Inspection on 02/09/05 for Redstacks

This inspection was carried out on 2nd September 2005.

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

The inspector 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 18/01/06

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 Sarah Urding Unannounced 2nd September 2005 9:30 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 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 J53_s19715_Redstacks_v247072_020905_Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Redstacks Address 36 Heads Lane Hessle East Yorkshire HU13 0JH 01482 64068 01482 647533 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Audrey Zeane Redmore Mrs Audrey Zeane Redmore Care Home 12 Category(ies) of OP Old Age (12) registration, with number DE(E) Dementia - over 65 (12) of places Redstacks J53_s19715_Redstacks_v247072_020905_Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 12th January 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 that has been extended to provide accommodation for 12 service users. It is situated in a residential area of Hessle and is well maintained, decorated and furnished. Redstacks provides comfortable accommodation that consists of a lounge, conservatory and dining room. The home has 4 single rooms and four double rooms. 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 the conservatory. A stair lift has been fitted to the main stairs to enable service users to have access to all areas of the building. The home has a car park at the front of the building. Redstacks J53_s19715_Redstacks_v247072_020905_Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over six hours and was an unannounced inspection. The inspector looked around the home and inspected a number of records and policies. Seven of the twelve service users and three staff were spoken to. What the service does well: What has improved since the last inspection? What they could do better: The home had not yet carried out several requirements identified at previous inspections. This is poor practice as some areas compromise the safety of service users. Redstacks J53_s19715_Redstacks_v247072_020905_Stage 4.doc Version 1.40 Page 6 The assessment of and care planning for residents is not as detailed as is required. The home does not evidence well that all the needs of residents are met in the areas of foot, dental and eye care. These are basic needs and the home must identify how these health care needs are to be met by staff. The recruitment of staff was not as rigorous as it should be. In some instances staff had been employed without a criminal records bureau check and references in place. It is vital that the home secures all the necessary checks to ensure that the protection of service users is not compromised. Staffing levels in the home are not adequate enough at all times to ensure that service users needs will be met. Consultation with service users around whether they would like their doors to be lockable needs to take place. If service users would not like this facility, the registered manager should record this to evidence the consultation process. 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 J53_s19715_Redstacks_v247072_020905_Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Redstacks J53_s19715_Redstacks_v247072_020905_Stage 4.doc Version 1.40 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 standard(s) 1, 3, 6 Service users are well informed by the home’s statement of purpose and service user guide. The assessment that the home carries out on service users prior to admission is not comprehensive enough to ensure that all of their needs will be met. EVIDENCE: On admission the home provides comprehensive information to service users and their families about the facilities on offer so that they can make an informed choice about where to live. The recommendation made at the previous inspection to include the views of service users about the home in this document is not yet in place but the home is in the process of compiling this. One service user who had only been in the home for a short period did not recall having seen the brochure about the home. This is to be expected when working with people with dementia and memory impairment so should be revisited by staff on a regular basis. A copy of the service user guide should be available to all service users in the home. The assessment of service users covers most aspects identified in standard 3.3. However this does not include reference to how dental, foot and optical care needs will be met. In order to ensure that these basic needs are met for Redstacks J53_s19715_Redstacks_v247072_020905_Stage 4.doc Version 1.40 Page 9 all service users, reference should be made to these aspects of care, however routine. The home does not offer intermediate care to service users. Redstacks J53_s19715_Redstacks_v247072_020905_Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9, 10 Service users are well cared for and treated with respect but shortfalls in the assessment could result in their health care needs not being fully met. EVIDENCE: Care plans are in place for all service users, which identify how assessed needs, are to be met by staff. These plans are reviewed regularly and clear in format. Service users are involved in the reviews of their care. Individual risk assessments based around identified need are in place. This protects service users from harm. Not all areas of care are identified in the care plans of service users. Dental, optical and foot care needs are not addressed as a matter of course although it was clear from reading service users records that access to dental, optical and chiropody services is made available. The home must address these shortfalls so that staff are clear about how to meet all aspects of care for service users. The home was not meeting the needs of one service user regarding weight. It was identified in the local authority care plan that the home should weigh this service user. This had not yet occurred and the manager must ensure that this takes place. Redstacks J53_s19715_Redstacks_v247072_020905_Stage 4.doc Version 1.40 Page 11 Service users receive health care privately in their rooms and are able to register with a GP of their choice. The home has a comprehensive medication policy and trained staff administer medication to service users. Records kept were clear and concise. The ethos of the home is positive in that medication is kept under review and only held if required. This is good practice. All service users spoken to spoke warmly about the staff in the home. They consistently stated that their privacy was respected and dignity upheld during personal care tasks. Staff were observed to knock on service users