Inspection on 08/06/06 for Redstacks

This inspection was carried out on 8th June 2006.

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

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

Other inspections for this house

Redstacks 10/05/07

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 Diane Wilkinson Unannounced Inspection 8th June 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.V298773.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.V298773.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 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.V298773.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 18th January 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 £337 - £425 per week, and there is an additional charge for hairdressing, private chiropody, toiletries and newspapers. The home was fully occupied on the day of the inspection. 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.V298773.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was undertaken by one inspector over one day; the site visit commenced at 9.35 am and finished at 5.40 pm. This inspection report is based on information obtained from the pre-inspection questionnaire, information received by the Commission for Social Care Inspection (CSCI) since the last inspection of the home and from the site visit on the 8th June 2006. Meetings were held with the registered provider/manager on the 15th May 2006 (at their request) and the 19th June 2006 (to conclude feedback following the site visit on the 8th June 2006). The site visit consisted of a tour of the premises and examination of documentation, including four care plans. On the day of the inspection the inspector spoke on a one to one basis with three service users and four care staff, as well as the registered provider/manager, the company director and the deputy manager. Surveys were handed to one service user and one member of staff to be completed and returned to the inspector. Prior to the site visit surveys were sent to seven relatives, six health and social care professionals and eight general practitioners. Six were returned by relatives and four were returned by health and social care professionals. The inspector would like to thank service users, staff, the deputy manager, the registered provider/manager and the company director for their assistance on the day of the inspection. What the service does well: Service users who remain in bed are well cared for, with particular attention being paid to pressure care. The inspector observed that service users were spoken to in a sensitive manner regarding their personal care needs. Service users are able to choose where and how to spend their day. One service user said, ‘I chose to come here and I am very pleased that I did’. One relative commented that they were delighted with their mum’s care and another said ‘I am very happy with both her surroundings and care’. Accommodation and furniture and fittings are of a high standard. The home is maintained in a clean and hygienic state and laundry facilities are suitable for the number of people resident at the home. There is a specially designed garden that provides a safe area for service users to sit outside or to take a walk. Redstacks DS0000019715.V298773.R01.S.doc Version 5.2 Page 6 One social care professional said, ‘this is always an odour free residential home’. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Redstacks DS0000019715.V298773.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Redstacks DS0000019715.V298773.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are provided with the information they need to make an informed choice about where to live but some service users do not have a contract to confirm the terms and conditions of their residency. Service users are only offered accommodation at the home if their assessed needs can be met. EVIDENCE: The statement of purpose and service user guide have been updated and now include service users’ views of the home, i.e. the outcome of recent service user and relative surveys. The service user guide is available in the home to be given to prospective service users and to current service users. One service user told the inspector that they did not have a contract with the home, even though their relative has asked for one on several occasions. On checking, it was found that several service users did not have a contract or Redstacks DS0000019715.V298773.R01.S.doc Version 5.2 Page 9 statement of terms and conditions with the home. The registered provider/manager agreed to rectify this situation. The inspector observed in care plans that a full assessment of a service user’s needs takes place prior to their admission to the home. This information is used to begin to formulate an individual plan of care. Community care assessments and the resulting care plan are obtained for those service users that are funded by local authorities. One service user said, ‘I chose to come here and I am very pleased that I did’. Redstacks DS0000019715.V298773.