Inspection on 08/02/06 for Redholme Memory Care Ltd

This inspection was carried out on 8th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Redholme Memory Care Ltd 05/09/06

Redholme Memory Care Ltd 20/01/05

Redholme Memory Care Ltd 29/06/04

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

CARE HOMES FOR OLDER PEOPLE Redholme Memory Care Ltd 11 Carnatic Road Mossley Hill Liverpool Merseyside L18 8BY Lead Inspector Pat Kearney Unannounced Inspection 8th February 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Redholme Memory Care Ltd DS0000060551.V282021.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Redholme Memory Care Ltd DS0000060551.V282021.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Redholme Memory Care Ltd Address 11 Carnatic Road Mossley Hill Liverpool Merseyside L18 8BY 01517242016 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) Redholme Memory Care Ltd Ann McCann Care Home 55 Category(ies) of Dementia - over 65 years of age (55) registration, with number of places Redholme Memory Care Ltd DS0000060551.V282021.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 10 PC (DE/E) within the overall number of 55 beds Date of last inspection 8th June 2005 Brief Description of the Service: Redholme is situated in the Mossley Hill area of Liverpool close to Sefton Park. Redholme Memory Care Home provides 55 places for people over the age of 65years that have organic mental illness. Mrs Ann McCann is the owner and Registered Manager. Mrs Mc Cann is a qualified nurse with many years experience working with the service user group. Nursing staff and qualified care staff are in attendance 24 hours per day to facilitate care. Accommodation is provided on three floors, because of the design of the original building, the first and second floor exit at ground level into a well maintained large garden area. The home has developed an additional garden facility for service users and this will provide wheelchair access. A sensory garden is sited at the bottom of the garden. There are pleasant well-decorated lounges, dining rooms and small sitting areas around the house. A selection of bathrooms and toilets are provided, walk in showers and assisted bathing facilities are available. 45 single rooms and 5 double rooms are available with some en-suite toilet and washbasin facility. Redholme Memory Care Ltd DS0000060551.V282021.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This statutory unannounced inspection took place on 8th February 2006 over a period of four and half hours. During this time the inspector was able to speak to services users, relatives, visitors, the owner/manager and staff. A full tour of the premises took place. Sample documentation was viewed which included pre assessment documentation, care plans, staff personnel files, policies & procedures medication charts and safety certificates were examined. What the service does well: What has improved since the last inspection? The pre assessment documentation has been completely reviewed and updated. The home has a continuous programme of maintenance and refurbishment. Since the last inspection a number of new purchases have been made these include new stainless steel shelving for the kitchen store cupboard, the kitchen floor has been retiled and a new food processor and potato peeler has been purchased. Redholme Memory Care Ltd DS0000060551.V282021.R01.S.doc Version 5.1 Page 6 Some bedrooms have been refurbished and 12 new mattresses have been purchased for some of the bedrooms. A new mini bus has been purchased In collaboration with a pensioners art club a mural has been painted depicting Sefton Park and shows its individual attractions, this was stimulating discussion between the service users during the inspection. A software package has been purchased to maintain staff personnel files. The chef was appointed in September 2005 and is in the process of gathering information about the service users dietary choices and preferences this information will inform future menus. The skin mapping and tissue viability care has improved since the last inspection. The qualified nurses have attended a tissue viability course 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. Redholme Memory Care Ltd DS0000060551.V282021.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Redholme Memory Care Ltd DS0000060551.V282021.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1.2.3.4.5.N/A The homes Statement of Purpose and Service User Guide are well written and provide potential residents and/or their visitors with details of the services the home provides enabling an informed decision about admission to the home. The pre assessment documentation for self funding service users requires minor adjustments so that the holistic needs of service users is assessed, a plan of care developed so that the individual needs of service users will be met. EVIDENCE: In the past year the pre admission assessment document has been revised and rewritten in partnership with the multi-disciplinary team and Mersey Care National Health Service Trust (N.H.S.) The home has adopted the revised assessment format, the assessment tool is comprehensive and is developed to ensure that all the needs of the service user are identified. Since the last inspection the pre inspection assessment document for those service users who self fund has been totally revised and rewritten, further Redholme Memory Care Ltd DS0000060551.V282021.R01.S.doc Version 5.1 Page 9 minor amendments are needed to ensure that all holistic needs of service users will be assessed and provide the staff with sufficient information to develop a comprehensive care plan and ensure that all potential risks are identified and a plan of care implemented to minimize any risks. The manager or one of the qualified nurses visits the prospective service user at home or in hospital to undertake an assessment and records of this are kept. All service users in the home are provided with a statement of terms and conditions, plus a contract when they move in to the home on a permanent basis. A copy of this contract is kept on their personal file. Residents and or their relatives are able to visit the home or have an overnight stay before they move in on a permanent basis. Service users and their relatives spoken with during the inspection said that they had been provided with information and a “brochure” prior to moving into the home and the information had helped them reach their decision to move in. Redholme Memory Care Ltd DS0000060551.V282021.