Inspection on 18/08/06 for Redfern

This inspection was carried out on 18th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Redfern 18/01/08

Redfern 20/11/06

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Redfern 6 St Vincent Terrace Redcar TS10 1QL Lead Inspector Joanna White Key Unannounced Inspection 18th August 2006 11:20 Redfern DS0000066806.V308152.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Redfern DS0000066806.V308152.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Redfern DS0000066806.V308152.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Redfern Address 6 St Vincent Terrace Redcar TS10 1QL 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) 01642 487766 F/P 01642 487766 Milewood Healthcare Limited Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Redfern DS0000066806.V308152.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Accommodation to be provided for a named individual over the age category of 65 plus. First Inspection Date of last inspection Brief Description of the Service: Redfern is a terraced house situated in a quiet residential street in Redcar and is indistinguishable from other homes in the vicinity. The home is registered by The Commission for Social Care Inspection to provide accommodation for up to seven service users who have a learning disability. There are seven bedrooms all of which have en suites. Communal facilities comprise a dining room and sitting room. Externally there is a small front garden to the property and a large yard to the rear, which has been made into a courtyard style garden with a seating area. The property is near to local train and bus networks. Redfern DS0000066806.V308152.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a key inspection and was unannounced on the first inspection day. There were six visits to the home by two inspectors, which took place on 18th August 2006 commencing at 11.20 am and concluding at 1.10pm, the 23rd August 2006 commencing at 10.45 am and concluding at 2.25pm the 31st August commencing at 8.45 am and concluding at 4.50pm, the 13th September commencing at 1.00pm and concluding at 2.10pm am, the 21st September commencing at 11.25am and concluding at 11.45 am and a final visit on 25th September commencing at 3.45pm and concluding at 5.25pm. All of the key standards were examined during the inspection. Three of the resident’s files, all of the staff files, including recruitment and selection, and the homes medication records, health and safety records, and policies and procedures, were examined during the inspection. A tour of the home also took place. In addition a pre-inspection Questionnaire, which the previous manager had completed, was also provided. The inspectors spent time with two of the residents finding out what it was like for them to live in Redfern. The staff also participated in discussion with the inspectors about what life was like for the residents in the home. There was much discussion throughout the inspection with the Operations Manager. Redfern’s deputy manager and the deputy manager from another home in the Milewood Healthcare Ltd., who was providing additional staff cover, also provided extra information. The manager informed the inspectors that the charges for residents’ care and accommodation were £1389.81 per week. £13.13 per hour was charged for any resident who required additional one to one support. The pre inspection questionnaire confirmed extra charges were made for toiletries, clothes etc. What the service does well: The residents can choose the décor and furnishings for their bedrooms, which is in line with Milewood’s policy to encourage the residents to exercise choice and to make decisions about issues affecting their lives. Redfern DS0000066806.V308152.R01.S.doc Version 5.2 Page 6 One resident said ‘ I chose my bedroom I really like the furniture and these are all of my pictures on the wall’ Another resident said ‘My bedroom is great I have been able to get everything in look at my en suite I can choose what I like’ The front garden is well maintained and flowers provide a welcome to staff visitors and the residents. One resident said ‘ the flowers are lovely ‘ The back courtyard area has been developed and now includes a seating area. There are plans to develop raised flowerbeds. The home is near to local shops. One resident said ‘this is a great place to live near the sea but also very near to the shops I like it here’ One member of staff said ‘this is the only job that I have ever looked forward to’. What has improved since the last inspection? What they could do better: Residents should not be admitted until their needs have been fully assessed. A written care plan should be completed detailing how resident’s health and welfare needs are going to be met. The care plan should be reviewed and the resident informed. The policies procedures and practices for the recording, handling, safekeeping, safe administration and disposal of all medicines received into the care home should be reviewed and updated. The complaints procedure should be reviewed and updated to contain the correct contact details. The protection of vulnerable adults procedure should be reviewed and updated to contain the local contact details. Staff who are on duty must at all times be suitably qualified, competent and experienced to meet the residents needs. Redfern DS0000066806.V308152.R01.S.doc Version 5.2 Page 7 The recruitment and selection procedures should be updated and robust. The registered person must ensure that their staff training and development programme meets Sector Skills Council workforce training targets. A suitably qualified person must be appointed to manage the care home. Reports of any quality assurance or quality monitoring activity that takes place within the home should be provided. 