Inspection on 23/08/07 for The Red House

This inspection was carried out on 23rd August 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Red House 14/09/06

The Red House 20/02/06

The Red House 24/05/05

The Red House 07/12/04

The Red House 20/07/04

The Red House 19/02/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE The Red House Clonway Yelverton Devon PL20 6EF Lead Inspector Helen Tworkowski Unannounced Inspection 23rd August 2007 11:30 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 The Red House DS0000046280.V343326.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. The Red House DS0000046280.V343326.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Red House Address Clonway Yelverton Devon PL20 6EF 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) 01822 854376 01822 853331 Crocus Care Limited Ms Marlene Treloar Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places The Red House DS0000046280.V343326.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of 28 people 65 or over can be accommodated at one time. 14th September 2006 Date of last inspection Brief Description of the Service: The Red House is owned by Crocus Care Limited. Ms Clare Hunter is the Responsible Individual for the company; Ms Marlene Treloar is the Registered Manager. The Red House is registered to provide accommodation and care for a maximum of twenty-eight people in the registration category of Old Age. The Red House is a large detached house with a landscaped garden. It is situated on the outskirts of the village of Yelverton, which has a number of shops, churches and public houses and a frequent bus service to and from Plymouth and Tavistock. Most of the bedrooms are single rooms with en-suite toilet facilities. The Service Users Guide and Statement of Purpose are available in the office. The Service Users Guide makes up part of the homes “welcome pack” and is given to each Service User. Information regarding the fees was not included in the Service Users Guide and was not available for this report. The Red House DS0000046280.V343326.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced Key Inspection included two site visits to the home, the first on 23rd August (11.30am to 5pm) the second on the 24th August 07 (9.30am to 6pm). During this visits the inspector looked around the building, looked at records and looked at the medications system. We looked at the care of four individuals, and we talked with staff, service users, and visitors to the home. We also ate lunch with the service users. In addition we surveyed staff and service users about the care at the Red house. We also spoke with two care managers and a medical professional about the care. An “Annual Quality Assurance Assessment” form completed by the Registered Provider was also received. What the service does well: What has improved since the last inspection? New Service Users are given the opportunity to invite friends and relatives to tea. They are also given change of address cards. This helps ensure that people do not loose contact with old friends when they move. The Red House DS0000046280.V343326.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. The Red House DS0000046280.V343326.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 The Red House DS0000046280.V343326.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 (Standard 6 is not applicable). Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service Users can be confident that their needs will to some extent be known, however this may not be to any great depth. This means that they cannot be confident that their needs will be consistently met, when they first move to the Red House. Service User receive some of the information that they need to make an informed decisions about moving to the Red House. EVIDENCE: The Manager, Marlene Treloar, told the Inspector that people who visit the Red House with a view to moving are provided with information about the home, initially this is a general brochure. If the person is seriously considering moving to the home they are provided with a “Resident’s Guide” (or Service User’s Guide). The law says that this guide must contain specific information about the home. This must include the terms and conditions (other than those relating to the fees), the details of the fees payable, the arrangements in place The Red House DS0000046280.V343326.R01.S.doc Version 5.2 Page 9 for charging and paying for any services, and the standard form of contract. This information was not in the Resident’s Guide. Ms Treloar said that at the point of moving to the Red House the individual is given a copy of the contract, which contains information about fees and terms and conditions. This information should form part of the Resident’s or Service User Guide. Ms Treloar said that before anyone moves to the Red House they and their relatives are given the opportunity to visit. The Inspector was shown change of address cards that are given to people who have decided to move to the Red House. They are also given the opportunity to invite friends and relatives to tea, in their new home. The assessments of three people who had recently moved to the home were looked at as part of this inspection. Assessments are important as they inform staff about what a persons needs are and clarify if they can be met. At the last inspection it was noted that the information recorded was insufficient to provide an adequate understanding