Inspection on 28/02/08 for 55 Daventry Road

This inspection was carried out on 28th February 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

55 Daventry Road 13/03/09

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Redwood 55 Daventry Road Dunchurch Rugby Warwickshire CV22 6NS Lead Inspector Julie Preston Unannounced Inspection 28th February 2008 11:00 Redwood DS0000070703.V360559.R01.S.doc Version 5.2 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 Redwood DS0000070703.V360559.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 Adults 18-65. 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. Redwood DS0000070703.V360559.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Redwood Address 55 Daventry Road Dunchurch Rugby Warwickshire CV22 6NS 0121 430 6306 0121 430 6306 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) Care Through The Millennium Beverley Ann Lunn Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Redwood DS0000070703.V360559.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: 2. Learning Disability (LD) 6 The maximum number of service users to be accommodated is 6. Date of last inspection Brief Description of the Service: Redwood House is a newly built, spacious house situated in the village of Dunchurch, approximately four miles from Rugby. The home is registered to provide care to up to six people with a learning disability. At this visit there were three people living at the home. There are six bedrooms, all with en suite bathrooms. Two bedrooms are on the ground floor and four are on the second floor. There is a large lounge, a “quiet room” that is smaller and is used by people who want to relax away from their bedrooms or the main lounge. A separate dining room that leads onto the rear garden can comfortably seat ten people and there is a well equipped kitchen. Bathrooms are provided on each floor. The fees charged range from £1250 - £1600 per week. People pay a contribution from their individual benefit. Redwood DS0000070703.V360559.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home and a questionnaire about the home. The questionnaire is called the Annual Quality Assurance Assessment (AQAA). The visit took place over one day and staff and people who live at the home did not know that we were coming. This is the home’s first inspection since registration in October 2007. Two service users were “case tracked” and this involves discovering individual experiences of living at the home by meeting or observing them, discussing their care with staff, looking at medication and care files and reviewing areas of the home relevant to these people, in order to focus on outcomes. Case tracking helps us to understand the experiences of people who use the service. Staff files and health and safety records were reviewed. The inspector looked around the building to make sure that it was warm, clean and comfortable. There were no immediate requirements after this visit. This means that there was nothing urgent that needed to be done to make sure people stayed safe and well. What the service does well: People’s needs are assessed before they move into the home so they can be confident their needs will be met there. People that live in the home receive good support to make choices and decisions about their lifestyles. Independence is encouraged so that people do not lose skills that they have learned. Redwood DS0000070703.V360559.R01.S.doc Version 5.2 Page 6 There are lots of chances to go out so that people take part in things they enjoy. People are supported to keep in touch with their families and friends so that they do not lose relationships that are important to them. People choose their food and enjoy their meals. One person said, “the food is good”. There are good systems to help meet people’s personal and health care needs so that they have care they like and keep healthy. People have their own large bedroom, with en suite bathroom, which are decorated and furnished in a way that they have chosen. The home is very clean, warm and well decorated so that people live in a homely place. The home has a small, well established team of staff who clearly know people well and have formed good relationships with them. Relatives of the people who live in the home say: “First class home”. “The staff are exceptionally polite”. “I know I can complain and am aware of the procedure”. “I am very happy with the care”. “Polite and helpful staff”. What has improved since the last inspection? What they could do better: People do not have access to all the information they need before moving in to decide whether the home is suitable for them. Plans that explain how to care for people and help them stay safe need to be better written so that their needs are understood and met. Medicines are not always well looked after which could mean people’s needs are not met. Staff need to have training to help them understand how to keep people safe from harm. Sometimes people’s health and safety is not always fully looked after. Redwood DS0000070703.V360559.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Redwood DS0000070703.V360559.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Redwood DS0000070703.V360559.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4, 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People do not have access to all the information they need before moving in to decide whether the home is suitable for them. EVIDENCE: The home has a service user guide and statement of purpose, which is made available to people who live there and their relatives. The documents explain the services and facilities provided and include a copy of the complaints procedure and information about fees and charges. The service user guide is not accessible to people whom live in the home as it is written and people do not read. It is recommended that other formats be considered to help people understand the content of the guide. There are systems in place to ensure that individuals’ needs are assessed before they move into the home and that people have an opportunity to visit and stay over prior to making any decisions about whether to move in. The records for one person recently admitted to the home were sampled and showed that information had been received from a number of sources including the person, family members and healthcare staff. This should enable the staff Redwood DS0000070703.V360559.R01.S.doc Version 5.2 Page 10 team to determine that services and facilities in the home are suitable to meet the person’s assessed needs. There were no records of people’s trial visits to the home. The registered manager explained that the purpose of trial visits was to enable the person to experience life in the home and for staff to get to know more about them. It is recommended that records be kept to aid the assessment process. Contracts that describe the terms and conditions of living in the home were in place, however had not been filled in for each person. This should be done so that people have accurate information about their stay at Redwood. Redwood DS0000070703.V360559.