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7.8.9.10.11. Service users individual health, personal and social care needs are clearly recorded, and provides care staff with all the information they need to meet the service users individual care needs. Personal support in the home is offered in such a way as to promote and protect the resident’s privacy and dignity and independence. EVIDENCE: As part of this inspection, a series of the service users documentation was case tracked. Care plans and risk assessments for service users had been fully completed and the documents were signed and dated in accordance with the National Minimum Standards (NMS) and the Nursing & Midwifery Council (NMC) Codes of Practice. Skin mapping evidence for pressure sores is recorded in the service users personal file. It was evidenced that great care has been provided at the care home since admission and the inspector saw major improvements in the tissue repair and viability of a service user who was admitted from hospital with Redholme Memory Care Ltd DS0000060551.V282021.R01.S.doc Version 5.1 Page 11 advanced pressure areas. This improvement was documented through the use of photographic evidence Daily records were detailed and record critical incidences and reflect the ongoing events and changes in the service users daily life. All service users in the home can access their NHS entitlements, i.e.; GP, opticians, dentist, chiropody, etc. Care staff will accompany service users for hospital or clinic appointments if the service users family are unable to do so. GPs visit service users in the care home as and when the need arises. No service user in the home self medicates, all medications for service users are administered by the nurses in the home a dossette box system is in place. The protocols for the receipt, storage, disposal, and documentation of medications in the home are in accordance with the National Minimum Standards (NMS). During the inspection residents and their visitors said that staff in the home were always courteous, respectful, and maintained their privacy and dignity when giving personal care. Relatives commented to the inspector “that Mum is well cared for and I am kept informed of any changes” another relative told the inspector “Mum has been well cared for since she has been at the home the staff are lovely and I am always made welcome”. A family whose relative had recently died at the home, expressed the wish to speak with the inspector. The family spoke at length of the care and concern shown to their loved one during the last days of his life the family said “ he could not have received better care anywhere the staff were all fantastic” commenting that they “as the family were looked after too” “Refreshments were offered frequently as they sat with the service user” “The care was outstanding” Redholme Memory Care Ltd DS0000060551.V282021.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12.13.14.15. Service Users have choice and flexibility how they spend their day in the home, leisure activities are organised according to their choice and preferences. this allows maximum independence and individuality for each resident. Dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service users tastes and choices. EVIDENCE: Many of the service users at the home are severely cognitively impaired so individual choices are not always an option for them. Service users and or their relatives in the home are asked on admission about their lifestyle, choice of foods, and choices and preferences of the social activities they would like to participate in. The home has been working with young people from a local secondary school to produce a mural which reflects Liverpool places and people, this was recently launched and is the subject of discussion with the residents. Since the last inspection a older peoples art group have produced a mural which depicts scenes and features of the local park which is Sefton Park the images include the bandstand, the statue of Eros, the avariary Redholme Memory Care Ltd DS0000060551.V282021.R01.S.doc Version 5.1 Page 13 Visitors confirmed they are made welcome at all times, and are able to enjoy a meal with their relative or friend if they so wish. Service users may use their own room or a quiet area for private visits. Throughout this unannounced inspection there was evidence that a number of relatives and visitors were visiting the home, and were greeted and welcomed by the staff on duty. The residents and their visitors said that they enjoyed the variety of food in the home, which was “always presented well with lots of variety” and seasonal menus. Relatives said that they were invited to have a meal with their relative if they wished to. Since the last inspection a new chef has been appointed and the inspector saw copies of the questionnaire regarding dietary choices and preferences he had distributed to service users and /or their relatives. Redholme Memory Care Ltd DS0000060551.V282021.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16.17.18. The home has a detailed complaints procedure, with evidence that residents and or their relatives feel their views are being listened to and acted upon. EVIDENCE: Service users relatives and visitors said that they felt able to discuss any concerns they may have with the owner/registered manager and commented that “she works in the home on a daily basis, any issues raised are addressed immediately”. The visitors commented that the registered manager “runs a tight ship and the care of the service user is paramount to her”. “Any concerns are addressed, the manager is approachable and available most days”. On the day of the inspection there was evidence that many of the staff in the home had undertaken training on POVA protocols. The registered person is a member of Liverpool’s interagency Adult Protection Group. Since the last inspection a member of staff has been the subject of a disciplinary and was subsequently dismissed and referred to the P.O.VA. Register. There have been no other complaints recorded since the last inspection. Redholme Memory Care Ltd DS0000060551.V282021.