Inspection on 10/05/07 for Redstacks

This inspection was carried out on 10th May 2007.

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

Other inspections for this house

Redstacks 08/06/06

Redstacks 18/01/06

Redstacks 02/09/05

Redstacks 12/01/05

Redstacks 12/08/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Redstacks 36 Heads Lane Hessle East Yorkshire HU13 0JH Lead Inspector Janet Lamb Unannounced Key Inspection 10th May 2007 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 Redstacks DS0000019715.V340099.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. Redstacks DS0000019715.V340099.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Redstacks Address 36 Heads Lane Hessle East Yorkshire HU13 0JH 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) 01482 640068 01482 647533 Redstacks@redmore1.karoo.co.uk Mrs Audrey Zeane Redmore Yvette Donnelly Care Home 14 Category(ies) of Dementia - over 65 years of age (14), Old age, registration, with number not falling within any other category (14) of places Redstacks DS0000019715.V340099.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th June 2006 Brief Description of the Service: Redstacks is a privately owned care home that is part of a local organisation. The home is a large old house set in its own grounds and has recently been extended to provide accommodation for 14 service users. It is situated in a residential area of Hessle and is well maintained and decorated. Fees paid range from £334.80 - £425.00 per week, and there is an additional charge for hairdressing, private chiropody, toiletries and newspapers. The home had two vacancies on the day of the site visit. Communal accommodation consists of two lounges and one dining room. Private accommodation consists of 12 single bedrooms and 1 twin bedroom. Good quality furniture and furnishings are provided throughout the home. Service users are able to bring their own possessions into the home to personalise their rooms. The garden has been specially designed to provide a safe environment for service users and it is easily accessible via various exits. Service users can access the first floor of the premises via a stair lift and a passenger lift. There is a car park at the front of the premises. Redstacks DS0000019715.V340099.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Key Inspection of Redstacks has taken place over a period of time and involved sending a request for information to the home in March 2007 concerning service users and their family members, as well as staff and details of the home’s policies, procedures and practices. The Commission received the requested information in April 2007 and questionnaires were then issued to all service users and their relatives, their GP and any other health care professional with an interest in their care, to social service departments commissioning their care and to the staff working in the home. This information obtained from surveys and information already known from having had contact with the home over the last few months, was used to suggest what it must be like living there. A site visit was made to the home on 10th May 2007 to test these suggestions, and to interview service users, staff, visitors and the home Manager. Some documents were viewed with permission from those people they concerned, and some records were also looked at. The communal areas of the home were viewed, along with two bedrooms on the ground floor and one on the upper floor. A total of three service users and two staff were interviewed and the Manager and one relative were asked to provide information or were spoken to during the site visit. A second relative offered to discuss the service provided and all of the information collected was checked against the information obtained through questionnaires and details already known because of previous information gathering and contact with the home. What the service does well: Service users are assessed on entry to the home, having been given good information on what the home is like and what to expect, and they are provided with a good care plan for staff to follow. They are well supported with health care that meets their needs and their expectations. They are protected from possible harm due to taking the wrong medication, because they have their medication handled by the staff in the home, and the staff follow robust practices and procedures. The service handles medication satisfactorily and staff dealing with drugs have been trained in medication administration. Service users have their dignity well maintained, and their right to make decisions is respected. Redstacks DS0000019715.V340099.R01.S.doc Version 5.2 Page 6 They are encouraged to maintain contact with family and friends and enjoy visits from these people any time of the day, and they are encouraged to exercise choice and control over their lives, wherever possible. Service users enjoy very good food, which matches their expectations and preferences, but also offers a satisfactory level of nutrition. They are fairly confident their complaints will be listened to and acted upon. Service users are protected from abuse by robust recruitment and selection procedures and practices, as well as by the service’s policies, procedures and practice under the safeguarding adults systems. They experience a safe, clean and well-maintained environment. The Manager runs the service in the best interests of the service users, safeguards their financial interests, and maintains their health, safety and welfare. What has improved since the last inspection? What they could do better: Redstacks DS0000019715.V340099.R01.S.doc Version 5.2 Page 7 The service could make sure the new contract or statement of terms and conditions meets the requirements of standard 2.2. The service could make sure any activities undertaken are recorded on the activities record, but make sure health or care activities are recorded on diary notes. The service could make sure service users have their levels of privacy improved when staff wish to enter rooms. The service could make sure food provision is based on greater consultation of service users to seek their preferences and choices. The service could make sure staff fully understand their responsibilities for the referring of safeguarding adult’s issues. The service could make sure staff induction programmes are completed within six weeks. The service should make sure there are sufficient staff on duty each shift to meet the needs of service users and to enable the Manager to undertake managerial tasks instead of caring and cooking ones. The service could make sure two signatures are obtained for any transaction of service users’ money held in safekeeping. 