Inspection on 18/01/06 for Redstacks

This inspection was carried out on 18th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 10/05/07

Redstacks 08/06/06

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 Diane Wilkinson Unannounced Inspection 18th January 2006 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 Redstacks DS0000019715.V278736.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Redstacks DS0000019715.V278736.R01.S.doc Version 5.1 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 Mrs Audrey Zeane Redmore Mrs Audrey Zeane Redmore 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.V278736.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd September 2005 Brief Description of the Service: Redstacks is a privately owned care home that is part of a local organisation. The home is accommodated in 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, decorated and furnished. Redstacks provides private accommodation that consists of a three lounges, and all include a small dining area. Private accommodation consists of 12 single bedrooms and 1 shared 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.V278736.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over seven hours, including preparation time for the inspector. The inspection consisted of a tour of the premises and examination of documentation, including care plans. The inspector spoke to two service users (one to one), the deputy manager, the registered manager and a director of the company. What the service does well: What has improved since the last inspection? What they could do better: On some days the home does not employ enough staff to provide sufficient care for service users. There must be a mobility hoist in place to ensure that staff do not have to lift service users when transferring. The procedures for recruiting staff are not robust enough to ensure the safety of service users. Some requirements and recommendations that have been highlighted at previous inspections have yet to be actioned. Redstacks DS0000019715.V278736.R01.S.doc Version 5.1 Page 6 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. Redstacks DS0000019715.V278736.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Redstacks DS0000019715.V278736.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Information available to service users needs to be updated to ensure that they have all of the information needed to make an informed choice about admission to the home. Service users are assessed prior to their admission to the home and only offered a place if their assessed needs can be met. EVIDENCE: The statement of purpose and the service user guide have not yet been updated to reflect the recent refurbishment of the home. There is therefore no accurate information that can be given to service users to assist them in making an informed choice about where to live, or to relatives who make enquiries about the home. All service users must be issued with their own copy of the service user guide. The deputy manager informed the inspector that prospective service users are always visited at home or in hospital to commence the assessment process. Service users are only offered a place at the home if their assessed needs can be met and if the prospective service user is compatible with other service Redstacks DS0000019715.V278736.R01.S.doc Version 5.1 Page 9 users. Some amendments need to be made to the assessment form to ensure that a full assessment of a person’s care needs can take place. Redstacks DS0000019715.V278736.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8 There is insufficient evidence that the health, personal and social care needs of service users are met. There must be a mobility hoist available for staff to ensure the safe moving and handling of service users. EVIDENCE: Care plans record the needs of service users, and the assistance that should be offered by care staff. In some instances there is no record of how these needs have been met by staff. In one instance the care plan records that a service user is not weight bearing. The home does not have a mobility hoist so care staff must be lifting when transferring the service user. This is not acceptable practice and a hoist must be purchased as a matter of urgency. Other care plans state that fluid and diet intake should be monitored but there is no record that this has taken place. Monthly summaries of the care plan needs have ceased. Care plan records include details of all contact with GP’s and other health professionals. Appropriate risk assessments are in place. The risk of pressure care is recorded appropriately, as is the care offered to service users to prevent pressure sores developing, such as ‘regular turns’. Redstacks DS0000019715.V278736.R01.S.doc Version 5.1 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 The home does not offer all service users the opportunity to experience activities suited to their needs. EVIDENCE: Care plans record the interests and hobbies of service users, such as listening to music, watching TV and reading. However, there is no record of the time that service users spend taking part in these interests or activities. There is no activity plan in place to record or advertise any activities that are arranged for service users. Service users informed the inspector that they have visitors and that their visitors are always made welcome at the home. The inspector observed that some service users spend time in their own room reading and watching television, but that these activities are not recorded. Redstacks DS0000019715.V278736.R01.S.doc Version 5.1 Page 12 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): 18 Service users are protected