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments do not always fully describe how people’s needs should be met so that they receive consistent care in a planned and safe manner. People that live in the home receive good support to make choices and decisions about their lifestyles. EVIDENCE: Care plans were sampled for two people who live at Redwood. Both gave detailed information about how staff should support people in order to meet their individual needs in relation to health, personal care, communication, culture and social and leisure preferences. It was considered positive that care plans promoted people’s independence so that individual’s maintain and develop their living skills. For example, plans Redwood DS0000070703.V360559.R01.S.doc Version 5.2 Page 12 referred to supporting people to launder their clothes, make their own drinks and meals. Some care plans contained information that was not reflective of people’s current needs. It is recommended that files be reviewed so that accurate information is made available to staff in order for them to offer consistent care to people who live in the home. The home completes risk assessments for people so that consideration is given to supporting them to take responsible risks and promote their independence. Some areas of risk had been identified but did not have a clear plan of action to reduce those risks for the well being of the person. For example, one file referred to an individual “running away” from staff when out in the community. There was no written strategy for responding to this behaviour for the protection of the person. People who live in the home need assistance to manage their money. There are systems in place to record individuals’ income and expenditure, which are audited for their ongoing protection. From observation during this visit, it was evident that people are making choices about their lifestyles, such as what they do during the day, what they spend their money on and what they eat and drink. Staff are learning Makaton sign language to enable them to communicate more effectively with individuals so that they have better understanding of people’s needs. Redwood DS0000070703.V360559.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in the home experience a meaningful lifestyle that promotes their independence and is reflective of their individual needs. EVIDENCE: People’s social and leisure preferences had been recorded in their plans of care. Daily records were sampled to check that people had regular opportunities to take part in things they enjoy doing. Records showed that people undertake many activities such as visiting local places of interest, going to local day centres where they meet their friends, shopping, meals out to restaurants, cafes and pubs. The home is good at supporting people to keep in touch with their friends and relatives. Within the care plans sampled there was information about peoples’ Redwood DS0000070703.V360559.R01.S.doc Version 5.2 Page 14 relatives birthdays, so that cards and presents could be sent. The home has a visitor’s policy and the manager commented that relatives have regular contact either by telephone or in person. People are involved in planning their weekly menu, which is done each Sunday with the help of staff. Photographs of food have been taken to assist people to decide what they would like to eat. Menus and records of food consumed by individuals were sampled to establish that a balanced and varied diet is provided that meets peoples’ needs and preferences. A range of food had been offered including Sunday roasts, which is reflective of individuals cultural needs. Lunch was taken with people who live in the home. Staff offered sensitive support to individuals that require assistance with eating to promote both their dignity and independence. It was evident that people had enjoyed their meal. One person said, “the food is good”. Redwood DS0000070703.V360559.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are effective systems in place to meet peoples’ personal and health care needs. Medicines management is not always robust, which could lead to peoples’ needs not being met. EVIDENCE: Two personal and health care plans were sampled at this visit. There was some good information about individuals’ personal care needs and preferences, which staff clearly understood so that people receive care in a manner they need and like. One person said, “I get a cup of coffee in bed every day”. This was recorded in the individual’s plan of care as being important to them. Both male and female staff are employed, which is reflective of the gender of the current group of people living in the home. Redwood DS0000070703.V360559.R01.S.doc Version 5.2 Page 16 There is a “same gender” personal care policy. This means that people do not receive personal care from someone of a different gender. Financial and daily records showed that people shop for their own toiletries and clothes and use local hairdressers and barbers, with the support of staff as part of their regular personal care routines. Records showed that people have regular appointments with healthcare professionals and the outcome of this contact had been documented so that staff had accurate information about individuals’ state of health. Some people living in the home have a Health Action Plan. These are personal plans that describe what a person needs to stay healthy and the healthcare services they need to access to do so. The manager said she was keen to develop Health Action Plans for everyone to enable better systems of monitoring people’s healthcare needs. The system of storing, administering and recording medicines kept in the home was looked at to establish that people are protected by robust procedures. Medication was observed to be securely stored in a locked cabinet and it was considered positive that staff had received training in the safe handling of medicines to further safeguard individuals health and well being. There were, however some issues that need to be addressed so that people receive their medication as prescribed and to ensure that medicines can be audited for people’s ongoing protection. Where people are prescribed medication on an “as required” basis, written protocols were not in place to guide staff as to when they should be given. There was a discrepancy in the recording of one person’s tablets. The amount of stock did not match what had been entered on the medication record. A tub of E45 cream had not been labelled with the date of opening and it was not clear from the label, who the cream had been prescribed for. Redwood DS0000070703.V360559.