Inspection on 07/09/05 for Redwood Close 11

This inspection was carried out on 7th 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

Redwood Close 11 05/12/06

Redwood Close 11 08/03/06

Redwood Close 11 09/03/05

Redwood Close 11 30/11/04

Redwood Close 11 12/03/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

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

CARE HOME ADULTS 18-65 11 Redwood Close Bridlington East Yorkshire YO16 7GX Lead Inspector Diane Wilkinson Unannounced 7 September 2005 10:45 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. 11 Redwood Close J53_s19782_11 Redwood Close_v204537_070905_Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 11 Redwood Close Address 11 Redwood Close Bridlington East Yorkshire YO16 4SH 01262 675862 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) East Yorkshire Housing Association Limited Christine Lessentin (awaiting registration) Care Home 3 Category(ies) of LD Learning Disability (3) registration, with number of places 11 Redwood Close J53_s19782_11 Redwood Close_v204537_070905_Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 9th March 2005 Brief Description of the Service: 11 Redwood Close is a owned by East Yorkshire Housing Association Limited. The home is registered to provide accommodation and care for three male or female service users with a learning disability. There are currently 2 service users living at the home. The home is generally well maintained and bedrooms are individually decorated to reflect the style and taste of the service users. Service users have access to all communal areas and can spend time with others in the lounge and dining room or take time to be alone in their bedroom. The home has its own transport for taking service users to day centres or on outings in the surrounding countryside and has good access to the local bus service. 11 Redwood Close J53_s19782_11 Redwood Close_v204537_070905_Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over a period of 4.5 hours, including preparation time for the inspector. The inspection included a tour of the premises and examination of documentation, including person centred plans. The inspector spoke to a service user, a member of staff and the acting registered manager. What the service does well: 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. 11 Redwood Close J53_s19782_11 Redwood Close_v204537_070905_Stage 4.doc Version 1.40 Page 6 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 Standards Statutory Requirements Identified During the Inspection 11 Redwood Close J53_s19782_11 Redwood Close_v204537_070905_Stage 4.doc Version 1.40 Page 7 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 A thorough assessment is undertaken prior to any decision being made about admission to the home, and service users and carers are involved in this process. EVIDENCE: The current service users have lived at 11 Redwood Close for many years. Their needs were assessed prior to admission to the home and are reassessed on a regular basis. There is evidence elsewhere in the organisation that service users are only admitted into a particular care home following a full assessment of their care needs, and that the service user, care management, health professionals and relatives are involved in this process. The homes own assessment and the assessment and care plan from care management are used to form the basis of an individual care plan, or person centred plan. Compatibility with other service users is one of the main considerations when placing a new service user. 11 Redwood Close J53_s19782_11 Redwood Close_v204537_070905_Stage 4.doc Version 1.40 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 & 9 Person centred plans provide staff with the information they need to meet a service user’s individual needs. Service users are supported and encouraged to make decisions about their lives, and to take responsible risks. EVIDENCE: Service users are aware that there is a person centred plan that records their individual care needs. Service users are able to express their wishes, their likes and dislikes and the way in which they wish to be assisted with personal care and other tasks – this information is understood and recorded by staff. Care plans are a very thorough record of the individual needs of service users and include a detailed personal profile and a person’s ‘hopes and dreams’. Care plans record a service user’s method of communication. An updated assessment was undertaken in April 2005 and monthly summaries of the person centred plan take place. Formal reviews (involving care management and relevant others) take place appropriately. Service users are encouraged and supported to make decisions about their day-to-day lives to extent that they are able to do so, and relevant details are recorded in care plans. 11 Redwood Close J53_s19782_11 Redwood Close_v204537_070905_Stage 4.doc Version 1.40 Page 9 There are ‘risk taking’ assessments in place, for example, for service users getting in and out of the bath without assistance. These are very detailed and evidence that service users are supported to take responsible risks and that safeguards are put in place to minimise any identified risks. 