CARE HOME ADULTS 18-65
Redgate Court (38) Peterborough PE1 4XZ Lead Inspector
Lesley Richardson Key Unannounced Inspection 10th May 2006 10:00 Redgate Court (38) DS0000015130.V291848.R01.S.doc Version 5.1 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 Redgate Court (38) DS0000015130.V291848.R01.S.doc Version 5.1 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. Redgate Court (38) DS0000015130.V291848.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Redgate Court (38) Address Peterborough PE1 4XZ 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) 01733 313501 01733 313501 www.sense.org.uk Sense East Elizabeth Ann Gray Care Home 6 Category(ies) of Learning disability (6), Sensory impairment (6) registration, with number of places Redgate Court (38) DS0000015130.V291848.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. LD only in association with SI Date of last inspection 7th February 2006 Brief Description of the Service: 38 Redgate Court consists of a purpose built property, situated on a residential estate on the north-eastern edge of Peterborough. The home is a two-storey, semi-detached property in an accommodation complex catering for adults with learning disability. It is owned by Sense East and provides care and support for up to 6 people with learning disability, associated with sensory impairment. Fees for the home range between £501 and £986.68 per week. The home has 6 individual bedrooms; 5 on the upper floor and 1 on the ground floor. There is a bathroom with shower and toilet on both floors, an open planned lounge dining area and a kitchen. There is a conservatory leading to the large, well maintained garden, which is shared with the adjoining house. The home is within walking distance of local shops, pubs, a post-office and public transport. Peterborough city centre is about 5 miles away and is easily accessed by public transport. Redgate Court (38) DS0000015130.V291848.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over 7 hours and was carried out as an unannounced inspection on 10th May 2006 and 17th May 2006. It was the first key inspection for this home for the 2006-2007 year. The lead inspector and a second inspector attended the first part of the inspection on 10th May 2006. 4 hours were spent with staff members, service users and undertaking a tour of the home. Not all of the people who live at the home were present during the inspection. Due to the levels of combined learning disability and sensory impairment in the people who live there conversations with two people were brief. The home is currently without the registered manager. The first part of the inspection visit was conducted with the acting manager and the deputy manager and a team leader were present for the second visit. Inspection comment cards from five relatives, plus two comment cards completed on behalf of service users, were received prior to the inspection and have been included in this report. Thirteen requirements and three recommendations have been made as a result of this inspection. Some of these requirements have been carried over from the last inspection as they have not been met. What the service does well:
The home offers accommodation and care to people with combined learning disability and sensory impairment. The home obtains information before people start living at the home, so that the move is as easy for them as possible and so that the staff are able to meet all their needs. Potential service users are able to visit the home and stay for longer and longer periods of time, until they are confident they want this to be the home they live in. There is a wide range of activities inside and outside the home available to service users. Activities take place within areas used by the local community, such as swimming pools and cinemas, or those used by other people with learning disability. The family and relatives of people who live at the home are included in their lives. In a survey conducted by the Commission for Social Care Inspection relatives said they could visit in private and were made welcome when they visited the home. The home takes steps to make sure contact is maintained and keeps notes of conversations so that the person living at the home is able to refer back to them. Staff members have written guidance and training about how to deal with complaints. The home has had no complaints since the last inspection. Three out of five relatives said they were aware of the complaints procedure, but none of them had felt the need to make a complaint about the home. Redgate Court (38) DS0000015130.V291848.R01.S.doc Version 5.1 Page 6 The relatives responding to the survey said they were happy with the home and how staff cared for the people living there. What has improved since the last inspection? What they could do better:
