Inspection on 08/04/08 for Redlands House

This inspection was carried out on 8th April 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Redlands House 02/04/09

Redlands House 24/04/07

Redlands House 26/10/06

Redlands House 29/11/05

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 Kim Patience Unannounced Inspection 8th April 2008 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.V363361.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V363361.R01.S.doc Version 5.2 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) Redlands@fireflyuk.net Rhoderick James Robert Smart Mrs Frances Smart Position vacant Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Redlands House DS0000060855.V363361.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Thirty-three (33) Older People, not falling within any other category may be accommodated. 24th April 2007 Date of last inspection Brief Description of the Service: Redlands House is a care home providing personal care and accommodation for 33 older people. Mr Rhoderick Smart and Mrs Frances Smart are the owners and the Registered Manager is Lisa Rutter. The home is located on a busy road in Hellesdon on the outskirts of Norwich and is close to all local amenities. Redlands House is a large detached house that has been 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. The range of monthly fees at the time of writing the report is from £340 to £400. Redlands House DS0000060855.V363361.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that people who use this service experience adequate quality outcomes. This inspection comprises of a review of the last inspection report, information received from the service and about the service since the last inspection and a site visit. The site visit included a tour of the premises, interviews with residents, relatives, staff and management, assessment of residents and staff records and observations of daily life in the home. Verbal feedback was given to the acting manager at the end of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Improvements are still to be made in ensuring the home only admits residents that staff have the skills and competence to care for. Care planning and associated record keeping must be improved to ensure that all health and care needs are fully assessed and met. The home needs an improvement plan for the environment and must have equipment in place to aid independence. Redlands House DS0000060855.V363361.R01.S.doc Version 5.2 Page 6 Staff need to be provided with appropriate training to equip them with the necessary skills and knowledge to care for the range of needs people have. In addition, training is needed to ensure that staff know how to protect people. Quality assurance processes need to be progressed and monitoring systems fully implemented so that information can be gathered to show results and feed into the overall improvement plan. The Providers have responded to the draft report by telling us what they have been and are doing to improve the issues highlighted as needing attention. This includes recruitment practice, NVQ training, medication management and the general philosophy of care delivery. We will look at these improvements when we next inspect the service. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Redlands House DS0000060855.V363361.R01.S.doc Version 5.2 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.V363361.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 Quality in this outcome area is adequate as prospective residents are given information about the facilities and services and their needs are assessed. However, it is not clear whether the home is fully aware of people’s needs before they are admitted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service has a service users guide and a statement of purpose that is supplied to all prospective residents so that they have sufficient information about the facilities and services available. The home has a pre admission policy and procedure that includes a pre admission assessment and the opportunity to view the accommodation before moving into the home. The records relating to one recently admitted resident were inspected. A pre admission assessment had been completed but was not signed or dated and there was no evidence of the resident or a representative involvement in the Redlands House DS0000060855.V363361.R01.S.doc Version 5.2 Page 9 process. The lack of a date and signature means that we are not able to establish if the correct pre admission procedures were followed. This was an issue at the previous inspection and a recommendation was made. The home does not provide intermediate care services. Redlands House DS0000060855.V363361.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate as the home does have systems in place to ensure people have their health and care needs written into care plans. However, improvements are needed in this area in order to continue to provide adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care records relating to six residents were inspected and observations of those residents going about their daily lives were made. This was to ensure that what was written in the care records reflected people’s needs and preferences. In general the records were in good order, they contained an identifying photograph, care plans and health assessments along with daily progress notes recorded by care assistants. Records of medical contacts were being maintained so that it is clear where people had health needs requiring medical intervention they were being met. Redlands House DS0000060855.V363361.R01.S.doc Version 5.2 Page 11 The care records showed some individualised information and life history and although it is not so important to have this information with people who have capacity to express their needs and expectations, it is good practice. One care plan showed good clear guidance about how to manage behavioural disturbances effectively. However, there were some inconsistencies in care planning and the home must have systems in place to ensure that care plans and health assessments are written where necessary for all residents. For instance, some residents did not have care plans that covered basic needs such as personal care, bathing and oral hygiene. In at least two cases there was evidence of falls but no falls assessment and action plan had been written in response to the risk. In two other cases nutritional needs assessments had been completed and showed risks but there was no care plan setting out what steps should be taken too reduce the risk. Another resident had a diagnosis of schizophrenia but there was no care plan guidance on how the mental health issues may affect the person’s daily living and