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. Redfern DS0000066806.V308152.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Redfern DS0000066806.V308152.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is Poor. This judgement has been made from evidence gathered before and during a visit to this service. A comprehensive assessment of the resident’s aspirations and their complex needs is not completed and recorded prior to their admission to the home. EVIDENCE: Redfern had a comprehensive statement of purpose and admission procedure, which stated that support would be provided from a trained staff team. An examination of three residents’ files revealed they had a variety of complex needs, which included learning / physical disability, mental health/ severe behavioural problems and drug / alcohol related issues and identified a need for “ mental health training. …And an understanding of working with people with a learning disability and severe personality disorder’” Redfern DS0000066806.V308152.R01.S.doc Version 5.2 Page 10 Assessments supplied by the placing authorities Care Manager provided the majority of background information about the residents. The pre admission assessments/admission forms, which had been completed by the home, contained only limited information. One file failed to record the needs of the resident or how those needs would be met. In addition there were no details about the residents learning disability despite the home being registered for adults with learning disabilities. References were also made to episodes of physical and verbal aggression but there were no strategies in place outlining how these should be dealt with. There was also no recorded evidence that the original assessments for one resident had been reviewed or updated as their needs changed although the operations manager was able to give examples of the work which had taken place on a multi agency basis which had included attending meeting, visits to the home by the key worker, telephone calls, discussions with the resident etc. Discussions with the staff confirmed that whilst they were all committed in their roles and saw the service users as their priority they had limited experience in caring for residents with complex needs. They stated the training had only provided basic information to equip and help them to understand the particular needs of the current residents in the home. One member of staff said “ I am petrified I do my best –frightened it will come back on me I am very worried” Redfern DS0000066806.V308152.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is Adequate. This judgement has been made from evidence gathered before and during a visit to this service. Residents assessed, changing needs and personal goals are not reflected in their care plans. Residents make decisions about their lives. The staff provide support when necessary. The residents live individual lifestyles and are supported to make appropriate decisions. EVIDENCE: Discussion with the operations manager confirmed comprehensive assessment information about the residents was not present in their files and their changing needs were not reflected in their care plans. She acknowledged that there was a need for further development and confirmed a review of all care planning documentation was taking place to clarify what information should be available. Redfern DS0000066806.V308152.R01.S.doc Version 5.2 Page 12 Each care plan included a detailed risk assessment but there was evidence that when changes were made for example one care plan said “1-1 time with support before and after accessing the community should be provided” the documentation recorded that a reduction in support had occurred, but there was no documentary evidence to support why this decision had been made. Another residents risk assessment stated they should have 2-1 support. The inspectors were informed a decision was made that the level of support should be reduced to 1-1.The operations manager confirmed this decision had been made following consultation with the other professionals involved but again there was no written explanation available to support the decision-making. This lack of updating of the risk assessments also led to confusion for staff members in terms of what level of service they were offering. A member of staff said “the support should be 2-1 where is the re assessment for one to one” Staff who spoke to the inspectors said they were aware of Care plans and risk assessments. One member of staff said “ I read the risk assessment before the resident came into Redfern so I knew what to expect, I complete the daily report sheet every day for the care plan - communication is part of this” Another member of staff confirmed that they were a key worker for one of the residents. The resident said “ I have a key worker who takes me out and I can talk to her in the home” The staff informed the inspectors that the residents participated in activities to promote their independence. The residents spent time in the kitchen where they made cups of coffee