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19.20.21.22.23.24.25.26. The standard of décor and furnishings within this home is of a high standard, with evidence of continuing improvements, through maintenance and planning. The home presents as a homely and comfortable environment for the service users. EVIDENCE: Redholme is accessible, safe and maintained to a high standard both inside and out. All rooms are redecorated on a regular basis. The home is set in well maintained gardens. A purpose built day centre is currently under construction in the grounds of Redholme on the completion of the building works the owner manager told the inspector that the rear garden of the home is to be landscaped and additional walkways constructed with raised beds and improvements to the sensory garden which will enhance the opportunity for service users to walk around the garden which will be a secure space and become involved in gardening. Redholme Memory Care Ltd DS0000060551.V282021.R01.S.doc Version 5.1 Page 16 On the day of this unannounced inspection the home was clean, odour free and the domestic style furniture and fittings result in a comfortable homely and pleasant environment. Since the last inspection there have been a number of improvements, a new laundry has been installed, the kitchen floor has been tiled, food processors have been purchased and new table linen bought. Stainless steel storage shelving has been purchased for the kitchen store room Visitors told the inspector ”There is always some improvements going on in the home- it is kept lovely”. The owner /Registered manger has developed the annual action plan for the care home which sets out in detail the improvements planned for the coming year. Redholme Memory Care Ltd DS0000060551.V282021.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27.28.29.30 The recruitment policies and practices of the home are robust, and the appropriate checks on staff are carried out. This ensures that service users are safeguarded from risk or harm. Records of staff training are kept and detail the training and development opportunities each member of staff have completed and evidence the competence of staff to do their jobs. Staff morale is high resulting in an enthusiastic workforce that works positively with service users and/or their relatives to improve the quality of life for service users. EVIDENCE: The care home operates a robust and comprehensive recruitment policy to ensure that staff have the required skills to facilitate care for all residents. On the day of this unannounced inspection a selection of staff personal files reviewed contained up to date enhanced CRB/POVA certificate. The Personal Identification Numbers (PINS) of all the registered nurse in the home were documented on Nursing and Midwifery Council (NMC) stationary. The home has a comprehensive staff development and training strategy. All members of staff at the care home have access to mandatory and specialist training and records are kept of courses attended. Redholme Memory Care Ltd DS0000060551.V282021.R01.S.doc Version 5.1 Page 18 All staff in the care home receive documented supervision six times per year to ensure that their performance/work with the service users is safe and promotes a sense of well being for each resident. Annual appraisal is in place for all staff. 85 of care staff hold N.V.Q Level 2 and other staff are currently working towards the award. Since the last inspection the qualified nurses have all completed a tissue viability course, which has seen an improvement in the management of tissue viability and pressure areas within the home. All qualified nurses hold City and Guilds Level 4 in Management Redholme Memory Care Ltd DS0000060551.V282021.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31.32.33.34.35.36.37.38. The owner/manager is supported well by the qualified nurses in providing clear and consistent leadership at the home and all staff work hard to meet the ongoing and changing needs of the service users. EVIDENCE: The care home benefits from the clear leadership of the registered manager who is also the registered owner. She is a qualified first level nurse who is constantly planning improvements at the home to enhance the quality of care provided to the service users Comments received during the inspection from residents, relatives, staff, visitors to the home and professionals who work with the home all confirm that the manager involves and informs them about all aspects of the management of the home. Relatives said that “the manager was always available to discuss any issues of concern or just to have a general chat.“ ”Relatives confirmed that they are kept informed of the changing needs of the service users.” Another family spoke about the additional care and Redholme Memory Care Ltd DS0000060551.V282021.R01.S.doc Version 5.1 Page 20 support the manager and her staff provided to the “whole family, offering constant reassurance at times of stress and crisis” Relatives said that the manager was always available to discuss issues with them and all those spoken with were confident that any complaints or concerns would be dealt with. The homes certificates of insurance and worthiness for gas, electricity, fire equipments, lift, hoists, Employers Liability were in date and valid. The home holds the Investor in People Award. The owner manager has recently drawn up her annual improvement plan for the home, and is in the process of implementing several of the initiatives, which include landscaping the rear garden computerising staff personnel records accessing further training opportunities for herself and the staff team. Since the last inspection the pre assessment documentation has been reviewed and updated minor amendments are still needed to ensure that a totally holistic pre-assessment is completed prior to admission. The information available will assist in the development of a comprehensive care plan which will meet the needs of individual service users and protect their health, safety and welfare. Redholme Memory Care Ltd DS0000060551.V282021.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 3 3 3 3 3 Redholme Memory Care Ltd DS0000060551.V282021.R01.S.doc Version 5.1 Page 22 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 OP3 Regulation 14 Requirement The registered person is required to ensure that all prospective service users have a holistic, relevant pre-admission assessment prior to admission into the care home.Minor amendments are needed to the newly reviewed and updated pre assessment doumentc Timescale for action 15/03/06 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 Redholme Memory Care Ltd DS0000060551.V282021.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Redholme Memory Care Ltd DS0000060551.V282021.R01.S.doc Version 5.1 Page 24 - 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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