Inspection on 29/11/05 for Redlands House

This inspection was carried out on 29th November 2005.

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

Redlands House 02/04/09

Redlands House 08/04/08

Redlands House 24/04/07

Redlands House 26/10/06

Redlands House 21/07/05

Redlands House 03/03/05

Redlands House 11/10/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Redlands House 134 Reepham Road Hellesdon Norwich Norfolk NR6 5PB Lead Inspector Ann Catterick Announced Inspection 29th November 2005 09:30 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 Redlands House DS0000060855.V260148.R01.S.doc Version 5.0 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. Redlands House DS0000060855.V260148.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Redlands House Address 134 Reepham Road Hellesdon Norwich Norfolk NR6 5PB 01603 427337 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) Rhoderick James Robert Smart Mrs Frances Smart Miss Lisa Rutter Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Redlands House DS0000060855.V260148.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Thirty-three (33) Older People, not falling within any other category may be accommodated. 21st July 2005 Date of last inspection Brief Description of the Service: Redlands is a care home providing personal care and accommodation for 33 older people. It has recently changed ownership and is now owned by Mr Rhoderick Smart and Mrs Frances Smart and the new registered manager is Lisa Rutter. The home is located on a busy road in Hellesdon on the outskirts of Norwich. It is close to all local amenities. Redlands is a large detached house that has been much extended over recent years. There is accommodation on the ground and first floor, providing seven double and nineteen single bedrooms. Some of the rooms have en-suite facilities and there are a number of other toilet facilities throughout the home. There are three bathrooms and one shower room. There are three communal lounges and a large dining area. There is a passenger lift. The grounds and garden area are well maintained and provide attractive outside facilities for service users in the summer months. Redlands House DS0000060855.V260148.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and took place on the 29th of November and lasted 7.5 hours. Prior to the inspection a pre inspection questionnaire was completed and returned to the CSCI with all relevant details. A copy of the staff rota was included as well as details of staff and a copy of the menu. Seventeen comment cards were received from service users, four from relatives and two from the local health practitioners. Twelve of the service users who replied said they liked living in the home and five said they sometimes liked living in the home. On the day of inspection service users were very positive about the staff and the care that they received. Overall the feedback was good. Comment cards were mostly very positive about the food and the new winter menus looked good. Staffing levels at the home are sufficient although some comment cards received from relatives and residents suggested more staff would be an advantage. The only part of the day when staffing is not good, but adequate, is between 2pm and 6.30pm. The manager has increased the staffing at this time and hopes to improve this further. Overall there is ample staffing to meet the needs of service users. Many of the service users living in the home have minimum care needs and are able to be fairly independent. On the day of inspection care needs of service users were being met. What the service does well: All of those service users spoken to were positive about the staff group. The home has a stable staff group who are committed to providing good quality care. Feedback from a relative gave some evidence of this, “my mother always looks well cared for, with her jewellery on and hair set and that means a lot to her and us.” The chef does lots of home made cooking and baking and the menu looked varied and appetising. The kitchen is well maintained and managed. One service user stated, “ The food is delicious.” Another said “food on the whole very good.” The new care plan format it good and includes all relevant information. All service users should have care plans in the new format by the next inspection. Redlands House DS0000060855.V260148.R01.S.doc Version 5.0 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. Redlands House DS0000060855.V260148.R01.S.doc Version 5.0 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 Redlands House DS0000060855.V260148.R01.S.doc Version 5.0 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): 0 None of these standards were inspected on this occasion. EVIDENCE: Redlands House DS0000060855.V260148.R01.S.doc Version 5.0 Page 9 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 and 10 The care plans of service users identify their health, personal and social care needs. The home has a policy and procedures for all matters regarding medication and these promote good practice. Staff treated residents in a way that respected their right to privacy. EVIDENCE: Three care plans were looked at in some detail. The manager is in the process of changing the format of the care plans. Each care plan had a front page with all relevant details, including a photograph. This form was identified as a missing person form and was seen as good practice. The care plans were easy to read and included all of the information needed to provide care and support to the service user. Another example of good practice was where the care plan identified whether or not a service user needed glasses it identified whether the service user was long or short sighted. Good information relating to health and medical conditions was on file. Good information relating to continence management and good risk assessments relating to manual handling was seen. Redlands House DS0000060855.V260148.R01.S.doc Version 5.0 Page 10 All records relating to administration of medication were inspected and good practice was seen in this area. Only senior staff have the key to the medication cupboard. Two medications from the medication administration record (MAR) sheet were tracked to the medication containers (MDS) and these were accurate and reflected good practice. The administration of medication to all service users takes about 30 minutes in the morning, less at other times and all service users have their medication at the correct time. No photographs are on the MDS system and this may be beneficial. The home does not need to use agency staff therefore all staff know all service users. Overall a safe system with good practice takes place. Staff were seen working with service users and they did this in a way that promoted their privacy and respected their dignity. All of those staff spoken to spoke positively about staff and said that they treated them well. Those staff spoken to had a good knowledge of service users needs and when they spoke of how they cared for service users they described good practice. Redlands House DS0000060855.V260148.R01.S.doc Version 5.0 Page 11 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, 14 and 15 Most service users find that the lifestyle experiences had at Redlands meet with their expectations. Service users are encouraged to make