and snacks and helped cook the meals. One of the residents was observed hoovering and with staff support, cleaning his/her en suite bathroom. Another resident told the inspector “I go shopping with staff and I am enrolled for classes at the local college. I also make cards and sew and go to craft classes at the local centre.” Appropriate risk assessments for these activities were available in the care plans. The operational manager said there were plans for residents meetings to commence as soon as there were more residents in the home. The records also evidenced that the residents were seen by the home as individuals in their own right who were able to make decisions about areas of their life, which were important to them such as, relationships, personal finances, community participation, leisure, work, education, and support. One resident said ‘ I am looking forward to going on holiday with a friend and a member of staff ‘ Redfern DS0000066806.V308152.R01.S.doc Version 5.2 Page 13 The staff said they respected the privacy, dignity, and rights of the residents and explained they always knocked on the door of residents before they entered their rooms. There was an awareness of gender issues. The inspectors also observed members of staff asking the residents their opinions about where they would like to go when they went out. One member of staff said ”It is important to promote the residents self esteem and make them feel good about themselves” Redfern DS0000066806.V308152.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,and 17 The quality outcome in this area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Staff help the residents to continue their education or training and take part in valued and fulfilling activities. Staff support the residents to become part of and participate in the local community in accordance with their assessed needs and Individual Plans. Residents have opportunities to develop appropriate personal family and sexual relationships. Staff ensure the daily routines and house rules promote independence individual choice and freedom of movement. The residents have a varied diet, which meets their nutritional requirements. Redfern DS0000066806.V308152.R01.S.doc Version 5.2 Page 15 EVIDENCE: The pre inspection questionnaire confirmed the residents within Redfern were involved in watching television and DVD’s and videos, playing bingo and board games, attending keep fit and literacy and participating in sport. The staff informed the inspectors the residents when they went out visited Eston Leisure Centre, the library, the local Methodist church, Redcar shops banks and building societies, day services, night classes, the cinema, restaurants, pubs, and social clubs. One member of staff who spoke to the inspectors said in addition they took the residents to bingo, for daily walks and played dominoes. The residents also enjoyed listening to the radio and one resident liked knitting and sewing. A resident said, “Look at that picture it is a tapestry I did it” Staff commented, “isn’t it good? We are really happy and proud for the resident we can put it on the wall” The freedom of movement of the residents was observed both within and outside of the home. One resident said, “I like it here I can go out easily and I am soon at the shops” Staff were observed offering support before accompanying a resident to go out. They offered re- assurance and said ‘we will be going out in 20 minutes time.” Due to the home being recently opened there was limited information available about the views of the community or community links with the home. On one of the inspection days a social worker and a perspective new resident were observed to be visiting. The operational manager confirmed that relative’s friends and professionals were very welcome to visit the home and stay for their meals. Staff were observed respecting the privacy and dignity of the residents, by seeking permission before entering their bedrooms and bathrooms. The residents could exercise choice in respect of whether or not they wanted to remain in their room or be in company. One resident said, “ I choose to spend time in my room at night watching videos” On one day of the inspection a resident was observed sitting in the courtyard. During another visit a resident was sitting in the lounge watching television. The inspectors also observed the staff interacting positively with the residents asking, “Are you ok?” “Do you need any help? We will be going out soon” Redfern DS0000066806.V308152.R01.S.doc Version 5.2 Page 16 A one-week menu was examined during the inspection which demonstrated that meals were offered three times daily including at least one cooked meal and a range of drinks and snacks to meet individual needs were available at all times. Staff confirmed that meal times were relaxed unrushed and flexible to suit the resident’s activities and schedules. One care plan examined confirmed that meals were prepared to meet the wishes of the resident. Fresh fruit and vegetables were also available for the residents in the home. Redfern DS0000066806.V308152.