what action should be taken when behavioural disturbances occur. It was evident from the individuals daily care records that there were episodes of social isolation and times when the person would sleep in their clothes. Some of the records looked at contained care plan reviews and others did not. For instance, one resident’s care plans did not fully reflect their needs and had not been updated as needs changed. This person has a diagnosis of dementia and records showed the person was confined to her room. When a care assistant was asked why this was so she replied ‘‘she’s got lewy bodies dementia’’ giving the impression that she thought the person should be kept in her room because of the dementia. The home is not equipped to care for people with dementia and must ensure staff are trained appropriately to meet the varying needs of people accommodated. In addition, those preparing care plans must have knowledge of the needs of people with dementia/mental health issues as good care planning is essential for people who do not have the capacity to express their health and care needs. The inspection of the medication standard was conducted at the same time by the Commission’s pharmacist inspector. He found that most medicines were properly and securely stored, however, the home currently does not have secured storage for external medicines that are currently held in resident’s rooms so people are at risk of harming themselves with such medicines. The controlled drug safe has a combination lock so it was advised that the combination number is changed regularly. The inspector found that there was information alongside medication charts to assist carers when given medicines to residents. This includes residentRedlands House DS0000060855.V363361.R01.S.doc Version 5.2 Page 12 identifying photographs and health-related information and known allergies on separate sheets. There were care plans in place for medicines prescribed at the discretion of care staff but there were inconsistencies evident needing amendment for the purposes of safety. For one resident prescribed a psychoactive (and potentially sedative) medicine for administration by staff at their discretion, written guidance was inadequate because it did not state nonmedicinal measures to be attempted first when managing the resident’s behavioural disturbances. In addition, when the medicine was administered for this purpose records did not indicate that the use of the medicine was clinically justified so it could not be seen if the use of the medicine was necessary. The inspector observed medicine administration at lunchtime and found procedures followed by the member of staff satisfactory. One resident was administered medicines by crushing them. There was a written instruction in place written by a GP authorising this practice when the resident is unable to swallow. There were two residents currently self-administering medicines, however there had been no risk assessment undertaken to establish the risks to residents and a plan in place to monitor risks. The resident was said to have a locked container in his room but security of medicines is not checked regularly by staff. For a resident self-administering eye drops there was no risk assessment in place examining the ability to safely handle and administer the eye drops. The inspector found that there were medicines that were not available and had not been administered to residents as prescribed. This included co-dydramol tablets (for moderate pain) for two residents who had not been given them for days but who from the records it was evident that they were needed. The manager gave assurances that urgent action would taken to ensure medicines currently unavailable would be obtained as soon as possible. On examining current medication records it was noted that records for the administration of medicines had been completed, however for some medicines that were not administered at lunchtimes there were records on the reverse of the charts stating that the dose had been ‘too close to morning medicines’. On discussion with the manager, it was evident that some morning medicine rounds had been delayed because of shortages in staffing levels. One resident with Parkinson’s Disease requiring frequent dosing to control symptoms had missed lunchtime doses because of this. The home conducts regular audits of medication records and medicine quantities. This is good practice to ensure records demonstrate medicines are being given as prescribed. During the inspection, sample audits found that most medicines could be accounted for by records. However, three discrepancies were identified. The manager had already been aware of two by the internal audit and had investigated them. Disposal records were also audited and found satisfactory however the records were poorly organised and they had not been signed by the recipient pharmacy. The disposal of controlled drugs had also not been recorded as Redlands House DS0000060855.V363361.R01.S.doc Version 5.2 Page 13 there had only been one person involved with this and quantities disposed of were not stated. It was evident that the home was regularly attended by a GP from Hellesdon medical practice on a weekly basis when medication reviews are conducted. There were records of GP interventions and changes to medication. This included one resident recorded as having Lewy Body dementia with significant doses of medicines. There were also two residents recorded as having schizophrenia. The inspector was provided documentary evidence of staff authorised to administer medicines receiving training, however, on discussion, internal assessments of staff competence have not been conducted. Redlands House DS0000060855.V363361.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good as residents social care needs and expectations are considered. A choice of nutritious food is provided in a comfortable setting. This judgement has been made using available evidence including a visit to this service. EVIDENCE: This home in the main accommodates people who are able to express their preferences in respect of daily life and social needs. However, there are at least three people who cannot and the home needs to pay particular attention to ensuring their social and psychological needs are documented and met appropriately. The home now employs an activities person who was available for interview during the inspection. She has been in post for approximately 8 weeks and is in the process of familiarising herself with the new role and what residents want in relation to activities. Some of the activities provided so far include taking people out of the home in the minibus, games, group activities, one to one sessions and hand massage. In addition, external entertainers