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. There is a lack of consistency in practice regarding the delivery of care (and recording of the same) and this means that service users cannot be sure that their health and personal care needs will be fully met. The mismatching of dates on medication records could lead to confusion and errors being made – this could put service users at risk of harm. Service users say that staff respect their privacy and dignity. EVIDENCE: Service user records examined by the inspector included an individual plan of care and, in most instances, appropriate risk assessments. One service user has been resident at the home for almost six months and there were no risk assessments in place. Care plans and risk assessments had been updated appropriately but some service users had not had a formal review of their care. In one instance the service user concerned had attended their annual review. Some service user plans were very detailed and all included a monthly Redstacks DS0000019715.V298773.R01.S.doc Version 5.2 Page 11 summary of the care offered by staff and others. Monthly summaries are completed by staff. The inspector observed that a relative had helped to write sections of one of the care plans, including the person’s life history and the needs assessment; this is good practice. Some service users or their relatives had signed to say that they agreed to the content of the care plan. One relative commented ‘we are delighted with our mum’s care’ and another said ‘I am very happy with both her surroundings and care’, and all relatives that returned the survey said that they are kept informed of important matters affecting their relative. One service user commented, ‘I would like to have my blood pressure and cholesterol tested regularly’. The registered provider/manager informed the inspector that this could be arranged for service users at any time. Records are held of all contacts with health and social care professionals. There is evidence that those service users who are permanently in bed are well cared for, with particular attention being paid to pressure care – there are associated risk assessments in place. Continence care is provided in a satisfactory manner. The inspector observed that service users that are confined to bed have fluid and food charts that are being well maintained. However, there was no evidence that other service users are weighed on a regular basis as part of nutritional screening. One social care professional commented that staff do not demonstrate a clear understanding of the care needs of service users, and that there is ‘room for improvement’. Another said, ‘service users are always clean’ and that ‘review paperwork is always received prior to reviews’. Medication systems were examined by the inspector. Medication is supplied in ‘blister’ packs by the local pharmacist as one month’s supply. The inspector was concerned that the date on the medication administration record sheets did not correspond to the date on the blister packs, and that this could lead to confusion and mistakes being made. This was discussed with the registered provider/manager at the meeting on the 19th June 2006 and a way of rectifying this issue has been agreed. None of the current service users have been prescribed controlled drugs but there are storage facilities for these should they be needed. None of the current service users have chosen to self-medicate. Staff that administer medications have undertaken accredited training. There is no longer a list of sample signatures held for staff that are trained to administer medications and this means that checks cannot be made to ensure that only trained staff are undertaking this duty. Redstacks DS0000019715.V298773.R01.S.doc Version 5.2 Page 12 Any medication that needs to be kept cool is stored in a fridge in the kitchen – temperatures are recorded. There is no special fridge for the storage of medications and the inspector recommends that this would be good practice. Most service users have their own room so are able to see visitors and health and social care professionals in private. There are also private areas of the home where meetings can be held. All relatives that returned the survey stated that they are able to visit their relative in private. Some service users have their own telephone and other service users have access to the telephone in the home. The inspector observed that service users were spoken to in a sensitive manner regarding their personal care needs. Redstacks DS0000019715.V298773.R01.S.doc Version 5.2 Page 13 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, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Meal provision is generally good although service users are not aware that there is a choice of meal at lunchtimes and there is no menu on display; this restricts personal choice and independence. The limited number of activities within the home results in service users not being stimulated and motivated to take part in leisure activities that meet their individual requirements. EVIDENCE: Care plans record the personal history and previous lifestyle of service users. Daily diary entries record any activities undertaken by service users, as well as visitors seen or any trips out. Service users told the inspector that activities on offer are minimal. One relative commented, ‘my relative is never seemingly taken out’. The registered provider/manager said that activities do take place but that these are not always recorded by staff. There is a record of group activities recorded in the quality assurance folder, but again, these appear to be infrequent. Some service users spend time in their room doing crosswords, reading or visiting each other in their bedrooms to pass the time of day. Redstacks DS0000019715.V298773.R01.S.doc Version 5.2 Page 14 Attention should be given to occupying time for service users with dementia. More one to one time would be beneficial – this could enable staff to take service users out for a walk or to spend time with them in their room. Those service users who are capable of undertaking activities could be encouraged to take a more active role in the home, such as running service user meetings, arranging activities and acting as ‘a voice’ for service users who are not able to fully express themselves. Service users are supported to maintain contact with family and friends, including via telephone. All relatives that returned the survey said that they are made welcome in the home at any time. Service users are supported and encouraged