of individual needs, and a requirement was made. There has been no improvement in this area. The information supplied by the provider states that one of the things that the home does well is that the prospective service user is “fully assessed”. The Inspector discussed with the Registered Manager this concern and was told that she is required by Crocus Care Ltd to use a particular assessment form. This form leaves very little space for detailed information. For example- one person had issues with continence- all the form left space for was a tick to indicate “incontinent of urine”. It was not clear the degree or frequency of this problem, the history, or how the person concerned managed their condition and with what help. Good assessments provide the basis for meeting needs, they should also reflect individual preferences, so that they can be assured that they will get the help that they want in the manner they prefer. The Red House DS0000046280.V343326.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service Users care needs are well met by staff, however the documentation that should ensure that this is done in a consistent manner are lacking in detail. The system for managing medication is not robust, and could lead to confusion about what has been given. EVIDENCE: The Inspector spoke with Service Users about the care they received. One person said that she had found the staff to be extremely pleasant and he/she had never found them to be “awkward”. Another person said that he/she felt well looked after. Nine service users returned surveys and eight people commented that they always or usually received the care and support they needed. One person commented that there were occasional delays. Seven of the nine people responding to the survey said that they felt staff listened and acted up one what they said, comments included: “they are excellent” and “staff sometimes don’t concentrate on thing they are asked to do”. Most of the service users spoken with in general said that were treated The Red House DS0000046280.V343326.R01.S.doc Version 5.2 Page 11 well by staff. As part of this inspection the Inspector spoke with two Social Services Care Managers. One person said that that she could not praise the Red House highly enough, she felt they managed care really well, and staff took care to do things to make sure that Service Users are comfortable, such as provide heated bean bags. The other person spoken to said that she thought the care was very good, that the staff were very caring and not only did things for service users but encouraged them to do things for themselves. Four Care Plans (also known Service User Plans) were looked at during this inspection. These documents were generally over two sides of A4 paper and contained information about the care to be provided. At the previous inspection requirements had been made that these plans should be more detailed. There had been some improvements in some areas for example one care plan noted that one person’s poor eyesight affected their ability to undertake their personal care, however it still did not advise staff on the sort of help that might be needed. It was also noted that for one person the assessment completed by the manager indicated that the individual was incontinent of urine. The care plan explained that this was the case, and that the individual was being assessed for pads from the NHS. However when the Inspector spoke with staff about this they said that this was not the case, the individual was not incontinent of urine, but merely wore small pads “just in case”. It was of concern that there was a discrepancy between the care plan and what was actually happening, and that none of the staff, including senior staff, had noticed this. It also was of concern that a discharge letter from the hospital gave the correct information but had not been taken into account. In looking at various documents it was noted that one person recently admitted to the home was in receipt of about 10 different types of medication, however it was unclear from the care plan if the person had any particular condition that might indicate that these were needed. One issue raised at the last inspection was concerns that where health care needs were identified- for example in relation to diabetes- that needs were not fully identified. The Manager said, and the District Nurse confirmed that training was to be provided to staff in relation to diabetes in the near future. This had been a requirement at the last inspection. One of the Care Plans did contain some information regarding diabetes, but this was limited. Whilst it is recognised that the District Nurses do visit twice a day, the care home still should be aware of the condition, and all of the implications for care including in relation to diet, skin care, chiropody, eye tests and in relation to what situations would require them to seek medical advice. The Inspector spoke with a medical professional, who has regular involvement with the service, and she confirmed that there had been some communication difficulties with staff, she had discussed this with the manager and believed the The Red House DS0000046280.V343326.R01.S.doc Version 5.2 Page 12 matter to be resolved. She was confident the home could cater well for older people who had straightforward needs. Care Plans had been regularly reviewed and changes to care needs noted. The Manager confirmed that these reviews were carried