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are appropriate procedures in place within the home to listen and respond to peoples’ concerns and complaints. Staff have not received the training they need to make sure they are fully aware of their role in safeguarding vulnerable people. EVIDENCE: The home has a complaints procedure which is made available to people who live in the home and their relatives. There has been one complaint since the home opened in October 2007, which was investigated by the registered manager and the complainant responded to promptly. There was a log of the processing of this complaint, which indicated that the complainant was satisfied with the home’s response. Staff spoken to during this visit were clear that they were aware of the procedure for responding to complaints. A questionnaire issued to relatives in 2007 indicated that those who responded are confident that the staff team take complaints seriously. The home has an adult protection policy, which has been developed as a document with plain language and pictures to clarify how staff should respond to report suspicions or allegations of abuse. Redwood DS0000070703.V360559.R01.S.doc Version 5.2 Page 18 Training in adult protection has not been completed by any of the staff team and none has been booked. This is needed to make sure that the staff team are fully aware of their role in safeguarding vulnerable people. Some people who live in the home demonstrate behaviour that is challenging and requires intervention from staff to help them stay safe. Records described staff responding to an incident where a person was “held” to prevent them being placed at risk. There was no written strategy or evidence that professional advice had been sought to make sure that this action was appropriate to safeguard the person. No inventories of peoples’ belongings are maintained so that staff can keep track if anything goes missing and look after peoples’ possessions. This is strongly recommended so that people can be confident their belongings are accounted for. Redwood DS0000070703.V360559.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a clean, safe, comfortable and homely environment that meets their needs. EVIDENCE: Redwood is situated in the Dunchurch area of Rugby, close to amenities in the village such as shops, cafes, hairdressers, pubs and the local church. There is a library in nearby Rugby, which is used by people who live in the home. The home is newly built and each bedroom has en suite facilities incorporating a shower, toilet and hand basin. There are two ground floor and four first floor bedrooms, all of which are spacious and well decorated. Shared space consists of a dining room which comfortably seats ten people, large lounge, “quiet room” with a sofa and music system, kitchen and additional bathrooms on each floor. Redwood DS0000070703.V360559.R01.S.doc Version 5.2 Page 20 There is a separate laundry room, with secure storage for cleaning products so that risks to people’s safety are minimised. All areas of the home are well decorated and furnished, clean and warm. There were adequate hand washing facilities for staff so that the risk of the spread of infection could be reduced and there was no evidence of poor cleansing routines. Two bedrooms were looked at. Both were clearly reflective of the tastes of the people who use them. It was evident that people had been supported to arrange their bedrooms according to their preferences and individual needs. The front and rear garden are not yet complete. At this visit the rear patio had been laid with a seating area for use in better weather. The registered manager commented that a greenhouse would be installed as one of the people who lives in the home enjoys gardening. There is off road parking for several cars at the front of the house and once the front garden is completed, this will create extra outdoor space for the people who live at Redwood. Redwood DS0000070703.V360559.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported by a well-trained and competent team of established staff who have good understanding of their individual needs. The home operates a robust system of recruiting staff for the protection of the people who live there. EVIDENCE: The home has a small staff team of five support staff, plus the registered manager and deputy manager. The registered manager commented that the number of staff employed was sufficient to meet the needs of the three people currently living at Redwood, but would be reviewed when more people moved in. The rota sampled showed that two staff work during the day with the resident group with two staff on duty overnight (one sleeping in and one waking night). The registered manager stated that once the home has no vacancies night time support will consist of two waking night staff. Redwood DS0000070703.V360559.R01.S.doc Version 5.2 Page 22 The rota is arranged so that male and female staff work together on each shift, which is appropriate to meet the needs of the people who live in the home. The Annual Quality Assurance Assessment (AQAA) completed by the registered manager prior to this visit showed that all support staff have either completed or are working towards a qualification in care work. This should equip staff with some of the skills they need to meet people’s needs more effectively. Recruitment records sampled showed that appropriate checks had been made to make sure that staff were suitably experienced and qualified to work with vulnerable adults. Criminal Records Bureau checks had been made and written references received before the employee began work so that people were protected from the risk of having unsuitable staff work in the home with them. The home has a training programme so that staff have access to training and development opportunities to assist them in their work and to help maintain people’s health and well being. The registered manager had booked training in infection control, first aid, food hygiene, health and safety and moving and handling to take place in February and March 2008, as some staff had not received this input. The staff present during this visit took an active part in the inspection process and were able to answer our questions about people’s care and support needs with confidence. The interaction between staff and people who live in the home was relaxed and friendly, which indicates that positive relationships have been formed. One person said, “the staff are good”. Redwood DS0000070703.V360559.