Inspection on 20/11/06 for Redfern

This inspection was carried out on 20th November 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Redfern 18/01/08

Redfern 18/08/06

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 D White Key Unannounced Inspection 20th November 2006 15:25 Redfern DS0000066806.V321591.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.V321591.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.V321591.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.V321591.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. 18th August 2006 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.V321591.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. The inspection was carried out by two inspectors and four visits were made to the home on 20th November 2006 from 3.25pm until 5.00pm, 21st November 2006 from 1.20pm until 5.15pm, 22nd November 2006 from 1.20pm until 6.50pm, and the 27th November from 1.05 pm until 5.15pm. The inspection was concluded on 31st January 2007 from 2.10pm until 4.50pm following one inspector’s period of sickness. All of the key standards were examined during the inspection. In total five residents files were examined. All staff files including recruitment and selection and personal training were inspected. In addition the medication records, health and safety records and policies and procedures, were read during the inspection. A tour of the home also took place. The inspectors spent time with four of the residents finding out what it was like for them to live in Redfern. One community psychiatric nurse also spoke to one of the inspectors about what day to day life was like for residents in Redfern. Three members of staff also spoke to the inspectors. The manager and registered throughout the inspection. provider provided additional information The manager informed the inspector that charges for residents’ care and accommodation were £1389.81 per week. £13.13 was charged for any resident who required additional one to one support. What the service does well: The staff and residents were observed to have a positive relationship. Residents talked to the staff about issues affecting their daily lives as well as participating in organised activities such as board games and dominoes. One resident said “I really like living here the staff spend time with me and help me to sort out any problems” Another resident said “ I can go on holiday and I visit the local shops it is great here I have lots of help. One member of staff who spoke to the inspectors said the residents were always occupied and “ I take the residents out a lot, we go for walks and to the local shops and we also go to the local pubs. It is great working here. I feel I am making a difference to all of the residents who live here.” Redfern DS0000066806.V321591.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Redfern DS0000066806.V321591.R01.S.doc Version 5.2 Page 7 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.V321591.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s Statement of Purpose is not specific to the current resident group. A comprehensive assessment of the resident’s aspirations and their complex needs is completed by the staff but not recorded by the home prior to their admission. EVIDENCE: The manager and the registered provider said they completed full comprehensive needs assessment of every new resident before their admission to the home. However, following an examination of a resident’s file that had recently been admitted to the home there was no evidence of this information being recorded and the manager and the registered provider agreed to review their recording processes. Redfern DS0000066806.V321591.R01.S.doc Version 5.2 Page 9 In addition an examination of five residents files confirmed the home obtained a summary of any assessments undertaken through care management arrangements, and received a copy of the care plan before each resident’s admission. Evidence was available that information was provided from a range of sources, which included other relevant professionals such as Community Psychiatric Nurses, GP’s, and psychologists. The views of relatives were also considered. The manager and the registered provider also gave examples of the resident’s involvement in the assessment process prior to admission and in one file there was written evidence of three visits which had been made by the perspective resident to the home prior to admission. The manager and the registered provider confirmed that all assessments were considered against the homes statement of purpose which was in the process of being reviewed and updated to ensure that the service was able to meet the needs of the resident. Redfern DS0000066806.V321591.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents assessed, changing needs and personal goals are 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: The acting manager and the registered provider confirmed that since the last inspection work had been undertaken by the home to update their care plans. Redfern DS0000066806.V321591.R01.S.doc Version 5.2 Page 11 A copy of My Plan, My Choice, My Prospect was shared with the inspectors and covered areas such as personal relationships use of leisure, spare time, daily living skills, domestic skills etc. The manager confirmed the residents were encouraged to complete these booklets, which were colourful and in a userfriendly format. Two booklets were examined one, which had recently been completed by a resident, and another where there was clear evidence that the resident had been consulted and had stated they did not want to be involved in the process. Staff confirmed, “ They were involved in care planning “ and added “ that each resident had a key worker”. One resident told the inspector “ I like my key worker she goes out with me into Redcar “ The manager stated that one resident had an advocate and that arrangements were being put in place for the other residents to also have access to an advocate. The wishes views and feelings of the residents informed the detailed risk assessments which were present in the files, which included for example, dealing with challenging behaviour, management of epilepsy, smoking, and verbal aggression, accessing the community, etc. The manager and staff understood the importance of residents being supported to take control of their own lives, and to encourage and enable them to exercise their rights and make their own decisions and choices such as going on holiday, use of leisure time, employment, and education. The manager said, “ We are currently exploring holiday arrangements for a resident to go abroad on holiday” The staff said they continued to respect the privacy dignity and rights of the residents. The inspectors also observed the staff asking the residents their opinions about going out and how they were going to spend their evening in the home. One resident said, “ We are going to play dominoes. He always wins.” Another said” I am going to watch TV.” Another said “ I am going out” The manager confirmed that training was taking place for staff to ensure that they had an awareness of Data Protection and an understanding of the procedures which were in place to ensure that the residents were informed of their rights to confidentiality, and understood when staff might have to share personal information to ensure individuals residents were safeguarded. Redfern DS0000066806.V321591.