Inspection on 26/08/06 for The Red House

This inspection was carried out on 26th August 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Red House 09/03/06

The Red House 23/09/05

The Red House 25/01/05

The Red House 17/05/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 The Red House 65 Ruspidge Road Cinderford Glos GL14 3AW Lead Inspector Mr Richard Leech Key Unannounced Inspection 26th August 2006 09:30 The Red House DS0000043069.V310062.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 The Red House DS0000043069.V310062.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. The Red House DS0000043069.V310062.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Red House Address 65 Ruspidge Road Cinderford Glos GL14 3AW 01594 822100 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) red.house@craegmoor.co.uk www.craegmoor.co.uk Park Care Homes (No 2) Ltd Miss Andrea Creed Care Home 8 Category(ies) of Learning disability (8) registration, with number of places The Red House DS0000043069.V310062.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th March 2006 Brief Description of the Service: The Red House is a detached care home situated in a residential area a couple of miles from the centre of the town of Cinderford. There is a shop and a pub close by. The home provides accommodation and care for up to eight adults with learning disabilities who may also have challenging behaviour. The accommodation is spread over three floors and the home is surrounded by terraced gardens. Fees were reported to be £1574 per week (base). Prospective service users and people involved in their care are offered information about the home and the opportunity to visit where appropriate. The Red House DS0000043069.V310062.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection began on a Saturday morning, lasting until late afternoon. A second visit was made on the following Wednesday from mid-morning to midafternoon. The acting manager (referred to as the manager in the report) was in the home for this second visit. Most of the service users were met and spoken with during the visit, along with many members of the staff team. Various records were checked including examples of care plans, medication charts, daily notes and risk assessments. The communal areas of the home and some of the bedrooms were looked at. Before the visit the manager completed a pre-inspection questionnaire. A range of survey cards were also sent out to service users and people involved in their care. There was a good response. What the service does well: There are good systems for assessing the needs of people who might move into the home and for making sure whether those needs could be met. Care planning in the home is good, helping to ensure that service users’ needs and goals are recorded and appropriate support is given. Service users are offered real choice and control over their lives. Sound risk assessment and management promotes people’s safety while enabling them to lead full lives. Service users take part in a range of activities reflecting their needs and interests, both in the home and community. Varied and wholesome food is offered to service users and their choices are respected. Service users’ personal and healthcare needs are met in ways which respect their privacy and preferences. Medication is handled well in the home. Service users feel listened to and safe in the home. Good systems are in place to help reduce the risk of people being harmed and abused. Challenging behaviour is well managed. The environment is homely and comfortable. Service users like their rooms and are able to personalise them. Staff are skilled and caring, providing high quality individualised support for service users. Good training further promotes this. The Red House DS0000043069.V310062.R01.S.doc Version 5.2 Page 6 The home is well run. Good arrangements are in place for checking how the service is performing and for making improvements. Health and safety is also well managed. 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. The Red House DS0000043069.V310062.R01.S.doc Version 5.2 Page 7 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 The Red House DS0000043069.V310062.R01.S.doc Version 5.2 Page 8 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 the following standard(s): 2 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Appropriate admissions policies and procedures help to ensure that the needs of people who move into the home are assessed and can be met. EVIDENCE: The organisation has a satisfactory admission procedure. Service users’ files included background and assessment material from the time of admission as well as some updated assessments of need. Information was viewed in respect of a forthcoming planned admission. This had been written in conjunction with others involved in the person’s care including family. The acting manager described how this had been put together and how she and other staff had spent time in the person’s current home meeting both the service user and staff. Interim support plans and risk assessments had been written. These were detailed and were clearly linked to needs assessments. The person had visited the home. Staff spoken with confirmed that they had been given information and had briefings about the support needs of the person moving in. The Red House DS0000043069.V310062.R01.S.doc Version 5.2 Page 9 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 the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A good care planning system helps to ensure that service users’ needs and preferences are identified and met. People’s choices and wishes are respected as far as possible such that service users feel in control of their lives. A sound system for assessing and managing risks promotes service users’ safety and wellbeing. EVIDENCE: Care plans were seen to be up to date, relevant and to reflect people’s goals, needs and wishes. The manager explained that work had been done since the last inspection to make them more person-centred. There was recognition of people’s skills and strengths. Review notes and minutes from other meetings provided evidence of service users’ involvement in care planning. Daily notes indicated that staff responded to service users’ questions about care plans and talked through them if requested. Detailed support plans about the management of challenging The Red House DS0000043069.V310062.R01.S.doc Version 5.2 Page 10 behaviour were in place, having been written in consultation with external professionals. Care plans placed a strong emphasis on respecting people’s choices. Evidence of this being