to take trips out with family and friends. Service users are supported to take control over their lives to the extent that they are capable. Members of staff told the inspector that service users ‘choose what they want to wear each day, where they want to spend the day and where they wish to eat their meals’. This was confirmed by service users. Information about advocacy services is displayed on the home’s notice board to inform service users and others about the availability of this service. Service users are encouraged and supported to maintain the level of independence that they have, and to undertake personal care tasks to the level of their capability. There is no menu on display – the inspector was told that the cook informs service users on a daily basis of the meals to be prepared. The inspector observed the serving of lunch – appropriate assistance is offered by staff and meals are served in a congenial setting. Some service users have a liquidised meal prepared for them, and some service users are assisted with eating their meal in their own room. Staff informed the inspector that there is always a choice of main meal on offer at lunchtime. However, service users spoken to by the inspector said that there is not a choice of meal at lunchtime, and one service user told the inspector that there is little choice of dessert for those service users who have diabetes. Redstacks DS0000019715.V298773.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Some members of staff are not aware of the policies and procedures in place about complaints and the protection of vulnerable adults from abuse and this could lead to these being applied inconsistently. Some service users are unaware of the complaints procedure and are not confident that their complaints will be listened to and acted upon. EVIDENCE: The home has appropriate complaints policies and procedures in place and the inspector saw that the complaints procedure is displayed on the notice board. Five of the six relatives that returned the survey said that they were aware of the home’s complaints procedure, and all said that they had never had to complain. There is a complaints log in place to enable complaints to be recorded appropriately, and complaints and compliments are collated, audited and then recorded in the quality assurance log on a monthly basis. One service user said that they were reluctant to complain due to a previous incident at the home. Two other service users told the inspector that they would speak to staff if they were concerned about anything, but were not convinced that they would be listened to. These service users were not aware of how to make a complaint. Some staff did not have relevant information Redstacks DS0000019715.V298773.R01.S.doc Version 5.2 Page 16 about the complaints procedure, i.e. where is it displayed and how do service users and others know how to make a complaint. Other staff were very clear about this process. The home has appropriate policies and procedures in place that are designed to protect vulnerable service users from abuse. In discussion with the inspector, some staff said that they did not know what the terms ‘POVA’ and ‘Whistle blowing’ meant but others were very clear about these terms. Some staff have undertaken training on the Protection of Vulnerable Adults from Abuse and others have not. Those staff that are undertaking NVQ Level 2 in Care will cover this topic as part of the training programme, and the organisation are planning in-house training on this topic. There have been no recorded allegations or incidents of abuse at the home since the last inspection. Redstacks DS0000019715.V298773.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 24 and 26 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are accommodated in well maintained and well furnished accommodation that is designed to meet assessed needs. The provision of a mobility hoist to ensure safe moving and handling of service users will improve safety for staff and service users. EVIDENCE: The home is well maintained and is furnished to a high standard, and there is a maintenance programme in place. Service users were taking advantage of the good weather on the day of the inspection by sitting outside in the specially designed garden. Some service users were assisted by staff to sit outside. Two of the lounge areas have patio doors that allow service users to easily access the garden, and to allow access to fresh air and sunlight if they do not wish to sit outside. Redstacks DS0000019715.V298773.R01.S.doc Version 5.2 Page 18 The inspector was informed that the home has been assessed by a suitably qualified person (the physiotherapist employed by the organisation) to demonstrate that recommended disability equipment has been provided and environmental adaptations made to meet the needs of service users. A report had not been received by the home on the day of the site visit, but a copy has since been sent to the Commission for Social Care Inspection. The registered provider/manager has had an assessment undertaken regarding the use of the hoist for two service users that are confined to bed. The assessment states ‘the care given to these ladies is excellent and involves no lifting at all, therefore does not require a hoist’. However, the inspector is concerned that service users who are not able to ‘weight bear’ would have to be lifted by staff if they had a fall, and feels that a hoist is needed. The provider stated that she does not like to use hoists, as service users find them ‘undignified’. She said that, if an accident should occur, she would contact male employees and ask them to lift the person from the floor on to a bed or chair. The registered person was informed that this is not good practice and she has reluctantly agreed to purchase a