out with service users. The Inspector was shown the medication system by one of the senior staff. The home uses a monitored dose system prepared by the pharmacist. Concerns had previously been raised regarding the medication system; this resulted in a visit by the Pharmacist Inspector in May 2006. Following this visit there were considerable improvements in the way that medication was managed. It had been reported to the Commission that there had been an error in the medication system, however this had been dealt with at the time. The Inspector was told that staff administering medication had received training in relation to medication in the last few weeks. A number of issues were noted. Not all medication was signed as administered. On occasions where one or two tablets could be administered it was not clear what had been given. The controlled drugs book had been incorrectly completed. Medication was signed as given before it was administered. Medication had not been properly entered in as received. It was unclear where individuals were self administering what they had been given and when. The Manager noted that in recent months they had built up a considerable stock of medication. The Red House DS0000046280.V343326.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service Users are offered well-cooked and well presented meals in pleasant surroundings. Service Users are offered a wide range of activities both in the home and in the community, and are provided with facilities and support to main contact with relatives. EVIDENCE: On the first day of the Inspection a group of Service Users, staff and relatives went out on a trip to Plymouth Hoe. On return everyone said how much they had enjoyed the day. It was noted that whilst some people had chosen not to go their needs were considered. The Manager showed the Inspector a file that had been set up with information about the home, and services that are available. It contained photos of the many events that had taken place in the home in recent months. This had included various theme days and a summer fete. The Inspector was given a copy of the monthly newsletter, which provides information about events and happenings in the home. The Inspector was told that there were regular Service User meetings where people have a chance to raise issues; relatives are also invited to these meetings. The Red House DS0000046280.V343326.R01.S.doc Version 5.2 Page 14 The Inspector spoke with one visiting member of the clergy who said that he felt that there was strong leadership and a culture of encouraging people to do things at Red House. The Manager said that individuals in the home received visits from five different members of the clergy. Through out the two days of the inspection visitors were coming and going, it was clear that they felt welcomed at the Red House. Service Users who were asked about the food at the Red House said the food was “tasty”. One person responding to the Survey said “The chef caters for all tastes and we are treated to 5 star treatment. Very impressed with the food choice.” They said that if they were wanted to have something different then the chef was very willing to make something to suit their tastes. The chef explained that they had a system for ensuring that each person has a choice of meals for the next day and that no one is missed out. One person said that the manager had helped organise a special party to celebrate an anniversary. It has also been noted that Service Users are able to invite relatives for meals and to hold “tea parties” when they first move. On the first day of the inspection the main meal was fish and chips, whilst on the second day it was roast dinner. The chef said that he always tried to give a selection of seasonal vegetables, although this year’s weather had made it more difficult. There was a selection of homemade cakes available including scones with jam and clotted cream. Sherry was offered before meals and wine with the meal. The Red House DS0000046280.V343326.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. 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 using available evidence including a visit to this service. Service Users and their relatives can feel confident that any concerns will be listened to. Service Users cannot be confident that all necessary measures have been taken to protect them from abuse, due to incomplete recruitment practices. EVIDENCE: All of the service users who responded to the survey said that they knew how to make a complaint, and the majority knew who to speak to if they were not happy. Comments included “If I have a problem I know Marlene (Registered Manager) will always try to sort it out for me”, and “not necessary so far”. As part of this Inspection the complaints record was looked at. The Red House had received some complaints and these had been properly investigated, the Commission referred two of these issues to Crocus Care Ltd to investigate. Whilst there was no concern about the outcome of the investigations of these complaints there was no information at the care home to show that these matters had been dealt with. The regulations require that a record of the complaint and actions taken must be kept in the care home. The information received from the Provider, before this inspection, states that all staff undergo “Protection of Vulnerable Adults Training”, and seven out of The Red House DS0000046280.V343326.R01.S.doc Version 5.2 Page 16 the nine people who responded to the Staff survey said that they were of the relevant procedures. It was noted at the last inspection that one of the ways Service Users are protected from abuse is by appropriate checks are completed on all staff recruited to work in the home. There was a lack of evidence to show that these checks had been properly completed. See section on staffing. The Red House DS0000046280.V343326.