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,and 20 The quality outcome in this area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Staff meet the residents healthcare and personal needs in a sensitive and flexible manner in accordance with the wishes of the individual resident. The residents’ physical and emotional needs are generally met. The homes medication policies and procedures are not as robust as required and need further review and development to ensure safe and effective systems are in place. EVIDENCE: The inspectors observed that personal support was carried out, in private by a person of the same gender. Staff who were spoken to confirmed that they respected the wishes views and feelings of the resident and would ensure at all times a person of the same gender was on duty. Redfern DS0000066806.V308152.R01.S.doc Version 5.2 Page 18 The resident’s preferences about how they were guided moved, supported and transferred were also complied with. In one care plan there was evidence of an Occupational therapist’s assessment “The Occupational Therapist has negotiated that removable aluminium /metal wheel chair runners will be purchased by the home. ” Times for going to bed were flexible. One resident in their care plan had agreed, “I will go to bed at 11 pm and no later than midnight at weekends”. The staff confirmed they encouraged the residents to choose their own clothes, hairstyle and make up to ensure they reflected their individual personalities. One resident said, “ Do you like my outfit I bought it for my holiday” The staff said they were just starting to get to know the residents. The operations manager explained that planned mental health training would assist the staff to have more insight into the emotional needs of the residents and ensure consistency of care was provided. Records confirmed the residents had contact with GP’s, Psychologists, Consultant Psychiatrist, Optician, Occupational Therapist, Community Psychiatric Nurse and the Assertive Outreach Team. Support was provided by the home to ensure that all health appointments were attended. The homes policies and procedures confirmed, “ We take a positive approach to our client’s health and will encourage regular Dental, Optical, and General Medical surveillance as well as the immediate treatment of illness and accidents” The deputy manager stated that none of the residents administered their own medication. The homes medication policies and procedures were examined and did not provide sufficient detail in terms of receipt, storage, handling, administration, and disposal of medication. No separate record for controlled drugs receipt, administration and disposal was available. The situation was discussed with the deputy manager who confirmed the matter would be addressed as a matter of urgency. During a subsequent visit to the home the operations manager said that a separate recording process for controlled drugs had been introduced. The medication administration records were examined but did not contain a photograph of the resident. The signature of the member of staff administering the medication was present. Redfern DS0000066806.V308152.R01.S.doc Version 5.2 Page 19 There was evidence that at each staff handover medication was audited. The deputy manager said medication must be “ physically checked to ensure that there are no errors /discrepancies before the shift leave” The operations manager added further tools were being developed for the managers to monitor staff implementing the homes medication policies and procedures. A copy of the homes competence assessment, medication training declaration record was shared with the inspectors but there was only one which was completed and present on a staff file. Discussions with the staff revealed that they had all undertaken two days medication training. The operations manager confirmed places for staff were being secured on the twelve-week safe handling of medication course. Redfern DS0000066806.V308152.R01.S.doc Version 5.2 Page 20 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made from evidence gathered before and during a visit to this service. The staff and operations and deputy manager listen to the residents and take their views seriously. Written procedures are in place to promote the welfare of the residents. EVIDENCE: The homes policies and procedures contained a complaints handbook the purpose of which was to, “ provide guidance for staff who become involved in managing our complaints process. It is intended to compliment the information produced separately for service users.” A copy of the information given to residents was examined which provided comprehensive and detailed guidance about the complaints process in an accessible format but it did not specify that residents could make a complaint to the commissioning authority. One resident during the inspection said they were fully aware of the complaints procedure and said, “ I have just had to make a complaint and the operations manager has said she will sort it out.” The operations manager was observed subsequently talking to the resident who later said to the inspectors, “ My complaint has now been sorted out” The complaints record was examined and revealed that one complaint had been dealt with satisfactorily within 28 days. Redfern DS0000066806.V308152.R01.S.doc Version 5.2 Page 21 Staff training records showed that none of the staff had had complaints training. However they confirmed they would know what to do if a resident wanted to make a complaint and they would actively offer their support. The home had a copy of the No Secrets Protection of Vulnerable Adults Teeswide Guidance but their actual procedure needed to be updated, as it did not contain details of local arrangements such as contact people