mobility hoist. There are now locks on bedroom doors and lockable storage is provided in each bedroom. The door locks do not enable service users to lock their door when they leave the room during the day, but they do enable service users to lock their room when they are inside to ensure privacy and security. The inspector was assured that all service users who have visitors in their bedroom have been provided with two comfortable chairs in their room. The inspector was assured that the door between the office and a service user’s bedroom is not used as a thoroughfare. The inspector was informed that this door cannot be locked as it is used as a fire exit. The new extension incorporates an additional staircase so there are now two means of exit at the home. The registered provider/manager should provide evidence from the fire department that the door in question is still required as a fire exit. The home was clean and hygienic on the day of the inspection. One social care professional said, ‘this is always an odour free residential home’. Service users spoken to on the day of the inspection said that the home is always fresh and clean, and were very complementary about the home’s housekeeper. The staff rota evidences that there is a housekeeper on duty for three days per week. There is an infection control policy in place – staff have not undertaken training on infection control but some staff have attended training on continence care. Laundry facilities are suitable for the number of service users accommodated. Redstacks DS0000019715.V298773.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. On occasions there are insufficient experienced and trained staff on duty to ensure the safety of service users. Staff have been employed at the home prior to satisfactory safety checks being carried out, leaving service users in a potentially vulnerable position. EVIDENCE: There is a staff rota in place and on the day of the inspection, the staff recorded on the rota were seen to be on duty. All relatives that returned the survey said that there are always sufficient numbers of staff on duty. Service users told the inspector that, when they ring the call bell, it is answered quickly. One member of staff did comment that there are not always enough staff on duty, although staff do ‘make time’ to spend with service users. The inspector was concerned that the two carers on duty in the afternoon were still undergoing induction training and neither had undertaken medications training, and that there was not a senior carer in the building (apart from the provider/manager calling in at tea-time). The night shift at the home commences at 8.00 pm and the inspector was informed that most service users are either in bed or in their bedrooms by then. The night carer assists a small number of service users to get ready for bed, and serves supper to those service users who are still up. The staff rota Redstacks DS0000019715.V298773.R01.S.doc Version 5.2 Page 20 records that the housekeeper is employed for four hours on three days per week and the cook is employed for six hours on five days per week. Care staff undertake these duties on other days. The cook is recorded as such on the staff rota. However, she occasionally administers medication (she has undertaken appropriate medications training), so she should be recorded on the staff rota as cook/carer. One social care professional commented that there is not always a senior member of staff to confer with, whereas another said that ‘staff are knowledgeable when questioned about residents’. Four of the nine care staff have achieved NVQ Level 2 in Care or above. A further four staff are working towards this award, so the home are on target to meet the 50 qualification requirement. New staff undertake induction training but this is not completed within six weeks of their employment at the home. The inspector examined recruitment records for staff that have recently started to work at the home. Two staff had commenced work prior to the CRB or POVA first check being undertaken and some staff had started work before two written references had been received. This has been a breach of regulation at previous inspections of the home and the practice of staff commencing work at the home before it is evidenced that they are ‘safe’ people to employ must cease. Individual training records are maintained and these evidence that staff have undertaken various training sessions. Some staff have yet to undertake training on food hygiene, moving and handling and the protection of vulnerable adults from abuse, and this is being addressed by the registered person. There is a training and development plan in place for the home. The training achievements of staff and their satisfaction with training offered by the organisation are audited as part of the quality assurance system. Redstacks DS0000019715.V298773.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home is managed by an experienced and skilled person. Health and safety practices are in place to protect service users from identified risks (apart from recruitment practices) and the quality assurance system allows service users and others to affect the way in which the service is operated. 