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. Redstacks DS0000019715.V340099.R01.S.doc Version 5.2 Page 8 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 Redstacks DS0000019715.V340099.R01.S.doc Version 5.2 Page 9 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 only. Standard 6 is not applicable. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users have their individual and diverse needs well assessed so they are confident needs will be met. They receive sufficient written information in the form of a statement of purpose and a service users guide so they can decide if the home is the right place for them. EVIDENCE: Service users and management spoken to and documents seen in case files, with permission from service users, reveal some service users have social service community care assessments and contract documents and some have Redstacks assessment and contract documents held in their files, depending on who is assisted with payment of the accommodation charge, and who pays privately. Redstacks DS0000019715.V340099.R01.S.doc Version 5.2 Page 10 All service users are assessed using one of the formats and both methods include details of such as personal care needs, health needs and social and emotional etc. needs, and considers individual differences to be taken into account because of religion, race, sexuality or disability etc. Redstacks contracts were put into place shortly after the requirement to hold them was made at the last inspection. Although they contain basic details of the contract agreement and have an accompanying sheet of the terms and conditions of residency, they do not contain all of the information suggested in standard 2.2, so the Manager was advised to review the document for any new service users coming to live in the home. Where possible service users sign all of these documents or their relatives do so, and signatures were seen on those viewed. There is a statement of purpose and a service user guide for prospective service users and family to view, but those in the home spoken to could not remember having seen them, though all did say they believe their family members ‘dealing with everything’ may have copies. One relative also thought another family member may have copies of these. Standard 3 is met, but standard 6 is not applicable. Standard 2 is now met. Redstacks DS0000019715.V340099.R01.S.doc Version 5.2 Page 11 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 and 10. People who use the service receive good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users have their health and social care needs well documented in care plans, so they are confident all their needs will be met. They have their medication needs well managed, and they enjoy good levels of privacy and their dignity is well maintained, so their overall quality of life is good. EVIDENCE: Service users, staff and management spoken to and documents seen in case files with permission reveal care plans are in place to show how health, care and social needs are met, that medication is handled appropriately and safely and that privacy and dignity are well maintained. All service users have a working care plan that shows admission details, a personal profile, a life history, and ten areas of need covering mobility, diet, Redstacks DS0000019715.V340099.R01.S.doc Version 5.2 Page 12 medication, health, social activities, etc. and which state goals for achieving improvements and any changes in need that affect the plan of action. Care plans are reviewed annually with the cooperation of the placing local authorities, following initial six week and three month reviews after admission. Care staff also review care plans monthly when they complete service users’ monthly summary reports, any changes in needs are noted and care plans are changed to reflect these if necessary. Standard 7 and 8 recommendations at the last inspection, to review care plans and include nutritional screening have now been met. Daily diary notes show how service users needs are met, what support and assistance they receive etc. and who has visited. There are also individual sheets recording GP or District Nurse visits or appointments at hospital, to show chiropody appointments, and to show physiotherapy, as well as weight charts and food and fluid intake if necessary. Service users spoken to were quite satisfied with the levels of care and support they receive, and state the care is provided in the way they prefer and request it. One said, “I look after myself mostly, but staff do help me when I take a bath.” Another said, “Yes, any help is given how I want it, I would say so. I ask for help and always get it, though I’m told I should ask more often. I try to be independent.” Medication handling and administration systems are satisfactorily controlled. Staff spoken to explain they have completed medication administration training and that they know of and follow the policy and procedure for handling drugs. The Manager showed where medicines are stored, and demonstrated that medicines are only signed for as given once they have been taken by the service user. Medication that is not used for any reason is returned to the chemist in the ‘blister packs’ or in bottles, labelled and accompanied with