and telephone numbers in the event that an allegation was made. Three members of staff who spoke to the inspectors confirmed they had attended the appropriate training and gave clear examples of how they would respond in particular situations. Staff files, which were audited, verified the staff had completed the relevant training. There had been one vulnerable adult referral, which had been dealt with appropriately. Redfern DS0000066806.V308152.R01.S.doc Version 5.2 Page 22 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is Good. This judgement has been made from evidence gathered before and during a visit to this service. Residents are provided with a homely, clean, hygienic and well-maintained environment, which suits their needs and lifestyles. EVIDENCE: The home provided the residents with a welcoming and comfortable environment that was bright, cheerful airy, clean and well maintained. Furnishings, fittings, adaptations and equipment were of good quality. The deputy manager said the walls were very bare and pictures would be provided as soon as consultation had taken place with the new residents as they were admitted to the home. Two of the residents confirmed they had been able to choose their bedrooms, and added, “ we chose the colours for our rooms and they have new furniture, carpets and coordinated curtains and bedding.” The residents both said, “we really like our rooms” There was also evidence of personal items, photographs, videos, televisions and items of personal interest. Redfern DS0000066806.V308152.R01.S.doc Version 5.2 Page 23 One resident said “I enjoy spending time in my room”” Another resident said, “my room is great “ The outside of the property was well kept and access was provided both inside and outside of the home for all residents, including wheelchair users. The staff confirmed a maintenance person was employed to maintain the garden, undertake repairs, and complete decorating jobs. Redfern DS0000066806.V308152.R01.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 Quality in this outcome area is Poor. This judgement has been made from evidence gathered before and during a visit to this service. The resident’s do not benefit from a competent, knowledgeable, qualified or well-trained staff team. The recruitment records do not contain sufficient information to ensure that service users are fully protected and the recruitment and selection processes are not sufficiently robust. EVIDENCE: Whilst the staff were observed to be accessible to, approachable by and comfortable with the residents, good listeners and communicators, reliable, and honest, and interested, motivated, and committed they lacked the essential knowledge about disabilities and the specific conditions of the service users. In addition they did not have the specialist skills necessary to meet the residents individual needs including for example dealing with anticipated behaviours, and understanding physical and verbal aggression as a way of the residents communicating their needs, preferences and frustrations. Staff said, “ We have not worked with residents with complex needs” Redfern DS0000066806.V308152.R01.S.doc Version 5.2 Page 25 Whilst the pre inspection questionnaire stated the staff had received training in Induction, Protection of Vulnerable Adults, Epilepsy, Diabetes, CPI training, Medication, Fire Training, Communication, Risk Management, and Manual Handling the staff confirmed, “ There has been no specialist training in learning / physical disability, mental health/ severe behavioural/personality disorders, drug or alcohol related issues.” The operations manager said a training manager had recently been appointed and the training programme for staff was being urgently reviewed to ensure all staff received the necessary training, which would fully equip them to meet the needs of the residents. In addition future planned training would include first aid, food hygiene, and National Vocational qualification Levels 2, 3, and 4. The pre inspection questionnaire also stated that currently 20 of the staff was trained to NVQ Level 2 or above. The recruitment and selection records for all of the staff were accessed and revealed that two written references were not always obtained before making an appointment and there was no evidence available to show gaps in the employment record were explored. There was also only one record of any verbal contact being made to verify or validate the content of at least one of the references. An application form in one file was not appropriately completed and in others there were no copies of job descriptions or personal specifications. However examples of good practice were also identified in respect of documentation being present on staff files which indicated they were confirmed in post following completion of satisfactory CRB. The operational manager explained these shortfalls had been identified by the home as a result of which the recruitment and selection policies and procedures and interview and selection documentation were being reviewed. New interview panels were also being introduced which would include residents who would be actively supported to be involved in the staff selection process. The staffing rota was examined and confirmed that there were enough staff on duty to provide quality time for each resident to pursue their own interests. Redfern DS0000066806.V308152.R01.S.doc Version 5.2 Page 26 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39and 