from all types of abuse. EVIDENCE: The home has appropriate policies and procedures in place about the protection of vulnerable adults from abuse. The inspector was informed that managers and senior staff have undertaken training on the protection of vulnerable adults from abuse. Care staff have yet to receive this training. The deputy manager is planning to obtain the training pack that has been developed by the Area Adult Protection Committee and to organise in-house training. Redstacks DS0000019715.V278736.R01.S.doc Version 5.1 Page 13 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): 22 and 24 Generally service users live in a safe and well-maintained environment but some outstanding issues could place service users at risk if not addressed. EVIDENCE: The building work has now been completed and the new bedroom accommodation is fully occupied. Now would be an ideal time to have the premises and facilities assessed by a suitably qualified person to demonstrate that recommended disability equipment has been provided and environmental adaptations made to meet the needs of service users. This has been a requirement of previous inspections and must be actioned. One service user informed the inspector that she had been inconvenienced and distressed by the building work. Some remedial work in the kitchen that was recommended by the Environmental Health Officer has not yet been fully carried out and this must be actioned as soon as possible. Redstacks DS0000019715.V278736.R01.S.doc Version 5.1 Page 14 Bedroom accommodation is provided with good quality furniture and furnishings. Bedside lighting is now in place for all service users. All service users have been asked if they require a lock and key for their bedroom door and their wishes for such are recorded in care plans. The inspector recommends that the fitting of locks to bedroom doors be included in the home’s maintenance programme. This will enable any new service users to be offered a key to their bedroom door at the time of admission. The deputy manager informed the inspector that lockable storage (in the form of cash boxes) is available for all service users. Ideally, a cash box should be placed in every bedroom so that this facility is in place for all service users. Some service users regularly have visitors and the inspector recommends that these service users have two comfortable chairs in their bedroom. The inspector was assured that the door between the office and a service user’s bedroom is not used as a thoroughfare, and the registered person must ensure that this is the case. The inspector was informed that this door cannot be locked as it is used as a fire exit. Redstacks DS0000019715.V278736.R01.S.doc Version 5.1 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, 28 and 29 Staffing levels are not sufficient to ensure that the needs of service users will be consistently met. Action needs to be taken to ensure that staff achieve the required qualifications. Recruitment and selection procedures are not sufficiently robust to protect service users. EVIDENCE: There is a staff rota in place that records all staff on duty, including ancillary staff. The role of each of staff member is recorded. There is no record of the time that the registered manager spends at the home carrying out managerial or care duties. The deputy manager has taken on the day-to-day management of the home and has applied to the Commission for Social Care Inspection for registration as the manager. The inspector was concerned that, on some occasions, the deputy manager was also taking on the role of care worker and cook for a full shift. This is not acceptable practice. There must be two care workers, a manager and ancillary staff on duty. A housekeeper is employed for three days per week and this ensures that the home is maintained in a clean and hygienic state. There is one night carer on duty and two relatives of the registered provider/manager are ‘on call’ in the bungalow that adjoins the home. There is no evidence that these relatives have the experience and skills to care for older people or that they have had a satisfactory CRB check. One member of staff has achieved NVQ Level 2 in Care. There must be an action plan in place that records the homes arrangements for ensuring that the Redstacks DS0000019715.V278736.R01.S.doc Version 5.1 Page 16 requirement for 50 of staff to be qualified to NVQ Level 2 in Care can be achieved, giving realistic timescales. The inspector examined the records for a recently recruited member of staff. These evidence that an application form is completed by prospective employees and that this includes a person’s employment history. Only one written reference had been obtained and the person started work at the home almost three months before the POVA first check was received. A satisfactory CRB check or POVA first check and two written references must be in place before staff commence work at the home. If staff commence work on receipt of the POVA first check, this must be accompanied by a risk assessment that evidences that the person will be supervised until a satisfactory CRB check has been received, and that all other checks are in place. Redstacks DS0000019715.V278736.R01.S.doc Version 5.1 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, 37 and 38 The home is managed by an experienced and skilled person. The health, safety and welfare of service users and staff are promoted with the exception of up to date maintenance certificates for some equipment. EVIDENCE: The registered provider is currently registered as the manager with the Commission for Social Care Inspection (CSCI). She is a trained nurse and has had many years experience in the