doors prior to entering and were aware of the sensitivities involved while carrying out personal care. Redstacks J53_s19715_Redstacks_v247072_020905_Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 The home does not offer all service users the opportunity to experience activities suited to their needs. The lives of service users are enriched by family and friends being able to visit the home. Meals are nutritious and balanced and offer a healthy diet for service users. EVIDENCE: The home offers some activities on a regular basis including slide shows and hairdressing but an activities plan is not available for service users to refer to. Some service users spoken to said that they did not get out much and that on a daily basis “there wasn’t much to do”. Other service users said that they chose not to take part in the activities on offer. It was clear from speaking to service users that the existing range of activities is not sufficient to meet needs and interests of everyone. The home must address this by providing activities for all. A regular plan of varying activities would enable service users to have more choice in this area. Contact with service users friends and family is promoted well by the home. Service users said that they are able to see friends and family when they wish. Relationships between staff and service users were positive and mutually beneficial, with staff speaking positively about the service users they care for. Redstacks J53_s19715_Redstacks_v247072_020905_Stage 4.doc Version 1.40 Page 13 One service user said, “staff are very good. Couldn’t wish for better”. Independence is promoted by the way in which staff work with service users on a daily basis and a range of advocacy services are made available to service users in the home’s brochure. Service users are given choice around where to have their meals. Staff ask service users daily what they would like to eat at lunch and teatime. The home provides healthy and well-balanced meals for service users who said that meals are “very good”. One service user commented on the fact that her sandwiches were put in the fridge and she didn’t like them “soggy”. This was passed on to the deputy manager who arranged for fresh sandwiches to be served in future. Redstacks J53_s19715_Redstacks_v247072_020905_Stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18 Arrangements for complaints and the protection of vulnerable adults are handled well and ensure that service users feel listened to and protected. EVIDENCE: Service users spoken to said that they had no complaints about the home but felt confident to raise issues of concern if they arose. Complaints are recorded in the diary and addressed by the manager. They are then reviewed at the end of every month as part of the quality assurance system and recorded appropriately. The home has a clear complaints procedure in place. The home has an appropriate policy in place for the protection of vulnerable adults. The local authority guidelines for the protection of vulnerable adults are also in place. Staff spoken to were clear about reporting procedures should a service user make an allegation and around the indicators of abuse. Training for some staff has been on an in house basis and it would be good practice if all staff received the local authority training on the protection of vulnerable adults. Service users spoken to said that they felt safe when being looked after by staff. Redstacks J53_s19715_Redstacks_v247072_020905_Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 22, 24, 26 Generally service users live in a safe and well-maintained environment however some outstanding issues could place service users health at risk if not addressed. EVIDENCE: The home is currently undergoing building works to extend the existing accommodation. On completion a further six bedrooms will be provided so that more service users will be able to have single rooms. A passenger lift will also be provided. Service users were positive about this as they recognise that it will give them more independence around the home. The building work is causing some disruption to service users but the manager has consulted with them and their families and is ensuring that this is kept to a minimum. The creation of more single rooms will be a positive addition to the home. The home is clean, well presented and homely. A planned programme of maintenance is in place. Recommendations made by the environmental health officer at their last inspection to repair or renew kitchen surfaces and Redstacks J53_s19715_Redstacks_v247072_020905_Stage 4.doc Version 1.40 Page 16 cupboards have only been partially carried out. The director plans to complete this work within the timescale of the current building works. It is recommended that the environmental health inspector be notified of these plans. The recommendation made at the last CSCI inspection regarding the need for an assessment of the home and facilities by a suitably qualified person has not been carried out. This must occur. In discussion with the deputy manager it was identified that there are outstanding requirements for doors, locks, keys and lockable storage space within service users bedrooms. This must be offered to all service users. If service users do not wish to have locks etc the manager must evidence this and the consultation process. Some service users did not have access to a bedside lamp. The director plans to purchase these when furnishing the new rooms. One shared room has an adjoining door to the office. This bedroom is still being used by staff as a cut through to the office. The office must be accessed via the rear stairs only or alternative arrangements made for the location of the office/bedroom. Service users spoken to were positive about standards of cleanliness in the home. Laundry facilities in the home are appropriate and meet the needs of the service users. Service users commented on the cleanliness of their clothes on the return from the laundry. One service user said that a number of her socks had gone missing. The manager should review practice in this area. Redstacks J53_s19715_Redstacks_v247072_020905_Stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 Staffing levels are not sufficient to ensure that the needs of service users will be consistently met. Staff are well trained and therefore competent to do their jobs. However, the procedures for the recruitment of staff are not robust and do not offer protection to people living in the home. EVIDENCE: The home is staffed by two carers during the day and one carer at night. There was evidence that on some occasions two junior members of staff were on duty without a senior member of staff present and that one member of staff was on