Although there has been some improvement in some areas, there are still a number of areas the home must improve to make sure they meet all the standards and regulations, and bring them up to an acceptable standard. Care records that are written to advise staff members about the best way to care for the people who live at the home are still difficult to read and do not provide all the information needed. This makes it difficult for staff, especially new or agency staff, to find out exactly what to do in any situation and puts the people who live at the home at risk of not receiving the correct care. Assessments that show the level of risk associated with an activity and how that risk can be reduced must also be improved. The home must make sure it keeps information about the people who live there confidential; this information must not be in a place where other people can read it. Staff members must receive training to make sure they have the knowledge and skills to care for all aspects of residents’ needs. Two areas where this must be improved are medication, and health and safety. The environment of the home needs improvement. There is no programme of maintenance, which means there are a number of areas that need to be repaired or replaced. This was raised as an issue at the last inspection and some work has been completed. However, other work and new problems identified at this inspection must be repaired or replaced to make sure the people who live at the home live in a comfortable and safe environment. It is recommended that the home start a programme to identify areas in need of maintenance and records when areas or equipment becomes defective. Fire escape route signs are not in place in all areas in the home. This places people whose bedrooms are on the first floor at risk in the event of a fire. The home Redgate Court (38) DS0000015130.V291848.R01.S.doc Version 5.1 Page 7 must consult the fire authority or a competent person for advice regarding this matter. People who live at the home and their relatives or representatives have little opportunity to comment formally about how the home is run. There has been no survey report identifying how the home could improve since 2003. This needs to change so that people living at the home have a say and a choice in how they would like to live. Staff records do not include all the information that must be kept in the home, not do they show the home has completed the proper checks to make sure the new staff member is safe to work with vulnerable people. Supervision of staff members does not take place on a regular enough basis to make sure they have the proper guidance and support. 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. Redgate Court (38) DS0000015130.V291848.R01.S.doc Version 5.1 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 Redgate Court (38) DS0000015130.V291848.R01.S.doc Version 5.1 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): 1, 2 and 4 The outcome for these standards is good. Admissions are not made to the home until a full needs assessment has been undertaken. The home is then able to confirm they can meet the needs of the individual through the service they deliver as detailed in the statement of purpose. EVIDENCE: Service users are referred to the home by the Learning Disability teams, who provide a detailed assessment about that service user, or a service user’s family may contact them privately. An assessment team, within the Sense organisation, assesses referred service users to ensure a specialised Sense home is the most appropriate place for that person to live. An assessment is also undertaken by the home, which makes sure that not only will the home be able to meet the assessed person’s needs, but also to reduce the risk of obvious personality clashes. Prospective service users are encouraged to visit the home for tea visits, day visits and overnight stays so the home is able to fully assess their needs. They are then able to decide if they would like to stay at the home, which is on a temporary basis for the first month and becomes a permanent arrangement following a review and the service user’s agreement. There have been no new service users in the home for 2 years. Redgate Court (38) DS0000015130.V291848.R01.S.doc Version 5.1 Page 10 The home has a statement of purpose that contains all the information required in the Care Homes Regulations 2001 and the National Minimum Standards for Younger Adults. Redgate Court (38) DS0000015130.V291848.R01.S.doc Version 5.1 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, 9 and 10 The outcome for these standards is poor. There has been little improvement in the care planning system to adequately provide staff with the information they need to satisfactorily meet service users needs. EVIDENCE: The home has three files that provide information about how to care for service users. One file that contains mostly older reports and archived material, a folder that contains up to date information and is taken with the service user when they attend day services, and a medical/medication file that contains details of health related issues and medication records. Care records looked at included one that had been examined at the last inspection. The documentation for this service user had not been updated to give staff advice and guidance on how best to meet his needs or strategies being employed to identify how specific needs could be met. A plan for another service user gave guidance about needs and how best to meet those needs but gave little description about behaviours were triggered or descriptions of behaviour. This information was available in another document although there was nothing to indicate this might be the case. Reviews of care