informed choices over their daily lives. The food provided within the home is wholesome and varied and the dining area is comfortable, well decorated and furnished. EVIDENCE: Some of those service users who live in the home have been resident for some time and are aware that the dependency levels of some service users has increased and that there may be less able people living in the home. The inspector was able to speak with these service users and explain to them that this is general throughout the care provision. Overall these service users were satisfied with their lifestyles within the home. All of those other service users spoken to were very positive saying that the home was comfortable and friendly and that they had the opportunity to go out in the mini bus each week if they chose to do so. There appeared to be ample staff on duty and staff are able to meet some of the social and emotional needs of service users as well as the personal care needs that they may have. Redlands House DS0000060855.V260148.R01.S.doc Version 5.0 Page 12 Staff encourage service users to make choices about their day-to-day lives. Examples of this are; whether or not service users’ chooses to bath in the morning or evening or whether a service users prefers to eat in the dining area or their room. Some service users spend most of their time in the communal areas whereupon others prefer to spend their time in their rooms. The chef is competent and enthusiastic providing good quality food that is variable and plentiful. Service users are encouraged to suggest what they would like included on the menu. A new winter menu had just been devised. Redlands House DS0000060855.V260148.R01.S.doc Version 5.0 Page 13 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 The home has a complaints procedure that is included in the Service User Guide. EVIDENCE: All of those service users spoken to said that they would know who to speak to if they wanted to make a complaint. No complaints had been received by the home in the last year. Redlands House DS0000060855.V260148.R01.S.doc Version 5.0 Page 14 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, 25 and 26 Service users live in a comfortable, homely, well -maintained environment that is clean, hygienic and well cared for. The radiators that are not covered could put service users at unnecessary risk. EVIDENCE: The overall quality of the environment is good. Private and communal accommodation is comfortable and a new carpet has recently been bought for the dining area. The new proprietors have further plans for improvements and no major decoration or refurbishment will take place until this time. Not all radiators are covered and a requirement has been made in this area. On the day of inspection the home was clean, tidy and free from offensive odours. Redlands House DS0000060855.V260148.R01.S.doc Version 5.0 Page 15 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): 27,29 and 30 The home has enough competent, experienced staff on duty at any one time to ensure that the needs of service users are met. The home has clear procedures regarding recruitment and selection and these procedures aim to protect and support service users. Staff receive induction and foundation training and are monitored to ensure that they are competent to do their jobs. EVIDENCE: The staff care rota was seen and the rota showed that there were sufficient numbers of staff on duty at all times to ensure that the needs of service users are met. On the day of inspection staff were seen to be working with service users in an unhurried way and had time to offer good quality care. During the hours of 2pm and 6.30pm staffing is adequate but at a minimum. The manager has improved staffing levels at this time and plans to improve this further. The home employs sufficient numbers of domestic staff but due to staff sickness there has been a temporary shortage in this area. However the home looked clean tidy and well cared for. Some staff files were inspected, all staff are required to provide two references and have a CRB check prior to commencing work. The homes application form was seen and gives opportunity for improvement. It does not give enough space for details of previous employment. On one reference a previous Redlands House DS0000060855.V260148.R01.S.doc Version 5.0 Page 16 employer has said she would not re employ a prospective employee. This matter should have been further investigated prior to appointment to ensure all parts of the recruitment and selection process was thorough. No statement of terms and conditions or evidence of supervision was seen on file. Evidence of induction was seen and signed. All new staff have induction training and the home provides foundation training that meets with recommended requirements. Redlands House DS0000060855.V260148.R01.S.doc Version 5.0 Page 17 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, 33 and 35 A person, who is experienced, trained and competent, able to complete her role in full, manages the home. Only part of standard 33 was inspected and a fuller inspection will take place at the next inspection. The home does not take any responsibility for service users finances. EVIDENCE: The manager is an experienced manager who has her NVQ level 4 in management and care. She is promoting good practice and aims to ensure that Redlands House DS0000060855.V260148.R01.S.doc Version 5.0 Page 18 the home provides good quality care. This was the case on the day of inspection. The inspector has not highlighted the area of self-audit visits as identified in regulation 26 of the Care Homes Regulations 2001 at previous inspections. Where the Registered Provider is an organisation or partnership a monthly visit needs to take place as set out in the regulation and a written report completed and a copy sent to the CSCI and the manager of the home. This is a requirement and the Proprietor has now been made aware of his responsibility in this area. The home takes no responsibility for service users finances. Service users and/or their families take responsibility for the finances and if a bill such as hairdressers or chiropody needs to be paid and a resident does not have the money the home will pay it and give the bill to the family. Information about financial advocacy services is available for residents and their families. Redlands House DS0000060855.V260148.R01.S.doc Version 5.0 Page 19 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 x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 3 x x x x x 2 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x x x 3 x x x Redlands House DS0000060855.V260148.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP25 Regulation 13.4 Requirement The registered person must ensure that all radiators that the service users have access are covered or are of low surface temperatures. Timescale for action 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP29 Good Practice Recommendations It would be good practice to devise an application form that enables prospective employees to give as much information as possible about their previous employment. Redlands House DS0000060855.V260148.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Redlands House DS0000060855.V260148.R01.S.doc Version 5.0 Page 22 - 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!