a self-carbonating ‘Tabag’ form saved from a previous dosage system. There are no service users self-medicating at the moment. Those spoken to say, “My medicines are looked after by the staff, I get them on time,” and “Staff look after my medication, they change the chemist though sometimes and the tablets are different. I like the caplet paracetamols best because I can snap them in half. I take one and a half tablets every night you see.” A requirement made at the last inspection under standard 9, to hold staff sample signatures for signing the administration of medication and the recommendation made, also under standard 9 to obtain a medication fridge, have now been met. Service users spoken to and observation of interaction with staff and management reveals service users privacy and dignity are being well maintained. One service user said, “If I needed some time in private I Redstacks DS0000019715.V340099.R01.S.doc Version 5.2 Page 13 imagine I should get it. Oh yes any care I need I only have to ask for it and staff would be discreet.” Another said, “When some staff knock on my door they wait for me to reply, others just knock and enter.” This was observed while interviewing a service user and their relative. A staff member came in with tea, without waiting for a reply on knocking. Service users were observed being spoken to quietly and discreetly and no one appeared to be embarrassed by anything that was suggested to them in respect of staff assisting with care. Redstacks DS0000019715.V340099.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 and 15. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users enjoy flexible routines, good contact with relatives and friends, good opportunities to be self-determining, and satisfactory food provision, although they could experience a wider variety of activity, so they are confident their daily lives meet their expectations, but not entirely in respect of pastimes. EVIDENCE: Service users, staff and management spoken to, observation of interaction between service users and staff and some documents and records seen reveal that daily life and social activity within Redstacks is satisfactory, but could be better. Routines are minimal and mainly centred around meals, but service users are able to exercise their autonomy and choice if capable and can make decisions of their own about rising, going to bed, going out with family or staying in their Redstacks DS0000019715.V340099.R01.S.doc Version 5.2 Page 15 room etc. Some are less able, but staff and management assist them to make decisions where possible. Care plans show details of preferences. Service users receive visitors regularly and in private if wished, and there are no restrictions on visiting times. At least three visitors were seen in the home during the site visit and two were briefly spoken to. They express satisfaction with the service of care provided in the home and state their relative could not be better cared for anywhere else. Where possible service users are encouraged to handle their own finances and all do or have family members that do. Nearly all have some money held in safekeeping in the home though and have good access to it. Records viewed show money in/out, reasons why, running balance and signature of staff making the transaction. Two signatures are recommended to ensure greater accountability and security. Service users made no comment about the service of care they received in respect of finances except to say they are happy with everything. Service users spoken to state satisfaction with the provision of food, which generally is a fixed menu on a rotating basis and changed if and when service users express any special preferences or likes, or seasons warrant a change. The lunchtime menu is a hot two-course meal and an alternative is supplied to those that do not like it, while teatime sees a variety of sandwiches, pies and rolls etc. Service users spoken to say they do not have any real input into compiling menus, but the management say they are asked in service users’ meetings. Comments from service users are, “The food is very good, though sometimes I cannot be bothered with a dinner, so I get a sandwich instead,” and “The food is reasonable, I like some of it. We’re not asked what goes on the menu, they just tell us, but you can ask for something else if you don’t want it.” Lunch seen on the day of the site visit looked appetising and nourishing, and two or three service users said they preferred the cooking of the cook, who happened to be the Registered Manager covering the cook’s day off. Redstacks DS0000019715.V340099.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 and 18. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users make use of informal complaint processes and systems and have all issues dealt with appropriately and they do not need to make formal complaints, so service users are confident their concerns are dealt with effectively and efficiently. They also experience good promotion and protection of their welfare and so feel confident the systems in place to protect them are robust. EVIDENCE: Service users, staff and management spoken to and documents seen reveal there are policies and procedures on complaints and protection and that generally these are rarely used, but staff know the basic outline of their responsibilities. Service users say they have no need to complain as they are quite contented with their lifestyles and receive good care. They know who to talk to if they have any concerns, grumbles or worries and every communication is recorded in the complaint/compliments book maintained by the home. This had several entries since the book was begun in September 2006, but all of them were minor concerns that had been dealt with quickly and satisfactorily. Relatives spoken to also say there is never any need to complain, though one says they Redstacks DS0000019715.V340099.R01.S.doc Version 5.2 Page 17 have had a few reasons to discuss issues with