Redgate Court (38) DS0000015130.V291848.R01.S.doc Version 5.1 Page 12 are undertaken every 6 months, although care plans are not always updated to reflect changes identified at these meetings. Risk assessments are completed to enable service users to continue with a particular activity but with strategies to reduce the level of initial risk. However, the risk assessments seen did not show how the initial risk level had been obtained. It was difficult to identify how service users are supported to take risks, although clear guidance in behavioural guidelines shows staff how they are to support service users in making decisions and choices. Staff say visual risk assessments are also completed prior to activities taking place. This ensures subtle changes in behaviour, and therefore whether a service user is happy with the situation or not, are acknowledged and acted upon. Care records are poorly dated, giving little guidance about whether a particular document is current or out of date. Not all documents are signed by the person writing the entry, which makes clarifying information difficult and can potentially result in incorrect care being given. Staff members said only one service user would have any knowledge of her care plan, although there was no evidence she had been consulted about the plan. Parents of service users usually act as advocates and they are invited to attend review meetings, but staff members said they didn’t think parents were consulted about plans either. Staff say finding independent advocacy services for deaf blind people with associated learning disability has proved difficult and if service users either want or need advocacy services this is referred to Sense East. All relatives responding in comment cards said they were kept informed and were consulted about decisions about their relative. They were all satisfied with the overall care given at the home. Confidentiality issues were identified at the last inspection, and although that information has been removed and placed in an appropriate place, information about a service user’s bath routine was placed on the inside of a bathroom door used by most of the service users. Redgate Court (38) DS0000015130.V291848.R01.S.doc Version 5.1 Page 13 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, 14, 15, 16 and 17 The outcome for these standards is good. Social activities provide stimulation and opportunities for community links for people living in the home. Visits from relatives and friends ensure continued social contact. EVIDENCE: Service users access day placement and workshop activities during the day. The home works closely with each placement to ensure there is continuity and the placement is aware of ongoing issues that arise. Service users participate in activities, such as swimming and horse-riding, at local venues, and attend clubs and entertainment venues aimed at the general public and their peer group. A service user said she liked going out to her day placement and working with staff on activities. Her room has recently been decorated and she enjoys listening to music there on her stereo. Staff members interact with service users in a polite way, keeping in mind service users wishes and when they would rather be alone. Service users are able to go to their rooms alone and their movement around the home is not restricted. Doorbells and flashing lights are fitted to service users room doors
Redgate Court (38) DS0000015130.V291848.R01.S.doc Version 5.1 Page 14 to ensure privacy is maintained. Participation in housekeeping tasks ensures service users are able to maintain skills and responsibilities for their home. The home encourages service users to maintain contact with family and friends; they are able to communicate by telephone or letter and visits to stay with relatives are organised by staff members. Care records showed details of telephone contact the home had with family members, so that service users and staff members are able to refer back to conversations. Where it is not possible for service users to stay with relatives, they are invited to the home to visit service users or staff support service users in meeting at another location. 80 of relatives responding in comment cards said they were able to visit in private. Service users accompany staff members on shopping trips and they help with food preparation. Snacks are available throughout the day and service users, who are able to, can make drinks when they wish. Fresh fruit and vegetables are offered and meals are prepared on a daily basis. The home keeps a record of meals taken by service users and a general 4-week rotating menu. Records detailing food that service users are given have improved since the last inspection. Redgate Court (38) DS0000015130.V291848.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 The outcome for these standards is adequate. The systems for the administration of medication must improve to ensure service users are not at risk. EVIDENCE: Staff members interact with service users in a positive way, asking if they would like to participate in personal care activities, but respecting their wishes if they decline. Care records show service users have access to a variety of health care professionals to ensure these needs are met. A requirement made at the last inspection regarding the need for service users to have access and advice from healthcare professionals has been met. Behavioural guidelines are completed on a 6 monthly basis. These reviews highlight emotional issues that need addressing and ensure issues that have been addressed are also reviewed. Staff say service users are able to either clearly say what they would like or this may be indicated by behaviour. Service users choose particular toiletries and information about this was seen in one person’s plan. The home uses a system of Medication Administration Records (MAR) and blister packs for medication administration. None of the service users presently living at the home self-medicate. Records had been signed appropriately and indication was made for medication not administered.