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Red House is clean, comfortable and generally well maintained, though a number of issues were identified during this visit that require attention to ensure that that Service Users are kept safe. EVIDENCE: As part of this inspection a member of staff showed the Inspector around the building. All of the bedrooms were clean and comfortable; many of the Service Users had brought in items of their own furniture or pictures. Each room reflected the personality of the occupant. Many of the rooms have views over Dartmoor and the surrounding countryside. The Inspector asked the member of staff if any of the service users had keys to their rooms, she replied that they did not. The Manager confirmed that new service users were not offered a room key as a matter of course. One person was in hospital at the time of the inspection. The Inspector discussed with the Manager whether the person’s room should be locked on their behalf whilst they were away. The Red House DS0000046280.V343326.R01.S.doc Version 5.2 Page 18 Changes have been made to the dining area since the last inspection. One of the lounges has now become a dining room, and the area that had been used for dining is now a lounge area with additional dining room space. The Manager felt that this was a better use of space, as Service Users could see what was happening from the lounge area. From the observations of the Inspector is was also well used both at meal times and as a lounge. The bathrooms were all clean and apart from in the laundry there was an ample supply of disposable towels, gloves and aprons. It was noted that there were no containers for the paper towels. These were left on the nearest shelf or on the floor. Paper towels should be readily accessible and clean. The temperature of a number of showers and baths was checked during this inspection, the water was found to be hot, but not so hot that it might scald a person. It was noted that in one bathroom (on the first floor) the bath seat had become badly discoloured by emersion and when turned over leaked rusty water. Also a ground floor toilet has a hook and eye bolt, that should any person fall in the toilet it would not be possible to gain access to the room in an emergency. The Red House DS0000046280.V343326.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service Users needs are met by sufficient staff who are well supported to carry out their roles. However the recruitment procedures are not robust and this could mean that people who are not suited to the work are employed, potentially putting people at risk. EVIDENCE: Three out of the nine people who responded to the service user survey felt that staff were always available when they needed them, whilst a further five people felt that they were usually available. The Inspector spoke with staff about whether there were sufficient staff and it was generally felt that there were, although it could be busy in the mornings. All of the staff responding to the survey said that they had enough time to provide the care required. The Manager said that there had been a number of staff changes since the last inspection. The recruitment files of three staff were looked at during this inspection. One of the files belonged to an individual who came from abroad to work for the summer. The person had been recruited through a recruitment agency. All of the documents relating to the individual were photocopies, and it was not clear if any of the information had been verified. There was no evidence of UK Criminal Records Bureau check being initiated or of a completed Protection of Vulnerable Adults (POVA) Check. This POVA check is required before any individual can start work in a care home, and allows an The Red House DS0000046280.V343326.R01.S.doc Version 5.2 Page 20 individual to work in a supervised capacity until their check on Criminal Records has been completed. The inspector was told that this individual had completed a basic induction but had not training in relation to moving and handling or other training. It was of concern as the Inspector observed one Service User being inappropriately pulled towards the a dining table. One of the other files related to an individual who was employed as a night worker. The application form contained a work history, however there were gaps in the employment that were not accounted for. Two references had been taken prior to employment, however neither of these related to the most recent period of employment that was in a care home. The Manager told the Inspector that the individual had a CRB done, however there was no evidence of this on their individual file or in a file containing a record of either a POVA or CRB checks. The file for the third individual showed that they had started work two days after their Criminal Record and POVA check had been sent by the manager to Crocus Care Ltd head office. The process of carrying out these checks means that the form must be countersigned and checked by