11 Redwood Close J53_s19782_11 Redwood Close_v204537_070905_Stage 4.doc Version 1.40 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15, 16 & 17 Service users are well integrated into the local community and benefit educationally and socially from attending day centres and college. Service users are supported to maintain contact with family and friends and to have appropriate relationships. Service users rights are respected and they are given some responsibility for their day-to-day lives. Meals provided by the home suit the needs of service users. EVIDENCE: Both service users attend day centres and/or college but neither would be able to take up any kind of employment. They undertake activities that meet their needs and their wishes, such as literacy skills and IT skills. The day centre and college are local to the home and service users form friendships with other people who attend these facilities. Service users enjoy trips out into the countryside and enjoy eating out. They prefer to have 7 separate days out per year, rather than having one week’s holiday and this has 11 Redwood Close J53_s19782_11 Redwood Close_v204537_070905_Stage 4.doc Version 1.40 Page 11 been recorded in their individual plans. All activities undertaken by service users are recorded. Service users are supported to maintain contact with family and friends and relatives are encouraged to visit the home and to take service users out. Daily routines promote independence and individual choice. The inspector observed that service users are asked about how they want to spend their time at home and are given various options to choose from. Service users and staff were observed to interact well with each other and service users were given time and space to express themselves. Service users are able to choose whether to sit in the lounge or to spend time alone in their bedroom. Service users do not have any special dietary needs. One of the service users likes to accompany staff to the shops to buy food - he points to the food he would like. A record is kept of all meals provided by the home for service users. Nutritional screening takes place to ensure that meal provision is maintaining the health of service users. 11 Redwood Close J53_s19782_11 Redwood Close_v204537_070905_Stage 4.doc Version 1.40 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 & 20 Service users are assisted with personal care in a way that promotes privacy, choice and independence. The health care needs of service users are thoroughly assessed, actioned, recorded and monitored. The systems in place for the administration of medication protect the health and safety of service users. EVIDENCE: Person centred plans are a very detailed record of the way in which service users wish to receive personal support. Times for getting up and going to bed are flexible, and service users choose when to take a bath, where to eat their meals and when to take part in activities. Service users choose what clothes to wear and are taken out shopping to choose their own clothes. Physical and emotional health needs are met in a sensitive way. A record is kept of all contact with GP’s, chiropodists and other health professionals. Each service user has a record of medication that is currently prescribed, and service users have had their medication needs reviewed. Service users are not able to hold their own medication, and this is recorded. There are appropriate medication policies and procedures in place and the records for the administration were examined by the inspector and found to be satisfactory. Medication is stored securely. 11 Redwood Close J53_s19782_11 Redwood Close_v204537_070905_Stage 4.doc Version 1.40 Page 13 11 Redwood Close J53_s19782_11 Redwood Close_v204537_070905_Stage 4.doc Version 1.40 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 The home has a satisfactory complaints system with some evidence that service users views are listened to and acted upon. There are policies and procedures in place to ensure that service users are protected from all types of abuse. EVIDENCE: There is an appropriate complaints policy and procedure in place. The procedure is included in the service user guide and each service user has a copy. The procedure has been updated to include the contact details for the Commission for Social Care Inspection. There is a complaints log available for use. Tenants meetings are held every month and symbols are used to assist service users to express their views – staff feel that service users would use these meetings to express any dissatisfaction as they are not able to use the complaints procedure. Staff stated that they would know by a person’s behaviour if they were unhappy about something. Training about the protection of vulnerable adults from abuse is considered to be mandatory training for staff within the organisation – the inspector was informed that all staff undertake this training on a regular basis. There are appropriate policies and procedures in place, and these include a whistle blowing policy. 11 Redwood Close J53_s19782_11 Redwood Close_v204537_070905_Stage 4.doc Version 1.40 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 & 30 The standard of the environment within this home is good providing service users with an attractive, homely, hygienic and safe place to live. EVIDENCE: Service users live in a homely, comfortable and safe environment. The house is furnished with good quality domestic furniture and furnishings. Service users rooms are personalised to suit their personalities and their choices. The premises are in keeping with the local community and are safe, bright, airy and clean. One of the service users has moved into a bedroom with en-suite facilities. Staff now use the converted conservatory as their ‘sleep in’ room. Ideally, staff should have their own shower and toilet – they currently use the same facilities used by service users. A maintenance log is kept. Laundry facilities are situated in the garage and equipment is suitable to meet the needs of the service users. There is an infection control policy in place and staff undertake appropriate training on the control of infection and good hygiene. The home was free from offensive odours on the day of the inspection. 