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. Quality in this outcome area is, good. This judgement has been made using available evidence including a visit to this service. Staff enable as far as possible the opportunities for the residents to maintain and develop their social, emotional, communication and independent living skills whilst respecting their rights and responsibilities in their daily lives. 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. Residents are clearly offered and encouraged to have a balanced, varied and nutritional diet, which caters for individual likes, and dislikes. Redfern DS0000066806.V321591.R01.S.doc Version 5.2 Page 13 EVIDENCE: During discussion with the manager and the registered provider they confirmed that the residents visited the local college, shops and cafes and went on holiday. Activities provided for the residents within the home, included board games, watching television, and videos listening to the radio and CD’s. One resident was actively involved in craftwork. Arrangements were also made for the residents to visit residents in other homes and to go to birthday parties. One resident was involved in a drama group and another resident attended circus skills and yoga classes at the local college. One member of staff who spoke to the inspectors said the residents were always occupied and “ I take the residents out a lot, we go for walks and to the local shops and we also go to the local pubs. It is great working here. I feel I am making a difference to all of the residents who live here.” The manager confirmed that the residents had the opportunity to develop and maintain important personal and family relationships. Family members were encouraged to visit the home regularly and stay for their meals. The residents were also able to access information and specialist guidance about issues such as intimate relationships. One member of staff said, “ I help the residents make choices but also to stay safe and their rights are very important.” One resident said “ I look after my room with help from the staff. I dust and Hoover.” The residents also said “ We choose our menu with the staff we have lots of good food here, sometimes we can cook and make cups of tea or sandwiches”. The menu was examined and confirmed the meals were balanced and nutritious and catered for the dietary needs of the residents. Fresh fruit and vegetables were also present. One resident said “ I feel as if I am becoming a part of the community now I go shopping regularly into Redcar and have a coffee in the café. “ Another resident said, “ I go to the youth club and I have lots of friends there” Another resident said “the staff take me to the pub” It was noted during a tour of the home that the bedroom doors did have locks fitted and residents were provided with keys for their rooms. The inspectors also observed that staff respected the privacy and dignity of the residents by entering the residents’ bedrooms and bathrooms with their permission. The residents told the inspectors that they could choose when to be alone or in company and when not to join in an activity. Redfern DS0000066806.V321591.R01.S.doc Version 5.2 Page 14 On one day of the inspection a resident was observed watching television in the lounge, on another day a number of residents were observed in the dining area talking to each other and playing board games. On another day a group of residents were observed sitting in the lounge and on another day a resident was observed in their room playing their guitar. Redfern DS0000066806.V321591.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a 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 met. The storage of medication is not appropriate. EVIDENCE: Residents were involved in discussion about their individual life within Red fern. A very relaxed life was demonstrated through observation and discussion with residents and staff. One resident said, “I really like living here it is the best place I have ever lived in ““ and another resident said, “It is great here the staff are really helpful and the manager is great”. A staff member also commented, “I enjoy coming to work every day” Another resident said, “ I can have a lie in and meal times are flexible. I can have a shower when I want.” Redfern DS0000066806.V321591.R01.S.doc Version 5.2 Page 16 Another resident said, “ I can choose my own clothes. I have just been shopping. Do you like my new trousers?” Aids and adaptations to meet the individual needs of the residents were also present in the home. A member of staff said, “ All of the staff make sure the residents receive consistency and continuity of support from the staff that work in Redfern”. All of the staff on duty provided sensitive and flexible personal support to maximise the residents’ privacy, dignity, independence, and control over their lives. A member of staff said “ We always make sure a member of staff of the same gender provides any personal care for a resident. It is very important. “ Care plans confirmed the residents had contact with Psychiatrist’s, Community Psychiatric Nurse’s, Care Managers, Occupational Therapists, Chiropodist, and Optician and a social worker and support worker were observed visiting Redfern during the inspection. The manager said “a resident has recently experienced dental problems and the staff all encouraged her/him to go to the dentists.” He added all of the residents were registered with GP’s at the local surgery. The staff said they were