someone authorised to carry out the procedure and sent to the CRB office. It may be possible to obtain confirmation that the individual is not on a “POVA List” 72 hours after the CRB have received this documentation. Given these timescales it is difficult to see how a POVA check had been completed prior to the person starting work. The Manager confirmed that she had not received POVA or CRB checks from Crocus Care Ltd. The Inspector was shown a file of Criminal Records Bureau checks for many of the staff employed at the home. All but one of these checks had been cut of so that it was not possible to tell what date the checks had been made. The manager had kept a list of dates of when she had sent the relevant documentation off to her head office, however there were no dates to show when clearance had been received. The recruitment practices are of concern particularly as the “Annual Quality Assurance Assessment”(AQAA) completed by the Registered Provider states that “all staff have a clear CRB check and a POVA check before they can work unsupervised”, this was found not to be the case. The “AQAA” document completed by the Registered Provider stated that new staff undergo an initial induction and then go on to a more in depth induction. The manager confirmed that this was generally the case, the exception being staff who were only on short-term contracts. Staff spoken with said that they had had sufficient training to do their job. Seven of the nine people responding to the staff survey said that they were not asked to care for people outside there area of expertise. At the last inspection a requirement was made that staff should be trained to meet the needs of Service Users including those with The Red House DS0000046280.V343326.R01.S.doc Version 5.2 Page 21 diabetes. This training has not taken place, though the inspector was told that it has been booked. The Manager said that she was now getting up to date with supervision (support) sessions with staff and seven of the staff responding to the survey confirmed that this was the case. The Red House DS0000046280.V343326.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service Users and other visitors can be confident that their views are listened to and taken into account in the running of this home. Money held by the home on behalf of Service Users is properly accounted for. Some aspects of health and safety are not well managed as checks are properly carried out. This could place service users at risk. EVIDENCE: The Manager, Marlene Treloar has now completed her registered Managers Award, and has some years experience managing a care home. Staff and service user feedback forms showed that there was a general confidence in Ms Treloar. One person commented, “My mother is extremely well looked after at The Red House DS0000046280.V343326.R01.S.doc Version 5.2 Page 23 the Red House. I visit daily and the staff are always cheerful and extremely kind and thoughtful and have endless patience. I am very satisfied with the efficient and caring way Marlene runs the home”. The Manager, Ms Treloar said that she had set up various ways of checking on the wellbeing of the Service Users. Regular residents meetings were held, (the minutes of these were seen), and she made time each day to see Service Users, even if it was only for a few minutes each. The Inspector was show the quality assurance system, which included surveys being sent out to service users, their relatives and to professionals visiting the home. The Inspector discussed with Ms Treloar the feedback from one visiting professional, and the actions she had taken in response. These actions had not been recorded. The inspector discussed with Ms Treloar how this information could be recorded to show that actions were taken in response to comments made. The Inspector looked at money held by the home on behalf of service users. There was a clear record of cash being signed in and out, and when the balance of one account was checked it was found to be correct. During the tour of the building the Inspector looked at whether electrical equipment had been checked, which it had; and fire extinguishers that had also been checked. It was noted during this inspection that some of the windows did not have window restrictors on them, the Manager said that she thought that these had restrictors and hence there was no risk assessment on them. It was also noted that there were no risk assessments in relation to the use of electric blankets. There was a fire risk assessment which identified when check were to be made on the fire system. Some of the checks on the fire equipment had slipped in recent weeks however in general they were up-to-date. The Manager said that staff received fire training every six months, after their initial induction, and that no fire drills were done. However the Fire Risk Assessment stated that staff would complete fire training every three months. During the tour of the building it was noted that two bedrooms doors were propped open, and therefore would not close in the event of a fire. An immediate requirement was made on this. The Legionella Risk Assessment had been completed in March 04, and this identified works that need to be completed. The Manager was unable to say if these had been done or if the assessment had been reviewed. There was a record of accidents in the home. The Inspector discussed with the manager the lack of any system to give an overview of falls