11 Redwood Close J53_s19782_11 Redwood Close_v204537_070905_Stage 4.doc Version 1.40 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 & 35 Recruitment and selection practices in place within the organisation ensure the protection of service users. Training opportunities within the organisation ensure that service users benefit from having a well-trained workforce with high staff morale. EVIDENCE: Records for recruitment and selection are held at the organisation’s head office, but all other documentation concerning staff members (such as supervision and training records) are kept on the premises. The inspector did not see recruitment information for the newest member of staff, but discussion with this person informed the inspector that appropriate procedures were followed. An application form was completed, the interview included a meeting with service users and two written references and a satisfactory CRB check were obtained before the person commenced work at the home. Staff undertake induction training as soon as they commence work at the home. Staff in the organisation are supported to undertake LDAF training and NVQ Level 3 training. Each member of staff has an individual training log and a list is sent out by head office each year recording the training that staff should undertake to update their knowledge and skills. All staff undertake mandatory training on a regular basis. Copies of training certificates awarded to staff are retained in their staff file. 11 Redwood Close J53_s19782_11 Redwood Close_v204537_070905_Stage 4.doc Version 1.40 Page 17 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39 & 42 The home is managed by an experienced and skilled person. The quality assurance system gives service users and others the opportunity to express their views about the way that the home is run. The policies and procedure in place for safe working practices ensure the health, safety and welfare of service users. EVIDENCE: The acting registered manager has applied to the Commission for Social Care Inspection (CSCI) for registration. The acting manager is already the registered manager for another home in the organisation and plans to continue to manage both homes. The acting registered manager has completed NVQ Level 4 in Care training. This standard should be met when the acting manager completes the registration process with the CSCI. 11 Redwood Close J53_s19782_11 Redwood Close_v204537_070905_Stage 4.doc Version 1.40 Page 18 The organisation has achieved the Investors in People award and QDS parts 1 & 2 - QDS is the local authorities quality scheme. Surveys are completed every six months by service users, staff and relatives. The results of these are audited centrally and a document recording the outcome is published – this is read by staff and discussed at tenants meetings. The inspector recommends that relatives and others should be informed of the outcome of quality surveys via the organisations newsletter. Tenants meetings and staff meetings are held on a monthly basis. Policies, procedures and practices are reviewed regularly. There is a fire risk assessment in place – the Fire Officer had visited the home on the same day as the inspector, and he reported that he was happy with the fire alarm system. A smoke detector has now been fitted in the hallway. Inhouse fire tests take place on a weekly basis and a three monthly fire drill is held – the most recent fire drill took place in August 2005. Fire extinguishers were tested by a contractor in June 2005. The radiators in bedrooms and bathrooms are guarded and there is a risk assessment in place for the radiator in the lounge. This states that the coffee table must be placed in front of the radiator at all times – this was the case on the day of the inspection. Fridge and freezer temperatures are checked daily. A portable appliance test took place in November 2004 and the electrical installation was tested in February 2005. There is a building regulations compliance certificate in place for gas appliances. Personal toiletries are locked up in each service user bathroom. All cleaning materials are stored in a locked cupboard in the garage and COSHH information is in place for all substances used. A new hot water boiler and thermostatic valves were installed in June 2005, and the water temperature was checked by a plumber in July 2005. This currently alleviates the need to have a test for the presence of Legionella in the water supply, although controls need to be in place to ensure that the water supply remains safe. 11 Redwood Close J53_s19782_11 Redwood Close_v204537_070905_Stage 4.doc Version 1.40 Page 19 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 11 Redwood Close Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 x 3 x x 3 x J53_s19782_11 Redwood Close_v204537_070905_Stage 4.doc Version 1.40 Page 20 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 Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 24 Good Practice Recommendations Ideally, staff should be provided with separate toilet and bathing/shower facilities. 11 Redwood Close J53_s19782_11 Redwood Close_v204537_070905_Stage 4.doc Version 1.40 Page 21 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 11 Redwood Close J53_s19782_11 Redwood Close_v204537_070905_Stage 4.doc Version 1.40 Page 22 - 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!