getting to know the residents very well and would be able to identify if there were any concerns regarding their emotional wellbeing. Currently none of the residents were self-medicating and during discussion with the manager it was identified that the arrangements for safe storage were suitable in the event that residents did want to do this and it was safe to do so. The manager and registered provider said that all of the homes policies, procedures and practices for the recording, handling, safekeeping, safe administration and disposal of all medicines received into the care home had been reviewed and updated. The medication records of two residents were examined and were observed to contain a photograph of the resident. In addition records were kept of all medicines received into the home administered and leaving the home or disposed of to ensure that there was no mishandling. A record was also kept of all current medication for each resident. However, the storage of medication did not comply with the Misuse of Drugs (Safe Custody) Regulations 1973. The manager confirmed that designated staff that were registered on the twelve-week safe handling of medication course administered and witnessed all medicines including controlled drugs. Redfern DS0000066806.V321591.R01.S.doc Version 5.2 Page 17 He confirmed that all staff within the care home would receive the accredited training, which would include the basic knowledge of how medicines are used and how to recognise and deal with problems in use and the principles behind all aspects of the homes policy on medicines handling and records. The receipt, administration and disposal of controlled drugs were recorded in a controlled drugs register a copy of which was shared with the inspectors. The records also confirmed that the manager sought information and advice from the pharmacist regarding medicines policies within the home and medicines dispensed for individuals in the home. A copy of the homes internal medication quality assurance-monitoring tool was shared with the inspector. Redfern DS0000066806.V321591.R01.S.doc Version 5.2 Page 18 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. 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 using available evidence including a visit to this service. The residents are listened to and the homes staff and the registered manager take their views seriously and staff are fully aware of how an investigation is conducted. Written procedures are in place to promote the welfare of the residents. EVIDENCE: The complaints procedure was available within the home, and was accessible to the residents. It had been reviewed and updated since the last inspection and was in a clear and effective format which included the stages of and timescales for the process. It also recorded how and to whom the residents should make a complaint. The manager confirmed the staff valued the opinions, concerns and views of the residents and that discussion and action were always encouraged within the home on any issues raised by the residents before they developed into problems and formal complaints. Since the last inspection, there had been no complaints. The manager confirmed the protection of vulnerable adults procedure had been reviewed and updated to contain the local contact details since the last inspection. The home had a copy of the No Secrets Protection of Vulnerable Adults Teeswide Guidance. Redfern DS0000066806.V321591.R01.S.doc Version 5.2 Page 19 Staff who spoke to the inspectors confirmed that they had received the in house training on abuse and adult protection and through discussion confirmed they knew who to contact should the need arise. Three residents financial records were audited and contained detailed information about each resident’s income, expenditure and savings. Redfern DS0000066806.V321591.R01.S.doc Version 5.2 Page 20 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. 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 using available evidence including a visit to this service. The residents live in a homely, comfortable, and safe environment, which is clean and hygienic. EVIDENCE: A tour of the home took place, which was observed to have a friendly atmosphere and provided a physical environment and specialist aids and equipment to meet the individual needs of the residents. The home was comfortably furnished and the residents had access to communal facilities in the lounge, dining room and back garden area, which promoted a non-institutionalised environment. The shared areas also provided a choice of communal space with opportunities to meet relatives and friends in privacy or in their own rooms. Redfern DS0000066806.V321591.R01.S.doc Version 5.2 Page 21 All of the bedrooms had en suite facilities and met the special requirements of the National Minimum Standards. Residents who spoke to the inspectors said, “ We can choose the colour for our walls and carpets. Look at our rooms we are really happy with them. “ Another resident said” I like the ceiling as it is “ Residents were also encouraged to personalise their rooms which the inspectors observed contained televisions, play stations, videos, CD’s, and personal photographs. One resident said,” Look at all of my things, it is great, I can have them all here, there are plenty of places to put them” The home was observed to be well lit, clean and tidy and smelled fresh. The outside of the property was well maintained. Redfern DS0000066806.V321591.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The resident’s benefit from a competent, knowledgeable, qualified and welltrained staff team. The recruitment records contain sufficient information to ensure that service users are fully supported and protected. EVIDENCE: An examination of all staff files and discussion with the manager and registered provider confirmed that two members of staff had started the National Vocational Qualification (NVQ) Level 3 and the remaining staff were registered on the NVQ Level 2. The registered provider added each member of staff had completed an Induction programme and the homes training and development programme now met the Sector Skills Council workforce training targets which ensured the staff had the necessary skills, experience and training to meet the needs of the residents. Redfern DS0000066806.V321591.R01.S.doc Version 5.2 Page 23 Examples of training, which had taken, place included resuscitation, protection of vulnerable adults, dementia, and