the management in the past. Again these were quickly dealt with to everyone’s satisfaction. Staff spoken to had some understanding of their roles and responsibility in respect of safeguarding adults and protection, but because the need to report or record issues has so far not been necessary, the processes are still very new to them and untested. Staff have had safeguarding adults training in July 2006, since the last inspection in June when a recommendation was made. This was provided in the form of a video and discussion about vulnerability and abuse etc. Staff understand the whistle blowing procedures and that all incidents or allegations must be reported to the management team. A further instruction needs to be given to the staff to make sure they understand they can refer any concerns directly to the social services department, the Commission or even the Police if necessary. The home maintains a record of allegations and possible abuse situations, but there has been no entry because of there being no incidents to report, over the last twelve-months. Generally complaints and protection issues do not arise in any major form and any minor issues are dealt with quickly. Redstacks DS0000019715.V340099.R01.S.doc Version 5.2 Page 18 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 and 26. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users have a well-maintained, clean and comfortable environment in which to live, so they are confident they have a good home. EVIDENCE: A brief view of the communal areas, three bedrooms with service users permission, and of the kitchen and laundry reveals the house is very well maintained, extremely clean and comfortable. Service users’ rooms are highly personalised and clearly organised according to their preferences. Service users spoken to are extremely satisfied with their environment and say their rooms are cleaned regularly enough. Not all rooms Redstacks DS0000019715.V340099.R01.S.doc Version 5.2 Page 19 contain two armchairs for when service users receive visitors, but some rooms are not large enough. Where this is the case the home needs to state so in the service user’s care plan. The kitchen is mainly domestic in nature but hygiene and cleanliness can easily be maintained. The laundry meets the Water Supply (Water Fittings) Regulations 1999 and infection control is well maintained. Redstacks DS0000019715.V340099.R01.S.doc Version 5.2 Page 20 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 and 30. People who use the service experience adequate quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users are cared for by wellrecruited, well-trained, confident and skilled staff but only in adequate numbers to meet their basic needs, so they enjoy an adequate service of care that could be better, if more staff were available to spend more time with them. EVIDENCE: Service users, staff and management spoken to and documents seen reveal the standards in this section are met, but could be improved on. The home rosters show there to be one senior carer and one carer on duty each morning and each afternoon, and one carer on night duty with two people on-call in the bungalow in the grounds of the home. The Manager is also oncall for any care emergencies. The total number of care hours a week, according to the home’s rosters seen for weeks commencing 23rd April and 30th April 2007, is 259, with an extra 14 hours over Wednesday and Thursday in the first week. The rosters also show the Registered Manager doing care hours on five shifts and cooking on two Redstacks DS0000019715.V340099.R01.S.doc Version 5.2 Page 21 days in the first week, and doing care hours on three shifts, the night duty on one night shift and cooking on two days in the second week. This does not meet the recommended Residential Staffing Forum hours for 6 high, 4 medium and 4 low dependency service users, as stated on the information provided by the home, which is 279.18 per week. Also the Manager is only achieving two days on management tasks in each week. This needs addressing so that the Manager has more time to manage the home and there is sufficient care staff to meet the needs of service users. There are currently 4 from 7 care staff with the required caring qualification (NVQ level 2), giving 58 of carers with the award. This meets the standard, but efforts need to continue to maintain this and achieve a higher percentage. All staff undertake an induction programme, which is comprehensive, but has taken up to 6 months for some to complete. Efforts should be made to complete induction in six weeks. Redstacks has a recruitment and selection policy and procedure that enables senior management to follow robust systems. Staff identification is verified by following the requirements of schedule 2 and through the security checks carried out by the Criminal Records Bureau, while initial security checks are made and references are also obtained. Staff complete a job application form, sit through an interview that is recorded, and are taken on for a probationary period and given a contract of terms and conditions and asked to follow the staff handbook they receive, as well as the home’s general policies and procedures. Staff confirmed most of this in interview and files seen with their permission back it up. Discussion with staff, viewing of their files and observation of the certificates of attendance and completion on various courses, which are displayed around the home, also reveal the level of training and development opportunities available to them. Mandatory training includes medication administration, fire safety and awareness, moving and handling, safeguarding adults, health and safety, first aid, food hygiene, use of the hoists and infection control. Other courses available include dementia and ‘dispelling the myths.’ Redstacks DS0000019715.V340099.R01.S.doc Version 5.2 Page 22 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 and 38. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users live in a home that is well run and in their best interests, where good systems are in place to determine the quality of the service, and where their financial interests are safeguarded and their health, safety and welfare are well promoted and protected, so they are confident they will be safe and well cared for. EVIDENCE: The Registered Manager’s application was approved by the CSCI in December 2006. She meets the criteria for the standard, has clear lines of accountability and has good managerial support from the company. Redstacks DS0000019715.V340099.R01.S.doc Version 5.2 Page 23 There is a quality assurance system in place as well as an annual development plan. This includes undertaking surveys with service users and others, the outcome of which are collated and published. Quality audits take place on various topics, and these are available for staff and others to see in the quality assurance folder. Staff say they attend staff meetings and that they feel quite comfortable in making suggestions and expressing concerns, and feel they are listened to. The home has achieved parts 1 and 2 of the local authority quality development scheme and the Investors in People award. There have been no changes to the way in which the quality assuring of the service takes place since the last inspection. Service users handle their own finances wherever possible, although most of them have some money held in safekeeping. Records are satisfactorily maintained, but see recommendation to have two signatures on receipt of or handing out money into/from safekeeping in section above. Money handled for service users is well recorded, has receipts maintained to correspond with transactions and balances checked were accurate. Areas looked at under health and safety were fire drills/safety equipment tests and systems, passenger and hoist lifting equipment, Environmental Health checks, ‘portable appliance testing’ and water temperature controls. Discussion with management and viewing of documents show there is a fire evacuation procedure in place and a risk assessment document has been completed (though it has no date on it). The last Fire Prevention Officer inspection took place in September 2006 and recommendations to replace the fire door intumescent strips that had been painted over took place in the same month. The fire safety system was last serviced and maintained February 2007, while extinguishers were checked in April 2007. There are weekly checks on the system and fire drill instructions are held every 6 months and supervised by a privately accessed Fire Prevention Officer. The record of checks shows weekly and on the odd occasion, monthly checks on the system, and the record of drills shows 7 staff were part of an instruction between 22/03/07 and 20/04/07, while 14 staff were part of an instruction between 08/09/06 and 14/11/06. The passenger lift, stair lift and lifting hoists are under the service contract of Pickering’s Lifts and certificates are held showing six-monthly maintenance checks are completed. The home maintains an annual list of when servicing is done and when the next ones are due. The last inspection from the Environmental Health Department was 24/02/06. The last portable appliance test was carried out in April 2007 and records of items checked are maintained. Redstacks DS0000019715.V340099.R01.S.doc Version 5.2 Page 24 Water temperature controls are monitored in bedrooms and recorded at different outlets each week, while general water supplies are tested two weekly. The home maintains satisfactory water supply checks and records. A legionella water test ought to be carried out on the tank, if this hasn’t already been done. Redstacks DS0000019715.V340099.R01.S.doc Version 5.2 Page 25 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 Redstacks DS0000019715.V340099.R01.S.doc Version 5.2 Page 26 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 3 X X N/A 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 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Redstacks DS0000019715.V340099.R01.S.doc Version 5.2 Page 27 Yes 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 OP27 Regulation 18 & 19 Requirement The Registered Provider must ensure that the home is staffed by suitably experienced persons in such numbers as appropriate for the health and safety of service users. The recommended Residential Staffing Forum figures must be adhered to, so there are sufficient care staff to meet the needs of service users. (Previous timescales of 28/2/06 and 08/06/06 not met). Timescale for action 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP2 Good Practice Recommendations New contracts in place should be reviewed to ensure they contain all of the items listed in standard 2.2, so that service users or relatives know exactly what they can expect from the agreement they have made to live in the DS0000019715.V340099.R01.S.doc Version 5.2 Page 28 Redstacks 2 OP12 3 4 5 6 OP15 OP18 OP30 OP35 home. Any activities undertaken by service users should be recorded in their care plan. It is important to ensure pastimes are recorded on the activity sheet and that any health or care activity is recorded in the diary notes of the care plan. Service users should be included more in the consultation process about selecting menus and providing an alternative at lunchtime. All staff should be instructed in the safeguarding adults referral process to ensure they know their full responsibilities on safeguarding adults. Staff undertaking induction training should complete the process within six weeks, so they have the basic skills to meet service users needs. Two staff signatures should be obtained for any transaction of money held in safekeeping for service users, so that the systems for protection are robust and transparent. Redstacks DS0000019715.V340099.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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. 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