put into practice was observed throughout the inspection, with service users being in control of how they spent their time. Further evidence of people being enabled to make decisions for themselves came from discussion with staff and service users and from the survey forms which they completed. The manager described how advocates were working with some service users to help them express their wishes. Risk assessments viewed appeared to address significant risks, were regularly reviewed and cross-referenced to care plans. The Red House DS0000043069.V310062.R01.S.doc Version 5.2 Page 11 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 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. Service users take part in a range of activities reflecting their needs and interests, both in the home and community, and lead full lives. Appropriate support is offered for people to maintain and develop contact with important people in their lives. The service is run in a way which respects people’s rights and promotes their independence, enhancing their sense of autonomy and individuality. A varied, wholesome diet is offered which reflects people’s choices and preferences, enhancing service users’ quality of life and wellbeing. EVIDENCE: On the first day of the inspection two service users were at home, one person went on a trip to various destinations of their choice in the area and three people went on a picnic. On the second visit service users were observed being offered choices of trips. The Red House DS0000043069.V310062.R01.S.doc Version 5.2 Page 12 Service users described their activities and were generally positive about how they spent their time. There was evidence of a wide variety of individual and group activities in the home and community, with programmes built around each person’s goals and interests. Review notes from meetings provided evidence that people’s satisfaction with their activities was kept on the agenda, and changes made to timetables accordingly. Observation throughout the inspection also indicated that there was scope for spontaneity and flexibility, for example, with people being offered a trip to a shop or pub or to go out for a walk. Some people were returning to college in the Autumn. Care plans included reference to activities and to community participation. Daily records provided more evidence of a range of different activities being offered and of everybody going out on most days. The manager and staff indicated that they would like the activities budget to be higher so that they could offer even more to service users. This was seen as a reflection of their commitment and service-user focus. Some service users said that they would like the chance to go out more on a one-to-one basis. Some staff commented on a lack of drivers at times. The manager said that this should hopefully ease as more people become able to drive the vehicles. Discussion with staff and service users provided evidence that appropriate support is offered for people to stay in contact with family and friends. Daily notes provided evidence of people having regular contact with family. Where there was less contact, discussion with staff provided evidence of the team attempting to promote and increase this. Files included lists of important contacts and also information such as their birthdays. A barbecue was planned for September with service users’ families being invited. Service users were observed choosing where and how they spent time in the home. Discussion with staff provided further evidence of people being in control of their own routines. Care plans included an emphasis on recognising people’s strengths and promoting their independence. Service users confirmed that they took part in household chores and that they were happy with this. Some staff spoken with confirmed that service users were offered the opportunity to vote in elections if they wished. People’s preferred form of address was noted on their files. A menu provided evidence that wholesome and varied food was being served in the home. Service users expressed general satisfaction with the food, and confirmed that they were asked for their views (e.g. during residents’ meetings. Staff were observed offering people choices about meals and accompaniments. The Red House DS0000043069.V310062.R01.S.doc Version 5.2 Page 13 A barbecue was observed. Service users appeared relaxed and to be enjoying the food, interaction and activities. During the inspection people were seen getting up at different times and having breakfast of their choosing. The Red House DS0000043069.V310062.R01.S.doc Version 5.2 Page 14 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 the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ personal and healthcare needs are met, promoting their wellbeing, although improvements could be made to aspects of recording and coordination. Medication is well handled in the home, helping to ensure that service users remain well and minimising the risk of errors occurring. EVIDENCE: Care plans included information about personal care support needs as well as service users’ preferences around routines and how this care was delivered. Staff spoken with described how they offered personal care and respected people’s privacy and dignity. Service users were dressed individually and were seen to express their personalities, for example through accessories, hair styles and make up. Healthcare records, along with discussion with the staff and manager, provided evidence that people were being supported to access routine and specialist services according to their needs. However, it was difficult to quickly ascertain The Red House DS0000043069.V310062.R01.S.doc Version 5.2 Page 15 when service users had last visited a particular professional. Staff said that there should be a summary sheet for each person, though these could not be located at the time. It was suggested to the manager that the team should look into health action planning formats and consider implementing this. Some information was given about starting points. Medication storage, records and procedures appeared to be in order. Files included other documents such as sample signatures for staff, GP approved homely remedies, PRN protocols and photographs of each service user. One cream was found to be out of date. The manager investigated this and the likely reason was accepted. Records provided evidence that staff were appropriately trained in the safe handling of medication. The Red House DS0000043069.V310062.R01.S.doc Version 5.2 Page 16 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 the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate