been no recorded checks on first aid supplies. Dressings prescribed to a service user who no longer lives at the home were found in the first aid supplies. There has been no recorded checks on electrical wiring. The Registered Person reported that a check had been made but recommended actions arising from the check had not been met. Records required by Regulation for service users, staff and health and safety were not in place. Staff do not receive any formal induction, have not undertaken required training and do not have group or individual meetings with their Manager. Refer to Requirement 24 – 30. REDCOTTS Version 1.10 Page 27 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 1 1 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 x 14 2 15 2 COMPLAINTS AND PROTECTION 1 2 2 2 3 3 x 2 STAFFING Standard No Score 27 3 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 1 1 1 x 1 x 2 1 1 1 REDCOTTS Version 1.10 Page 28 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. OP3 14 The Registered Person must ensure that, in consultation with the service user and their representatives, a thorough and detailed assessment of need is made on all service users prior to admission. This must be recorded. The Registered Person must: 1. In consultation with the service user, develop a service user plan, which details individual needs, for all service users. 2. Ensure that monthly reviews are conducted on all service user plans and that changes in need are appropriately recorded. 3. Obtain a photograph of each service user to be included within the service user plan. (Previous requirement made 03/11/04) REDCOTTS Version 1.10 Page 29 Standard Regulation Requirement Timescale for action 30/04/05 2. OP4 OP7 12(1), (2) & (3) 15(1) 17(1)(a), Schedule 3(1) & (2) 30/04/05 30/04/05 31/05/05 3. OP4 OP7 13(4) & (6) The Registered Person must ensure that accurate assessments of risk are in place for all service users. These must be subject to regular recorded review. The Registered Person must: 1. Ensure that an investigation is completed into why the amount of medication in stock does not match with the current records. 08/04/05 30/04/05 4. OP9 13(2) 2. Ensure that the quantity of 08/04/05 medication carried over from one month to another is recorded on the current administration records to provide a clear audit trail of medication. 3. Ensure that the actual quantity of medication given is recorded on the administration record. 4. Ensure that all service users self-administering medication have an appropriate detailed assessment and review. 5. Ensure that the allergy section on the administration record is completed for all service users. 6. Ensure that an appropriate record is made when extra medication from the monitored dosage system is used. (Previous requirement made 03/11/04) 5. REDCOTTS Version 1.10 Page 30 08/04/05 09/05/05 09/05/05 09/05/04 OP10 12(1), (2), (3) & (4)(a) The Registered Person must ensure that service users’ bedrooms are not used as a room for communal hairdressing appointments. The Registered Person must ensure that staff treat service users with respect, dignity and must maintain their privacy. The Registered Person must ensure that there is a full programme of activities organised in advance, with information available to service users. This programme must be kept under regular review and should be designed in consultation with service users. Records of activities should include information on each activity and the levels of participation and enjoyment. (Previous requirement made 03/11/04 and 14/07/04) 18/04/05 6. OP10 12(1), (2), (3) & (4)(a) 16(2)(m) & (n) 18/04/05 7. OP12 31/07/05 8. OP14 OP4 12(1), (2), (3) The Registered Person must 30/04/05 ensure that service users are appropriately consulted about the service and are supported to make informed choices about the service and their own lives. 30/04/05 9. OP14 OP4 12(1), The Registered Person must (2), (3) ensure that staff promote, and (5)(b) initiate and sustain positive interactions with service users and that their intellectual, emotional and social needs are met. The Registered Person must gain regular feedback from service users in respect of this. (Previous requirement made 14/07/04) REDCOTTS Version 1.10 Page 31 10. OP15 16(2)(i) The Registered Person must 30/04/05 ensure that fresh fruit is available for service users to help them selves after meals and as a snack. (Previous requirement made 14/07/04) 11. OP15 12(2) & (3) 17(2) Schedule 4 (13) The Registered Person must: 1. Ensure that menus are accurate and accessible to service users. 