and to ensure that any patterns of falls were identified. It was noted that one service user had fallen and had broken their nose; such an incident should have been reported The Red House DS0000046280.V343326.R01.S.doc Version 5.2 Page 24 to the Commission. Another incident involved an accident where a staff member had received an injury at work requiring them to be off work for more than 3 days. There was no evidence that this had been reported to the Health and Safety Executive, under “RIDDOR”. The individual concerned was not aware of any such report. The Red House DS0000046280.V343326.R01.S.doc Version 5.2 Page 25 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 2 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X 3 2 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 1 The Red House DS0000046280.V343326.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4,5 Requirement Timescale for action 01/11/07 2. OP3 14 3. OP7 15 The Service User Guide must contain all the information that is required in the regulations, including information about fees. A copy of the document must be supplied to the Commission. This is to ensure that Prospective Service Users have the information they need about a Care Home. Pre-admission assessments for 01/11/07 Service Users must be comprehensive, recording all known needs. This is to ensure that Service Users get the help they need from the time they move. (A similar requirement was made at the last inspection on the 16/9/06 to be met by 1/11/06, and has not been met). 01/12/07 Service User Plan must be comprehensive and detailed; they must include actions staff are to take to meet needs. This must include reference to health care needs. This is to ensure that service users get the need they require in the manner they prefer. (A similar requirement was made at the last inspection DS0000046280.V343326.R01.S.doc Version 5.2 The Red House Page 27 4. OP8 15 5. OP9 13(2) 6. OP18 18,19 7. OP29 18,19 8. OP18 18,19 on the 16/9/06 to be met by 1/1/07, and has not been met). Service User Plan must be comprehensive and detailed; they must include actions staff are to take to meet needs. This must include reference to health care needs. This is to ensure that service users get the need they require in the manner they prefer. (A similar requirement was made at the last inspection on the 16/9/06 to be met by 1/1/07, and has not been met). There must be appropriate arrangements for the recording and safe administration of medicines in the care home. This refers to the need to have a record of the receipt of all medication into the home and supplied to service users. A criminal records bureau check must be initiated before employment, and a named person must supervise any person working with out a completed check. There should be evidence of this in the home. (A similar requirement was made at the last inspection on the 16/9/06 to be met by 1/11/06, and has not been met). A criminal records bureau check must be initiated before employment, and a named person must supervise any person working with out a completed check. There should be evidence of this in the home. (A similar requirement was made at the last inspection on the 16/9/06 to be met by 1/11/06, and has not been met). All appropriate checks must be made as part of the recruitment process. This must include two relevant written references, and DS0000046280.V343326.R01.S.doc 01/12/07 01/11/07 01/11/07 01/11/07 01/11/07 The Red House Version 5.2 Page 28 9. OP29 18,19 10. OP30 19 11. OP38 23 (4) 12. OP38 13 (4) a POVA first check, before employment. There should be evidence of this in the home. (A similar requirement was made at the last inspection on the 16/9/06 to be met by 1/11/06, and has not been met). All appropriate checks must be made as part of the recruitment process. This must include two relevant written references, and a POVA first check, before employment. There should be evidence of this in the home. (A similar requirement was made at the last inspection on the 16/9/06 to be met by 1/11/06, and has not been met). Staff must be trained to meet the needs of service users accommodated, for example in relation to diabetes. There should be evidence of this in the home. (A similar requirement was made at the last inspection on the 16/9/06 to be met by 1/1/07, and has not been met). Immediate Requirement: Doors that have been designated as fire doors, with self-closing mechanisms, must not be wedged open. This is to protect service users, staff and visitors from the spread of a fire, and so prevent the unnecessary loss of life. Regulation 23 (4). Timescale: 7th September 07. Risk Assessment and checks to ensure the safety of service users must be up to date and acted upon. This must include in relation to fire training for staff and fire drills, the risks posed by Legionella, risks posed by unrestricted windows and in relation to the use of electric blankets. 01/11/07 01/12/07 07/09/07 01/11/07 The Red House DS0000046280.V343326.R01.S.doc Version 5.2 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Red House DS0000046280.V343326.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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. Extracts may not be used or reproduced without the express permission of CSCI The Red House DS0000046280.V343326.R01.S.doc Version 5.2 Page 31 - 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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