arrangements for handling concerns and complaints help service users to feel respected and listened to. There are good systems in place for protecting service users from the risk of harm and abuse, promoting their safety. EVIDENCE: The home has a complaints procedure in text and pictorial form. There was some reference to a specific inspector and this could be updated (or left as general CSCI). Through surveys and discussion there was evidence that service users knew who to speak to if they were unhappy about something, and that they had confidence that something would be done. Some people added that the staff were good listeners. Discussion with one person who had made a complaint indicated that they were happy with the outcome. The manager described how this had been handled and what the outcome had been. This provided evidence that it had been fully investigated and dealt with in a professional manner, with the service user being listened to and their views valued and respected. As noted, detailed plans are in place for the management of challenging behaviour. Records, along with discussion with the manager and staff provided evidence that these were effective and that the incidence of challenging The Red House DS0000043069.V310062.R01.S.doc Version 5.2 Page 17 behaviour had diminished. Staff spoken with described having training in the management of challenging behaviour and expressed confidence in this area. They talked through how they managed specific scenarios. Records included phrases such as ‘physically moved [service user]…using taught techniques (21/08/06). The actual technique used should be described so that the records provide a fuller account of the nature of the physical intervention. Some service users expressed anxiety about incidents of challenging behaviour in the home. Clearly it will be an ongoing task for the team to make people feel as safe and secure as possible, but there was evidence throughout the inspection that incidents were skilfully handled. In conversation, staff demonstrated awareness of abuse and of the whistle blowing procedures. They were clear that they would report any concerns and that they had confidence in the systems for investigating and addressing these. The manager talked through how service users’ finances were managed and the safeguards in place such as twice daily balance checks signed by two staff. Samples of records viewed appeared to be in order. The Red House DS0000043069.V310062.R01.S.doc Version 5.2 Page 18 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 the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A reasonable environment is provided, although there is scope for improvements to make the home a more spacious and pleasant place to live. EVIDENCE: The communal areas of the home were checked, along with two service users’ rooms at their invitation. The environment was generally clean, comfortable and fresh. A slight odour in one part of the lounge was pointed out and staff said that they would ensure that appropriate action was taken to address this. The lounge carpet was very stained. The manager confirmed that a new one would be ordered. Service users described being asked about their preferences for colour. A requirement is not made on the understanding that a replacement will soon be fitted. Some vegetables were being stored in the laundry. It was suggested that an alternative location be found which was cooler and less humid. The Red House DS0000043069.V310062.R01.S.doc Version 5.2 Page 19 Service users expressed satisfaction with their rooms. Some confirmed that they had chosen the colours. Bedrooms viewed had been personalised. The following additional points were noted: • The TV reception was poor in the lounge. Service users reported the same problem in their rooms. The manager said that quotes were being obtained to hopefully resolve this, and that the maintenance man was also looking into it. One person said that they wanted access to more television channels. The manager said that this would hopefully be addressed once the problem with general reception was resolved. Fridge temperatures appeared to be on the high side according to records (around 10 to 12°C in some cases). The manager said that she was aware of this and had obtained some new thermometers to check whether it was an issue with the fridge or if the recording were incorrect. One bathroom had a small area of mould. Staff reported that this was on the list for the maintenance person to address. • • People were seen making good use of the garden. New outdoor furniture had been obtained and there were also games and a barbecue. A requirement was made in the last report about providing plans for necessary improvements to the dining and kitchen area. This relates to creating more space and to promoting safety. The manager and staff reported that plans were now nearly finalised and that an update would be supplied in the near future. The proposals include improvements to other areas, and should significantly enhance the environment provided. Some staff felt that the cleaning budget should be increased so that, for example, better quality brands of laundry powder could be purchased. The Red House DS0000043069.V310062.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. 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. Staff are skilled and caring, providing high quality individualised support for service users. Good planning and provision in training further enhances staff members’ knowledge and competence. Sound recruitment practices help to protect service users, although one issue needs addressing to make procedures more robust. EVIDENCE: Staff were observed to interact with service users in a warm, supportive and professional manner. Service users in turn appeared comfortable and relaxed. In discussion and through their survey forms they provided positive feedback about the staff team. Discussion with staff provided evidence that they had a good understanding of people’s care plans and support needs. Staff were observed talking an upsetting incident through with one person, providing reassurance and helping them to calm down. The Red House DS0000043069.V310062.R01.S.doc Version 5.2 Page 21 Staff spoken with felt that communication in the home was good, particularly following some recent changes to the handover system. The communication book was seen to be well used. The manager reported that four of the staff team had achieved NVQ level 2 or 3 (excluding the registered manager). However, some more people were due to qualify shortly and a new intake was also planned. Once this has been