all mandatory training including fire, first aid, health and safety and food hygiene. The staff were also registered on the safe handling of medication course. Future planned training included LDAF, complaints, data protection, and confidentiality. The recruitment and selection records for all of the staff were examined and confirmed they included all of the information as stated in Schedules 2 & 4 of The Care Homes Regulations 2001. The homes recruitment and selection policies and procedures had been reviewed and updated. A copy was shared with the inspectors and included recruitment do’s and don’ts, introducing screening and interviewing, questions to ask before advertising, I need to advertise a job- What do I do? Advertisements, Examples of adverts, Vacancy authorisation form, Recruitment home manager responsibilities/check list etc. The staffing rota was examined and discussion with the manager confirmed that there were enough staff on duty to provide quality time for each resident to pursue their own interests. One resident said, “ My key worker goes with me to the GP’s and also to the hospital she is always there to support me when I need her” Redfern DS0000066806.V321591.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is no registered manager and no application for the registration of a manager has been made. The home has developed a quality assurance and self-monitoring system to audit, review and develop the services provided to the residents. As far as practicable the health and safety of the residents is promoted. Redfern DS0000066806.V321591.R01.S.doc Version 5.2 Page 25 EVIDENCE: Since the last inspection a new manager had been appointed who throughout this inspection displayed knowledge and competency in the day-to-day running of the home and confirmed that he was working hard to continuously improve services and provide an increased quality of life for the residents. He was person centred in his approach and said he was in the process of establishing a strong staff team. One member of staff said, “ He is the best manager we have had. He is very supportive. We are all pulling together. We all want what is best for the residents”. However, the manager said he did not currently have the necessary management qualifications in either care or management, but had registered for the NVQ 4 Registered Managers Award, which would commence in February 2007 and end in December 2007. He added he was in the process of completing the Registered Manager application with CSCI. The manager confirmed the homes policies and procedures, were being reviewed and updated to ensure all local contact information was included. Systems were in place e.g. The Milewood Competence Assessment Record, Medication Training Declaration Record and further systems were being developed to monitor the staff’s adherence to policy and procedures in practice. Health and Safety records were examined. Maintenance matters such as, fire alarm and equipment, emergency lighting and electrical wiring certificate, PAT (Portable Electrical Appliances) and the gas certificate were noted to be up to date. The records were of a good standard and there was evidence of them being routinely completed. There was also evidence in the home of the development of a health and safety audit tool, which was completed by the manager. The inspectors acknowledged that since the last inspection the quality assurance processes in the home had been developed and improved. The registered provider confirmed that resident questionnaires had been completed in August 2006 copies of which were available on the resident’s files and questionnaires had been sent to relatives on 29/11/2006. A letter had also been forwarded to relatives inviting them to attend relatives meetings, which were to be held at least four times per year at Redfern. A questionnaire for professionals had also been developed and was to be sent to them in the near future. Professionals were also given an audit form to complete following each visit to Redfern. Redfern DS0000066806.V321591.R01.S.doc Version 5.2 Page 26 The registered provider confirmed that all of the information obtained from the audits was being compiled into a report a copy of which would be shared with CSCI. In addition the operational manager and registered provider had undertaken an internal audit of the home on 27/11/2006 and areas of good practice had been identified with actions being taken to address any deficits. A copy of the completed audit was shared with the inspectors, which was observed to be very thorough and comprehensive. The manager confirmed staff meetings and residents meetings took place on a regular basis. The minutes of both meetings were shared with the inspectors. Redfern DS0000066806.V321591.R01.S.doc Version 5.2 Page 27 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 2 2 2 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 3 23 3 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 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 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 3 X X 3 X Redfern DS0000066806.V321591.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4 Requirement The registered person must ensure the homes statement of purpose is reviewed and updated to make sure that the service is able to meet the needs of the residents. The registered person must ensure the comprehensive assessment of the resident’s aspirations and complex needs, which is undertaken by staff is recorded prior to a residents admission. The registered person must ensure that all medicines are stored appropriately so that they are secure and are safe to use. Controlled drugs to be administered by staff must be stored in a metal cupboard, which complies with the Misuse of Drugs (Safe Custody) Regulations 1973. (Previous timescale of 15/11/06 identified at the last inspection not met.) Timescale for action 01/04/07 2. YA2 14 (1) 01/04/07 3. YA20 13 (2) 01/03/07 Redfern DS0000066806.V321591.R01.S.doc Version 5.2 Page 29 4. YA37 8 and 9 The registered person must submit an application for the registration of a manager for the care home. (Previous timescale of 01/12/06 identified at the last inspection not met.) 21/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Redfern DS0000066806.V321591.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Redfern DS0000066806.V321591.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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