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is being well managed for the benefit of the people who live there. Some areas of health and safety practice could have an impact on people’s well being if not addressed. EVIDENCE: The home has a registered manager, who is due to complete her registered manager’s award and is a learning disabilities nurse. The registered manager has twenty years experience working with people with a learning disability. The manager is supported by a deputy, who has achieved a National Vocational Qualification (NVQ) in care at Level 3 and has begun training at Level 4. Redwood DS0000070703.V360559.R01.S.doc Version 5.2 Page 24 The registered manager was present throughout this visit and was enthusiastic about making improvements to the service offered at Redwood for the benefit of people living there. Quality assurance systems are in place. A representative of the registered provider visits the home on a regular basis to report on the standard of care provided of which reports are made available to the home and CSCI. The registered manager had conducted her own quality audit, discussing the running of the home with the people who live there and focusing on environmental standards. As a result changes were made to cleaning routines and the way that medicines are received into the home. Questionnaires were issued to the people’s relatives about their satisfaction of the service and the following comments were made to the registered manager:“First class home”. “The staff are exceptionally polite”. “I know I can complain and am aware of the procedure”. “I am very happy with the care”. “Polite and helpful staff”. A number of checks are made by staff to make sure that peoples’ health and safety is maintained. Records showed that the fire alarm system had been regularly tested and serviced to make sure that it was working properly. One of the people who live in the home helps test the fire alarm system each week and staff said that he really enjoyed this responsibility. Fire drills had been conducted on a regular basis to enable staff and people who live in the home to practice evacuation in the event of an emergency; each drill had been recorded. There were records to evidence that hot water was regularly tested to make sure that it did not pose a scalding risk to people and that fridge and freezer temperatures were checked to ensure that food was being stored safely. A large mat in the entrance hall could present a trip hazard to people and needs to be secured to reduce this risk. One of the areas that had not been developed by the staff team was that of assessing the support needs of each person to evacuate the home safely in the event of fire, both during the day and during the night. This needs to be done so that staff have clear instructions about what they should do to assist people during an emergency evacuation. Some of the daily records sampled had not been written in a manner that accurately described events that had taken place in the home and in some Redwood DS0000070703.V360559.R01.S.doc Version 5.2 Page 25 cases were disrespectful to the person being written about. For example, a recording that a person had “been having tantrums” does not provide sufficient information to help other staff understand what occurred or the action that was taken to support the person. This was not the case with all of the records sampled. One member of staff had completed very detailed records, which gave the reader a comprehensive understanding of the way in which the person’s needs had been met throughout the day. Redwood DS0000070703.V360559.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 3 3 X 4 2 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X 2 2 X Redwood DS0000070703.V360559.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No. First 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 YA5 Regulation 5 Requirement Each person must have a contract, which describes the terms and conditions of living in the home so that people have accurate information about living there. There must be clear information in risk assessments to describe how staff must respond to identified areas of risk for each person living at the home so that their health and well being is protected. Protocols must be developed and implemented so that people receive “as required” medicines according to the prescribed advice. There must be a system of auditing medicines so that errors are recorded and investigated to make sure that people receive their medication as prescribed. Prescribed medicines must be labelled by the pharmacist so that it is clear to whom the medication is prescribed for. Staff must receive training in adult protection so that they are fully aware of their role in DS0000070703.V360559.R01.S.doc Timescale for action 01/05/08 2 YA9 13(4)(c) 04/04/08 3 YA20 13(2) 04/04/08 4 YA20 13(2) 04/04/08 5 YA20 13(2) 04/04/08 6 YA23 13(6) 01/05/08 Redwood Version 5.2 Page 28 safeguarding vulnerable people. 7 YA23 13(6) Written strategies that describe 04/04/08 how to respond to behaviour that is challenging must be developed and implemented so that an agreed and consistent approach is maintained for each person’s safety. The large mat in the entrance 28/02/08 hall must be secured so that people do not risk tripping over it and sustaining an injury. Each person must have a plan 04/04/08 that describes how they should be supported to evacuate the home in the event of an emergency so that they are not placed at risk of harm. 8 YA42 13(4)(a, c) 23(4)(c) 9 YA42 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 YA1 YA4 YA6 YA20 YA23 YA41 Good Practice Recommendations Consideration should be given to reviewing the format of the service user guide to help people understand the content. Records of trial visits to the home should be maintained to aid the process of assessing people’s needs. Care plans should be reviewed to make sure that accurate information is made available to staff in order for them to offer consistent care to people who live in the home. Creams should be labelled with the date of opening so that any surplus can be returned to the pharmacy in accordance with the instructions for each product. People’s personal possessions should be recorded so that they can be confident their belongings are accounted for. The manner in which daily notes are recorded should be reviewed so that staff are clear that they should make accurate and respectful comments about the people who live in the home. DS0000070703.V360559.R01.S.doc Version 5.2 Page 29 Redwood Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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