Redgate Court (38) DS0000015130.V291848.R01.S.doc Version 5.1 Page 16 However, incomplete instructions noted at the last inspection in one service user’s file has not improved, and another service user’s file also contains incomplete administration instructions. Medication training is given to all staff during induction and this is updated by senior staff in the home that have completed the Boots foundation and advanced care of medication courses. This is not adequate to ensure all staff members with the responsibility for medication administration have the knowledge and understanding to undertake this safely. It is recommended all staff receive medication training from an outside professional that not only covers medication administration systems but also information about the medications being used. Redgate Court (38) DS0000015130.V291848.R01.S.doc Version 5.1 Page 17 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 The outcome for these standards is adequate. Improvement has been made to the system for protection from abuse, ensuring service users are not at risk. EVIDENCE: The home is supported by policies and procedures on how to make and deal with complaints and allegations of abuse. The acting manager said the home has received no complaints since the last inspection. Staff members are aware of the home’s procedure and steps that are taken to resolve complaints. 60 (3 out of 5) of relatives responding to the questionnaire sent out by CSCI earlier in the year said they were aware of the home’s complaints procedure. However, none of the respondents had ever felt the need to make a complaint. Service users money and the associate financial records kept at the home were inspected. Although improvement was seen in the record keeping and balances checked were correct there remain some aspects, such as recording debits immediately and labelling of receipts that should improve to ensure a robust system. The two comment cards received on service users behalf said they felt safe at the home. Redgate Court (38) DS0000015130.V291848.R01.S.doc Version 5.1 Page 18 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 The outcome for these standards is adequate. Improvement has been made in the most serious matters, but there remain areas that require attention to ensure service users live in a homely and comfortable environment. EVIDENCE: The home was generally clean and tidy, décor is domestic in appearance and service users are comfortable with the layout. There were no offensive odours and the risk of cross infection is reduced, as access to the laundry is away from the kitchen and eating areas. Staff said although there is communal space for the number of service users living at the home, furnishings make the space cramped and sometimes difficult to move away or use diversion techniques with service users displaying challenging behaviour. Consideration is being given to changing some furniture because of this. A number of areas were identified at the last inspection as requiring attention. Six of these were made immediate requirements and these have been met. However, there remain areas in the home, also identified at the last inspection, that are unsightly and these must be repaired or replaced. This was discussed with the acting manager during the inspection. Other areas identified during this inspection are:
Redgate Court (38) DS0000015130.V291848.R01.S.doc Version 5.1 Page 19 • • • • • The extractor fan in the ground floor bathroom should be cleaned of dirt and dust. Soap and sponges must not be kept in communal bathing areas; soap dispensers, where available, should be stocked for use. Toilet paper holders should either be used or removed. The downstairs bathroom has a light switch instead of a cord pull. The Environmental Health department advised that guidance should be sought by the home from them and a competent person regarding the safety of this. The clear glass window in the first floor shower should be covered to ensure privacy. Redgate Court (38) DS0000015130.V291848.R01.S.doc Version 5.1 Page 20 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, 35 and 36 The outcome for these standards is poor. The arrangements for ensuring staff are appropriately trained has only improved slightly, therefore leaving service users at risk of being cared for by staff without the knowledge to ensure all their needs can be met. EVIDENCE: Staff members complete induction training that covers mandatory health and safety training and give an introduction to service users needs. Following this, extensive training is given over a period of about 6 months, which is specific to service user needs. This includes Makaton and BSL (British Sign Language). The home has a training matrix that shows when staff members last had particular training and when it is next due for update. This shows that not all staff have had mandatory training, training in communication or in dealing with anticipated behaviours in the last year and some staff members have not had this training at all. Service user specific training, such as diabetes and the use of blood sugar monitoring equipment, was given by senior staff who cascaded the information to other staff. Staff said training for this was still to be arranged with the district nurse, and confirmed that some elements of mandatory health and safety training, such as food hygiene and infection control, was given at induction but had not been updated. The need for staff to be suitably trained for their work was raised at the last inspection and a requirement was made. This has therefore not been met.