caring profession. The current manager is due to retire and the deputy manager is going to take over as the manager of the home and has applied to the CSCI for registration. The deputy manager has completed the NVQ Level 4 Registered Manager’s award and plans to continue with training until NVQ Level 4 in Care is achieved. Documentation that is required to safeguard the rights and best interests of service users is in place. The policies and procedures that are required are in Redstacks DS0000019715.V278736.R01.S.doc Version 5.1 Page 18 place and are reviewed appropriately. A photograph of each service user has not yet been obtained and monthly summaries of service users’ care plans are not maintained regularly. Work identified as part of the re-registration of the home has been undertaken. A new passenger lift was installed in October 2005 and a declaration of conformity was provided. All maintenance and checks on gas and electricity supplies are in place for the new extension. The stair lift was serviced in May 2005 but there is no evidence that the bath hoist has been serviced since March 2004. The director informed the inspector that the bath hoist has been serviced and evidence of this would be forwarded to the CSCI office. This has not yet been received. A portable appliance test took place in March 2005. There is no evidence that the nurse call system has been serviced since March 2004. In house weekly fire tests and monthly fire drills are being carried out on a regular basis. The fire alarm system and emergency lighting were tested by a contractor in November 2005. There is a current gas safety record in place. Water temperatures are tested in bathrooms but not at outlets in service users’ bedrooms. This practice must commence and water temperature tests must be recorded. There is a temperature dial on the hot water boiler to ensure that water is held at the correct temperature to control the risk of Legionella. Health and Safety training is undertaken by staff and Health and Safety notices are posted in the home. There is a written statement of the policy, organisation and arrangements for maintaining safe working practices, including risk assessments. Accidents are recorded appropriately and records are held in a service user’s care plan to ensure confidentiality. There is no mobility hoist in place at the home – see Standard 8. Redstacks DS0000019715.V278736.R01.S.doc Version 5.1 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 1 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 1 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X 1 X 2 X X STAFFING Standard No Score 27 1 28 2 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X X 2 2 Redstacks DS0000019715.V278736.R01.S.doc Version 5.1 Page 20 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 OP1 Regulation 5,6 Requirement The registered person must ensure that the service user guide includes views of the service users regarding the home (previous timescale of 11/04/05 not met). The registered person must ensure that all identified health care needs are met. Nutritional screening must take place. Previous timescale not met. A mobility hoist must be purchased to ensure that service users are transferred safely. The registered person must ensure that a suitably qualified person has made an assessment of the premises and facilities (previous timescale of 11/4/05 not met) The registered person must ensure that the home is staffed by suitably experienced persons in such numbers as appropriate for the health and safety of service users (previous timescale of 9/9/04 not met). DS0000019715.V278736.R01.S.doc Timescale for action 28/02/06 2. OP8 12, 13 31/01/06 3. 4. OP8 OP22 12, 13 16, 23 28/02/06 28/02/06 5. OP27 18, 19 28/02/06 Redstacks Version 5.1 Page 21 6. OP29 19 The registered person must ensure that new staff are confirmed in post only following completion of a satisfactory CRB check and two written references (previous timescale of 1/1/04 not met). The registered person must keep a photograph of each service user, as required in Schedule 3 of the Care Homes Regulations 2001 (previous timescale of 31/10/05 not met). There must be a current maintenance certificate in place for the bath hoist. Evidence of this must be sent to the CSCI. 18/01/06 7. OP37 17 31/03/06 8. OP38 23 17/02/06 Redstacks DS0000019715.V278736.R01.S.doc Version 5.1 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. Refer to Standard OP1 OP3 OP12 OP18 OP19 OP24 Good Practice Recommendations Staff should ensure that all service users are familiar with the guide for the home. A reference copy should be made available to service users at all times. The form used to assess service users prior to their admission should be updated so that a full assessment can take place. An activities plan should be made available for service users. Any activities undertaken by service users should be recorded in their care plan. Local authority POVA training should be made available to all staff. The remedial work on the kitchen recommended by Environmental Health should be fully carried out. The fitting of locks on bedroom doors should be included in the home’s maintenance programme. Lockable storage should be available in all bedrooms. An additional chair should be provided in the bedrooms of service users who like to see visitors in their room. There must be an action plan in place that identifies how the requirement for 50 of care staff to be qualified at NVQ Level 2 in Care will be achieved. 7. OP28 Redstacks DS0000019715.V278736.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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. 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