42. Quality in this outcome area is Adequate. This judgement has been made from evidence gathered before and during a visit to this service. Residents do not benefit from a well run home. The views of the residents are actively sought to underpin all self- monitoring, review and development by the home The homes policies and procedures require review and updating. As far as reasonably practicable the health, safety and welfare of residents and staff are promoted. EVIDENCE: Redfern did not have a registered manager at the time of the inspection. Redfern DS0000066806.V308152.R01.S.doc Version 5.2 Page 27 Initially staff that spoke to the inspectors said “ We aren’t sure who is the acting manager”. Subsequent discussions with the operations manager confirmed she and the Operations Director (Responsible Individual) would be providing cover until a new manager was appointed. During further visits to the home the operations manager displayed competence and experience in the day-to-day running of the home as well as motivating the staff team. She was aware of the written aims and objectives of the home, and the need for all policies and procedures to be implemented. The operations manager confirmed effective quality assurance and quality monitoring systems based on seeking the views of the residents were in place to measure success in achieving the aims objectives and statement of purpose of the home. No reports, or results of service user surveys were available due to the home being open for a relatively short period of time. The homes policies and procedures included a section entitled, “ Quality Assurance “ which contained examples of ‘service user questionnaires’, ‘care plan monitoring forms’ and ‘investigations and complaints monitoring’. Health and Safety records were examined. Maintenance matters such as, fire alarm and equipment, emergency lighting and electrical wiring certificate were noted to be up to date. However on the day of the inspection the gas certificate was not available although the operations manager said this inspection had taken place and the certificate was held at the head office. She also confirmed although internal PAT (Portable Electrical Appliances) had taken place she was making arrangement for this to be undertaken by a suitably qualified professional. The homes policies and procedures were examined and as they were corporate procedures they must also contain detail of any local arrangements. Redfern DS0000066806.V308152.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 1 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 1 33 X 34 1 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 1 X 2 X X 2 X Redfern DS0000066806.V308152.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14 (1) Requirement The registered person must not provide accommodation for a resident until the needs of the resident have been assessed by a suitably qualified or suitably trained person. The registered person must ensure each resident has a written plan which details how all of their needs are going to be met. The registered person must also ensure this plan is reviewed and the resident is told of any changes. The registered person must make arrangements for the recording, handling, safekeeping, safe administration and disposal of all medicines received into the care home. The registered person must make sure the complaints procedure is reviewed and updated and contains the correct contact details. The registered person must ensure the protection of vulnerable adults procedure is reviewed and updated to contain DS0000066806.V308152.R01.S.doc Timescale for action 01/11/06 2. YA6 15 (1) 01/11/06 3. YA20 13 (2) 15/11/06 4. YA22 22 30/11/06 5. YA23 13 30/11/06 Redfern Version 5.2 Page 30 the local contact details. 6. YA32 18,12 The registered person must ensure that at all times staff who are on duty are suitably qualified, competent and experienced to meet the residents needs. The registered person must ensure that the recruitment and selection procedures are updated and are robust. References must be appropriate and present on staff files. All application forms must be appropriately completed. All staff files must include all of the information as stated in Schedules 2 & 4 of The Care Homes Regulations 2001. The registered person must ensure that their staff training and development programme meets Sector Skills Council workforce training targets and ensures staff are equipped to fulfil the aims of the home by meeting the changing and complex needs of the residents. The registered person must appoint a suitably qualified person to manage the care home. The registered person must provide reports of any quality assurance or quality monitoring activity that takes place within the home. 20/02/07 7. YA34 17 and 19 30/11/06 8. YA35 18 01/02/07 9. YA37 8 and 9 01/12/06 10. YA39 24 23/02/07 Redfern DS0000066806.V308152.R01.S.doc Version 5.2 Page 31 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. Refer to Standard YA34 Good Practice Recommendations Evidence should be available to show any gaps in the employment record have been explored. Redfern DS0000066806.V308152.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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 Redfern DS0000066806.V308152.R01.S.doc Version 5.2 Page 33 - 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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