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 has Redstacks DS0000019715.V298773.R01.S.doc Version 5.2 Page 22 commenced NVQ Level 4 in Care training. The deputy manager has had several years experience working in a care setting and is gradually taking over the management duties of the home. There is a satisfactory 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 said that they attend staff meetings and that they feel quite comfortable in making suggestions and expressing concerns, and feel that they are listened to. The home has achieved QDS parts 1 and 2 (the local authority quality scheme) and the Investors in People award. One social care professional, when asked ‘Does the home communicate clearly and work in partnership with you?’ answered ‘No’. The home does not handle the financial affairs of service users. Three service users are subject to Power of Attorney – this role is undertaken by a family member or a solicitor. Records are held of the personal allowances of service users – these were checked by the inspector and were found to be accurate. Documentation that is required to safeguard the rights and best interests of service users is in place, including a photograph of each service user (in care plans). All maintenance certificates were examined and found to be up to date and there is a landlord’s gas safety certificate in place. Portable appliances were tested in March 2006, the passenger lift was serviced in April 2006 and the stair lift and bath hoist were serviced in December 2005. Water temperatures at outlets accessible to service users are tested on a regular basis and the temperature of the hot water boiler is tested monthly to control the risk of Legionella. Information about the control of substances hazardous to health (COSHH) is clearly recorded along with other risk assessments concerning safe working practice topics. Health and safety training is taking place, although some staff still need training on moving and handling and food hygiene. Induction training is not completed within the required six-week timescale, and this could result in some staff being unclear about health and safety issues. There are very clear fire safety procedures in place. The fire alarm system has been serviced by a qualified contractor and in-house weekly fire tests and fire drills are being maintained. The inspector was assured that the door between the office and a service user’s bedroom is not used as a thoroughfare. The inspector was informed that this door cannot be locked as it is used as a fire exit. The new extension incorporates an additional staircase so there are now two means of exit at the home. The registered provider/manager should provide evidence from the fire department that the door in question is still required as a fire exit. Redstacks DS0000019715.V298773.R01.S.doc Version 5.2 Page 23 The pre-inspection questionnaire completed by the company director recorded that two service users had been admitted to the accident and emergency unit following accidents at the home. No notifications under Regulation 37 of the Care Homes Regulations had been received by the Commission and the deputy manager was informed that the CSCI should be notified of accidents and incidents appropriately so that these can be monitored. Redstacks DS0000019715.V298773.R01.S.doc Version 5.2 Page 24 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 3 1 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X 2 X 3 X 3 STAFFING Standard No Score 27 1 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X 3 3 Redstacks DS0000019715.V298773.R01.S.doc Version 5.2 Page 25 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 OP2 Regulation 5 Requirement The registered person must ensure that each service user is provided with a contract or terms and conditions in place with the home. The discrepancy of dates on the medication administration records and on the ‘blister’ packs must be rectified. There must be a sample signature for all staff that are responsible for the administration of medication. 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 28/2/06 not met). The registered person must ensure that staff do not commence work until a satisfactory CRB check (or a POVA first check) and two written references are in place (previous timescale of 18/01/06 not met). Timescale for action 31/07/06 2. OP9 13 31/07/06 3. OP27 18 & 19 08/06/06 4. OP29 19 08/06/06 Redstacks DS0000019715.V298773.R01.S.doc Version 5.2 Page 26 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. 7. 8. 9. 10. Refer to Standard OP7 OP8 OP9 OP12 OP15 OP16 OP18 OP22 OP31 OP38 Good Practice Recommendations All service users must have a formal review of their care, and care planning documentation must be maintained consistently. The registered person must ensure that nutritional screening takes place for all service users. There must be risk assessments in place for all service users. The inspector recommends the provision of a specific fridge to hold medications. Temperature records would need to be held for this fridge. Any activities undertaken by service users should be recorded in their care plan. Service users should be made aware that there is always an alternative to the main meal on offer at lunchtime. A menu should be displayed. The home should ensure that all service users can be confident that their complaints will be listened to. Training on the Protection of Vulnerable Adults from Abuse should be delivered to all staff. A mobility hoist should be purchased by the 31st July 2006. The deputy manager should complete the registration process as registered manager with the CSCI, and should continue with training to achieve NVQ Level 4 in Care. Induction training should be completed within the required six-week timescale to ensure that staff are aware of good practice on health and safety topics. Regulation 37 notifications should be forwarded to CSCI as required. The registered person should contact the fire department to ascertain the position about the dividing door between the office and a bedroom. Redstacks DS0000019715.V298773.R01.S.doc Version 5.2 Page 27 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. Extracts may not be used or reproduced without the express permission of CSCI Redstacks DS0000019715.V298773.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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