duty alone during the day. This is unacceptable as it compromises the staff’s ability to meet the needs of all service users. Staff are supported by a housekeeper who works for three days during the week and a cook. A number of managers are on call for the home and available on request. Two relatives of the registered manager are currently living on site in separate accommodation and are part of the on call system. CRB checks are not in place for these individuals and it is unclear whether this is a staffing arrangement. It is also unclear who is on call at a given time. This must be addressed with priority. The shortage of staffing was raised with the registered manager and deputy manager who both believe that having one member of staff on duty at night meets the needs of the existing service users. The staffing levels are under the recommended level by 30.52 hours per week. The registered manager is Redstacks J53_s19715_Redstacks_v247072_020905_Stage 4.doc Version 1.40 Page 18 not identified as working in the home but does spend a substantial amount of time attending to service users. This must be evidenced as could go someway towards reducing the staffing deficit. Although it should be noted that time allocated for managerial tasks should be identified as separate to time allocated to the care task, so that the managerial task is not compromised. Recruitment practice in the home requires improvement so that service users are safeguarded. CRB checks and references are not in place prior to staff starting work but have been subsequently obtained. This must be addressed. Staff are appropriately trained and undergo induction and foundation training. As identified previously in this report it is recommended that local authority POVA training be provided to all staff. Redstacks J53_s19715_Redstacks_v247072_020905_Stage 4.doc Version 1.40 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35, 37, 38 High levels of consultation and regular reviews by the manager ensure that service users are looked after in an environment that is both safe and inclusive. Some minor areas require attention in order to ensure that service users are safeguarded in all aspects of care. EVIDENCE: The home operates an effective quality assurance system that seeks the views of service users and staff on a regular basis. There is a monthly audit system in place that looks at key areas aimed at improving standards. This is good practice. Service users are protected by the financial procedures of the home. The home does not act as appointee for any service user and looks after money appropriately. Written records of all transactions are accurately maintained. Redstacks J53_s19715_Redstacks_v247072_020905_Stage 4.doc Version 1.40 Page 20 The finances of one service user should be discussed with their care coordinator. The home has detailed policies and procedures in place. Most records are kept appropriately. Some elements of service users records are not in place. Photographs of service users were not kept by the home and must be as specified in schedule 3. Generally the home operates in the best interests of the health and safety of service users and staff. All safety checks are carried out within the specified time frame and policies are in place for safe working practice. Three areas require attention so that service users continue to be safeguarded: - A risk assessment must be carried out in respect of the building work, emergency lighting checks are not taking place and the yearly gas check is overdue by two weeks. The director explained that owing to the extension to the home, the gas and electric supply for the whole building needs work. This is to take place shortly. All staff receive health and safety training. Redstacks J53_s19715_Redstacks_v247072_020905_Stage 4.doc Version 1.40 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 4 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x 2 x 2 x 3 STAFFING Standard No Score 27 2 28 x 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x 3 x 2 2 Redstacks J53_s19715_Redstacks_v247072_020905_Stage 4.doc Version 1.40 Page 22 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 1 Regulation 5,6 Requirement Timescale for action Oct 14th 2005 2. 3. 3 8 4. 22 5. 24 The registered person must ensure that the service user guide includes views of the service users regarding the home(previous timescale, 11/04/05 not met) 12, 13, 14 The assessment of service users must cover all aspects of standard 3.3. 12, 13 The registered person must ensure that all identified health care needs are met. The weight of one service user must be monitored as identified in the local authority care plan. 16, 23 The registered person must ensure that a suitably qualified person has made an assessment of the premises and facilities(previous timescale, 11/4/05 not met) 12, 13, 23 The registered person must identify which service users wish to have locks on the doors to their private accommodation and a lockable storage space and provide these facilities. Consultation must be evidenced aswell as any service users decline for these facilities(previous timescale, J53_s19715_Redstacks_v247072_020905_Stage 4.doc Oct 31st 2005 Immediate and on going. 30th November 2005 Oct 31st 2005 Redstacks Version 1.40 Page 23 1/11/04 not met) 6. 24 16 The registered person must meet the minimum standards for furnishing service users bedrooms. Bedside lighting must be provided for all service users. 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, 9/9/04 not met). All staff hours must be evidenced on the rota and a copy of the on call rota must be available to staff at all times. 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,1/1/04 not met). The registered person must keep all records identified in schedule 3. To include photographs of service users. Oct 31st 2005 7. 27 18, 19 Nov 30th 2005 8. 29 19 Immediate and on going 9. 37 17 Oct 31st 2005 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. Refer to Standard 1 12 18 19 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. An activities plan should be made available for service users reference. Local authority POVA training should be made available to all staff. Environmental health should be notified of the homes J53_s19715_Redstacks_v247072_020905_Stage 4.doc Version 1.40 Page 24 Redstacks 5. 6. 24 26 plans for the kitchen. Staff should access the office via the rear stairs only. Current laundry practice should be reviewed to ensure that all items are returned to service users. Redstacks J53_s19715_Redstacks_v247072_020905_Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI Redstacks J53_s19715_Redstacks_v247072_020905_Stage 4.doc Version 1.40 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!