concluded the staff team should be around 50 qualified in relevant NVQs. The manager described the recruitment policies and procedures, including how equal opportunities was managed. Three staffing files were checked. All relevant documentation and checks appeared to be in place. However, examples of employment histories seen were not fully complete, in that there were gaps with no accompanying written explanation. The pre-inspection questionnaire and on-site training records gave evidence of a comprehensive programme of relevant in-house and external training. Where gaps were noted these were seen to have been identified with measures already in place to put people forward for necessary training. Staff spoken with expressed satisfaction with the training provided. Some people felt that more training was needed about autistic spectrum conditions. The manager described plans to deliver training about this in the near future based on a pack obtained from BILD. Some people in the team had been trained to train others in particular areas such as moving and handling and the management of challenging behaviour. Newer staff spoken with expressed satisfaction with their induction programmes. The manager and staff reported some recent difficulties around staffing levels. However, they said that this had now eased. The manager added that the situation with staffing the home at night was also being addressed, though adding that the latter was a long-standing issue in part related to conditions of service. Minutes of a recent staff meeting were viewed. These were very thorough and covered a wide range of subjects. The Red House DS0000043069.V310062.R01.S.doc Version 5.2 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run, promoting positive outcomes for service users. A thorough system is in place for monitoring and improving the quality of the service provided, including taking into account service users’ views. Measures are in place which promote the health and safety of staff and service users. EVIDENCE: At the time of the visit the registered manager was temporarily managing another home and the deputy manager was acting as manager. Staff spoken with said that the home was continuing to be well run. They described an open culture where ideas were encouraged and where the management listened to their views. The Red House DS0000043069.V310062.R01.S.doc Version 5.2 Page 23 Notification had been received of this arrangement. This will be monitored to ensure that the home is not without a registered manager for a prolonged period. A system of shift leaders operates. There is a structured training process for staff to become a shift leader. Minutes from a recent residents’ meeting were seen. These showed that a wide range of areas was discussed with contributions from many service users. A visit under Regulation 26 took place on the second day of the inspection. Whilst the reports are no longer automatically requested, it was agreed that copies would be forwarded to CSCI. The organisation operates a very comprehensive quality assurance system, consisting of a variety of internal self-audits (the results of which are forwarded from the home) and periodic external audits. Examples of internal audits on medication, health & safety and food safety were seen. Two examples of ‘overview’ audits from 2006 were also seen, with evidence of improvements having been made. Each audit was seen to result in an action plan and there was evidence of the points being addressed. Staff spoken with understood that there had recently been a survey of service users’ and relatives’ views. Routine testing of electrical appliances had been recently done. There was some uncertainty about whether the boiler and cooker may be due for a routine service. The manager said that she would look into this. There was evidence that fire alarms and emergency lighting were generally being tested at appropriate intervals. Fire drills were being recorded, although ways of enhancing this recording and actions arising were discussed. The fire risk assessment was viewed, dating from May 2005. Some information was forwarded about new fire safety legislation and the implications for care homes. The team should consider whether the fire risk assessment needs review in the light of this. A system of routine checks at set intervals operates. This had slipped a little recently, but the manager said that this was now getting back on track with the employment of a new maintenance man six weeks prior. Hot water temperatures were tested around the time of the inspection, highlighting some issues. The manager said that a contractor had been called out. A service user commented on the outside lights, saying that they were not working properly. The manager said that this was being addressed. The Red House DS0000043069.V310062.R01.S.doc Version 5.2 Page 24 The manager said that one service user helps out with routine health and safety checks. Staff spoken with felt that their health and safety was looked after. The Red House DS0000043069.V310062.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 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 x 2 4 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 x 3 x LIFESTYLES Standard No Score 11 x 12 4 13 4 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 4 x x 3 x The Red House DS0000043069.V310062.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 13 23 Requirement Provide plans and a schedule for the necessary improvements to the dining and kitchen areas. Timescale of 31/05/06 not met. Ensure that there is a full employment history for people working in the care home, together with a satisfactory written explanation of any gaps in employment. Timescale for action 31/10/06 2 YA34 19 31/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard YA12 YA19 YA23 YA24 Good Practice Recommendations Consider whether the activities budget is sufficient to meet people’s needs, wishes and aspirations. Look into ‘Health Action Planning’ and the formats available. Consider implementing this in the home. Ensure that records provide a full account of the nature of any physical intervention. Take necessary action to address the three bullet points made in the text in the environment section. DS0000043069.V310062.R01.S.doc Version 5.2 Page 27 The Red House 5 YA42 • • • Check whether the boiler and cooker are due a routine service. Consider how to improve the recording and monitoring of fire drills and the actions arising. Consider whether the fire risk assessment needs review in the light changes to fire safety legislation. 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