have been booked to do activities and seasonal events and volunteers visit the home to do reminiscence every six weeks. Redlands House DS0000060855.V363361.R01.S.doc Version 5.2 Page 15 There is a plan to assess social care needs and write individual plans with each resident. The activities coordinator is keen to ensure that all plans of activities take individual needs into consideration. The home employs a full time cook to cover 7am – 7pm who prepares menus based on what resident’s preferences are. Two main meal options are offered and on the day of inspection the choice was curry or toad in the hole. Alternatives are offered where people wish for something different. The cook said all the food is freshly baked using local produce. Residents spoken with said the food was good and they always enjoyed the meals. Meals are served in two sittings, one for people who can dine independently and the other for those that need support. Staff were observed to provide support in a sensitive and discrete manner giving people time to enjoy their food. It was noted that some residents required liquidised food and this was mixed together in one bowl giving a soup-like appearance. People requiring liquidised food must be given the opportunity to experience the various tastes, textures and colours of foods and as such food should be presented in separate liquidised portions. Observations during mealtime showed that people were offered choices of where to sit and whether they would like anything to protect clothing during dining. People were offered a choice of meal earlier in the day. During the visit visitors were seen coming into the home. Two were spoken with and said their experience of visiting was always positive. Staff were welcoming and they could visit at any reasonable time. One relative said he was happy with the care provided and communication with the home was good. Another visitor said the home was clean, tidy and comfortable. Redlands House DS0000060855.V363361.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate as residents and relatives are provided with information about how to make a complaint. There is a safeguarding adults policy but staff are yet to receive training in this area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints policy and procedure, which is displayed in the entrance hall. It was recommended that the procedure is written in larger print to make it more prominent and for those people with visual impairments. In addition the home has a suggestions leaflet so that people can make comments as they wish. Relatives meetings are now held quarterly and provides a forum for people to voice any concerns they may have. Since the last inspection there has been one complaint, which was referred to the Commission as the complainant was not happy with the outcome of the homes investigation. Elements of the complaint have been investigated as part of this inspection. The home has a safeguarding adults policy and procedure and although staff know how to raise concerns they have not received any training in the protection of vulnerable people. Redlands House DS0000060855.V363361.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 26 Quality in this outcome area is adequate as residents experience a clean tidy comfortable environment. However, improvements are needed in some areas to enhance psychological wellbeing and promote independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home offers private and communal accommodation that is comfortable, clean and homely. On the day of the visit there was a staff training session taking place in one half of the residents lounge. This meant that some residents did not have the choice to sit in there and were directed to another room. It is not appropriate to use the resident’s lounge for training sessions as this restricts people’s rights and choices. Redlands House DS0000060855.V363361.R01.S.doc Version 5.2 Page 18 Residents and relatives spoken with were please with the standard of accommodation provided. It was noted that some of the communal bathrooms would benefit from redecoration and refurbishment. In addition, the home appears to lack some aids and adaptations particularly in the communal toilets such as handrails, toilet frames and raised toilet seats. It is recommended that the home requests an occupational therapy assessment to ensure that appropriate equipment is in place to promote independent use of facilities. Redlands House DS0000060855.V363361.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is poor as residents cannot be assured that staff are trained and competent to meet the range of needs in the home. In addition recruitment practice is in need of further improvement. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has assessed people’s dependency levels and determined that the staffing levels should be maintained at 5 on duty from 7am – 2pm, 3 on duty from 2pm – 4pm, 4 on duty from 4pm – 6.30pm, 5 on duty 6.30 – 9pm and 2 during the night shift. The manager said the staffing levels were adequate to meet the needs of residents and there was no real evidence to the contrary on the day of the visit. However, staff interviewed said that residents would benefit from additional staff on duty in the mornings, as it was sometimes difficult to fully meet people’s needs. Copies of the staff rosters were taken and later analysed. The rosters show that staffing levels have fluctuated due to sickness and holidays and at times have been lower than the target levels but it is accepted that this is a temporary problem. Redlands House DS0000060855.V363361.R01.S.doc Version 5.2 Page 20 Residents and visitors spoken with said that the staffing levels were adequate and did not raise any concerns about their needs not being met. Staff training was assessed and during the visit the manager provided an up to date training matrix that showed what training staff had undertaken. The matrix shows that training in key areas such as fire safety, POVA, Moving and handling and infection control has not been provided to all staff. The home is currently in the process of developing a training and development programme for 2008, however, it is essential that the deficits in mandatory training are addressed as a matter of priority. All new staff undertake induction training that meets the skills for care common induction standards and 38 of staff are trained at NVQ level 2 or above. Again, the service must increase the provision of NVQ training to ensure that they meet the 50 workforce target. Recruitment procedures were assessed. Five new staff files were checked and showed that recruitment and record keeping could be improved. For instance one application form was not signed or dated by the applicant, it was not clear if the home had applied for POVA checks and CRB checks prior to the person commencing and some files did not have photo ID. However, all staff had an enhanced CRB check and disclosure numbers were recorded on the files. It is required that a file audit be completed to ensure the records comply with the requirements set out in schedule 2 of the Care Homes Regulations. Redlands House DS0000060855.V363361.