2. Ensure that service users are able to make informed choices about their food. 12. OP16 22(3) & (5) The Registered Person must ensure that all complaints are fully investigated. This must be evidenced. The Registered Person must ensure that service users are registered to vote and that they are given their polling cards. The Registered Person must ensure that all staff are trained in recognising and reporting abuse. (Previous requirement made 03/11/04) 15. OP18 OP24 13(4) & (6) The Registered Person must ensure that criminal record checks have been made on all staff. (Previous requirement made 14/07/04 & 03/11/04) 16. OP19 REDCOTTS 30/04/05 30/04/05 30/04/05 13. OP17 12(1) 30/04/05 14. OP18 13(4) & (6) 18(1)(c) 30/09/05 31/05/05 13(4) & The Registered Person must: Version 1.10 Page 32 (6) OP21 23(2)(b) & (d) 1. Ensure that all maintenance needs identified at inspection and summarised in this report are attended to. 2. Ensure that 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) 17. OP25 13(4) & (6) The Registered Person must: 1. Assess the risk of uncovered radiators and pipe work. This assessment must be recorded and appropriate action taken to minimise the risk of scalding. 2. Ensure that recorded checks on hot water delivery temperatures are made. (Previous requirement made 14/07/04 & 03/11/04) 18. OP20 12(1)(a) 13(4) & (6) The Registered Person must make suitable arrangements so that the area allocated for service users to smoke in does not result in smoke drifting into non-smoking areas of the home. (Previous requirement made 14/07/04) 19. OP20 12(1)(a) 13(4) & (6) The Registered Person must 30/04/05 ensure that staff do not smoke in the kitchen and appropriate disciplinary action is taken against any staff member found doing so. The Registered Person must Version 1.10 30/06/05 30/06/05 30/04/05 30/04/05 30/04/05 20. OP26 REDCOTTS 13(3) 30/04/05 Page 33 ensure that WCs are equipped with a supply of paper towels. 21. OP28 22. OP29 19(1) Schedule 2 The Registered Person must ensure that: 1. Criminal record checks and two written references are in place for all staff before they commence employment. 2. Staff records are complete. 30/04/05 18(1)(a) The Registered Person must support staff to undertake and achieve NVQ Level 2 or above. 30/03/06 30/06/05 (Previous requirement made 14/07/04 & 03/11/04) 23. OP30 18(1)(a) & (c) The Registered Person must 1. Ensure that staff are appropriately trained in first aid, food hygiene, abuse, health and safety and fire safety. 2. Ensure that training records are appropriately maintained for all staff. (Previous requirement made 14/07/04 & 03/11/04) 24. OP31 8 9 The Registered Person must recruit a suitably qualified and experienced individual to manage the home. The Registered Person must write to the Commission for Social Care Inspection outlining the arrangement for the management of the home until the post of Manager is recruited to. 25. OP33 REDCOTTS 30/09/05 30/04/05 31/07/05 30/04/05 12(2), (3) The Registered Person must Version 1.10 31/10/05 Page 34 & (5)24 implement a quality assurance programme that enables consultation with service users and other stakeholders. (Previous requirement made 14/07/04 & 03/11/04) 26. OP33 26 The Registered Person must visit 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) 27. OP35 17(2) Schedule 4 (9) The Registered Person must ensure that records accurately reflect the balance and transactions of money held on behalf of service users. The Registered Person must ensure that: 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) 29. OP38 13(4) & (6) The Registered Person must: 1. Cease the practice of wedging open fire doors. Consult with the Fire Officer about fire safety at the home. 2. REDCOTTS 30/04/05 30/04/05 28. OP36 12(5)(a) 18(2) 31/05/05 31/05/05 30/04/05 Ensure that first aid Version 1.10 30/04/05 Page 35 supplies are appropriate and are subject to monthly checks. 3. Make and record a full assessment of risk on the use of portable heaters. 4. Ensure that electrical wiring is appropriately checked and actions from this check are implemented. 5. Make a recorded risk assessment on windows at the home and equip windows with restricting devices where there is an identified risk. (Previous requirement made 14/07/04 & 03/11/04) 30. OP38 37 The Registered Person must ensure that the Commission for Social Care Inspection is appropriately notified in accordance with Regulation 37. 30/04/05 30/04/05 31/05/05 30/06/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. OP9 1. It is recommended that there is a record of sample initials of all staff administering medication. 2. It is recommended that a controlled drug be available for the storage of controlled drugs. 3. It is recommended that the dosage instructions be written fully in words for medications written on the administration record. Refer to Standard Good Practice Recommendations REDCOTTS Version 1.10 Page 36 Commission for Social Care Inspection South West London 41-47 Hartfield Road Wimbledon SW19 3RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI REDCOTTS Version 1.10 Page 37 - 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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