Redgate Court (38) DS0000015130.V291848.R01.S.doc Version 5.1 Page 21 The staff files were seen for two of the home’s most recently employed staff members. The employment history in both files had been written in months and years only. Nothing could be found in either file to show gaps had been explored. A full employment history, together with a satisfactory written explanation of any gaps in employment must be obtained. Although there was information in one file regarding return of satisfactory CRB and PoVA First disclosures, there was no information for either of these checks in the second file. The second file did not contain a photograph of the applicant. Staff members said supervision has been given erratically over the last year and no supervision had been given since February this year. However, this was due to start again now the acting manager is in post. There were no supervision records available in staff files. Redgate Court (38) DS0000015130.V291848.R01.S.doc Version 5.1 Page 22 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, 39 and 42 The outcome for these standards is poor. There has been no improvement in the systems for service user consultation, with little evidence that service user views are sought and acted upon within the home. EVIDENCE: The home has been without a registered manager since February 2006, although arrangements have been made to ensure continued management structure and an acting manager has been appointed. Staff members said this disruption has had a minimal impact and there is a feeling that the home is becoming more organised, and their views are being listened to. Checks are required to ensure the health and safety of service users and these must be recorded. Records were seen for fire safety checks and hot water temperature checks. These were recorded as acceptable and a previous requirement has been met. However, a fire exit route sign, located at the top of the stairs to the first floor remains insecurely attached. The door at the bottom of the stairs, leading to the garden, does not have any signage,
Redgate Court (38) DS0000015130.V291848.R01.S.doc Version 5.1 Page 23 although staff members said the door is a fire door. These potentially leave service users at risk in the event of a fire. There has been no improvement in how the home monitors, reviews and develops its service or in how it obtains service users or their representatives views. This must improve and a report must be produced to measure success in achieving the aims, objectives and statement of purpose of the home. Redgate Court (38) DS0000015130.V291848.R01.S.doc Version 5.1 Page 24 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 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 3 27 X 28 X 29 X 30 1 STAFFING Standard No Score 31 X 32 2 33 X 34 1 35 1 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 1 X 1 1 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 1 X 1 X X 1 X Redgate Court (38) DS0000015130.V291848.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 Requirement The registered person must prepare a written plan as to how the service user’s needs in respect of his health and welfare are to be met. The registered person must keep the service user’s plan under review. (Previous timeframe of 15/04/06 has not been met.) The registered person must, for the purpose of providing care to service users, and making proper provision for their health and welfare, so far as practicable ascertain and take into account their wishes and feelings. The registered person must ensure that any activities in which service users participate are so far as reasonably possible free from avoidable risks. (Previous timeframe of 15/04/06 has not been met.) The registered person must ensure the records specified in Schedule 3 are kept securely in the care home. (Previous
DS0000015130.V291848.R01.S.doc Timescale for action 07/07/06 2 YA7 12(3) 07/07/06 3 YA9 13(4)(b) 07/07/06 4 YA10 17(1)(b) 07/07/06 Redgate Court (38) Version 5.1 Page 26 5 YA20 13(2) 6 YA24 13(4)(a), 23(2)(b), 7 YA30 13(3) 8 YA34 19(b)(i) 9 YA35 18(1)(c) 10 YA36 18(2) 11 *RQN Care Standards Act 2000, timeframe of 1/04/06 has not been met.) The registered person must make arrangements for the recording and safe administration of medicines received into the home. (Previous timeframe of 1/04/06 has not been met.) The registered person must ensure that all parts of the home to which service users have access are free from hazards to their safety. That the premises to be used as the care home are kept in a good state of repair externally and internally. (Previous timeframe of 30/04/06 has not been met.) The registered person must make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home. The registered person shall not employ a person to work at the care home unless he has obtained in respect of that person the information and documents specified in paragraphs 1 to 9 of Schedule 2. The registered person must ensure that the persons employed to work at the care home receive training appropriate to the work they are to perform. (Previous timeframe of 30/04/06 has not been met.) The registered person shall ensure that persons working at the care home are appropriately supervised. Any person who carries on or manages an establishment or agency of any description
DS0000015130.V291848.R01.S.doc 15/07/06 31/08/06 31/08/06 01/07/06 07/07/06 07/07/06 07/07/06 Redgate Court (38) Version 5.1 Page 27 Section 11 12 YA39 13 YA42 without being registered under this Part in respect of it shall be guilty of an offence. 24(1)(a), The registered person must 31/07/06 (b), (3) establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided at the care home. The system must provide for consultation with service users and their representatives. (Previous timeframe of 30/04/06 has not been met.) 23(4)(c)(iii) The registered person must 01/07/06 after consultation with the fire authority make adequate arrangements for the evacuation, in the event of a fire, of all persons in the care home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3 Refer to Standard YA6 YA24 YA32 Good Practice Recommendations All care records should be signed and dated with day/month/year by the author of each entry. A programme of routine checks and maintenance should be commenced to identify and resolve environmental deterioration quickly. Staff training for specialist needs, such as challenging behaviour, should be updated on a regular basis. Redgate Court (38) DS0000015130.V291848.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE 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 Redgate Court (38) DS0000015130.V291848.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