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 Quality in this outcome area is adequate as the home has a manager who is supported by a consultant. Management systems are being implemented and will drive improvement in the service overall. Health and safety is in need of improvement, as the home cannot evidence that staff are trained in key areas. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home does not have a registered manager at present. However, there is an acting manager who has worked at the home for a number of years in other capacities. She currently undertaking an NVQ level 4 and will be submitting an application for registration in due course. Redlands House DS0000060855.V363361.R01.S.doc Version 5.2 Page 22 Since the last inspection, Mr and Mrs Smart have appointed a consultant who has completed an assessment of all the three homes owned in order to establish areas of improvement. The consultant has supplied the Commission with an interim improvement plan and is working closely with all managers to ensure it is achieved. The consultant will also be conducting the regulation 26 visits and monitoring progress closely. The manager talked about how beneficial she found the guidance and support that was now available. The Quality assurance process is underway and it is reported that the first quality assurance report will be produced in the near future. Quality monitoring systems are being introduced in all the homes. The home supports people with their finances by keeping small amounts of petty cash. Any monies are kept separate and locked away in a safe that only authorised people have access to. Copies of expense accounts are sent to relatives. A programme of supervision has commenced and all staff will undergo an appraisal to establish any training and development needs and to ensure they know what the homes aims and objectives are. It was noted during the visit that the homes policies and procedure are in need of updating and this must be given priority. There were no apparent health and safety issues around the home. However, it has already been identified that some staff have not undertaken training in fire safety and moving and handling and this could place people at risk of harm. A fire safety risk assessment has been completed this year along with all the equipment checks. Redlands House DS0000060855.V363361.R01.S.doc Version 5.2 Page 23 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X 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 X 18 2 2 X X 2 X X X 3 STAFFING Standard No Score 27 2 28 1 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 3 X 1 Redlands House DS0000060855.V363361.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 12.1 Requirement Each resident must have written care plans, health assessments and risk assessments to ensure that their health and care needs are met. All aspects of a resident’s care plan need to be reviewed and kept up to date. This will ensure that the appropriate care is provided as need changes. Medicines prescribed for external application when stored in resident’s rooms must be safely and securely stored. . Timescale for action 01/07/08 2. OP7 15.2 01/07/08 3. OP9 13.2, 13.4 02/05/08 4. OP9 5. OP9 13.2, 13.4 Medicines prescribed of a psychoactive (and sedative) nature must only be given to residents when clinically justified. This must be demonstrated by record-keeping practices. 13.2, 13.4 Residents self-administering medicines must have risk assessments undertaken to ensure they can safely manage their medicines. DS0000060855.V363361.R01.S.doc 02/05/08 02/05/08 Redlands House Version 5.2 Page 25 6. OP9 12.1, 13.2 The non-availability of medicines must be avoided and promptly obtained at all times so that residents can be administered them as scheduled 08/04/08 08/04/08 7. OP9 13.2, 13.4 Full and accurate records must be completed for the disposal of medicines. This must include records for the disposal of controlled drugs. 01/07/08 8. OP9 16.2(i) 9. OP37 17.2 Liquidised meals must be 01/07/08 presented in a manner that promotes dignity and enables people to experience the taste and texture of various foods. Within the home there should be 01/07/08 a file for all staff that includes all of the information as identified in schedule 2 of the Care Homes Regulations 2001. All staff must be provided with suitable training in fire safety and prevention. All staff must be trained to carryout their duties effectively. This includes the need for moving and handling and safeguarding adults training. 01/07/08 01/07/08 10. 11. OP38 OP38 23.4(d) 13.5 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Redlands House DS0000060855.V363361.R01.S.doc Version 5.2 Page 26 No. 1. 2. 3. 4. Refer to Standard OP3 OP19 OP22 OP30 Good Practice Recommendations The date on which an assessment of a prospective resident takes place should be noted on the assessment form. It is recommended that the home has a plan of maintenance and renewal for improvements that need to be made to the environment. It is recommended that the home has an assessment of the communal facilities to ensure that aids and adaptations that promote independence are in place. It would be good practice for the manager to devise a training profile enabling her to monitor what training has been completed and what further training needs to be completed or updated. It is recommended that the home has an up to date set of policies and procedures. It is recommended that the combination code to the controlled drug cabinet is regularly changed It is recommended that detailed care plans are developed for the management of resident’s behavioural disturbances including non-medicinal measures. In addition, the exact circumstances when the administration of psychoactive medicines should be considered when prescribed for administration at the discretion of staff should be included. It is recommended that following training, the competence of staff authorised to handle and administer medicines is assessed on a regular basis via supervision events. 5. 6. 7. OP37 OP9 OP9 8. OP9 Redlands House DS0000060855.V363361.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Redlands House DS0000060855.V363361.R01.S.doc Version 5.2 Page 28 - 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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