Inspection on 03/01/07 for The Redhouse

This inspection was carried out on 3rd January 2007.

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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Redhouse 09/11/07

The Redhouse 30/11/05

The Redhouse 02/08/05

The Redhouse 19/01/05

The Redhouse 21/07/04

The Redhouse 14/01/04

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

CARE HOME ADULTS 18-65 Redhouse, The The Redhouse Wharncliffe Road Ilkeston Derby Derbyshire DE7 5GF Lead Inspector Claire Williams Unannounced Inspection 03 January 2007 12:30 Redhouse, The DS0000052210.V292223.R01.S.doc Version 5.1 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 Redhouse, The DS0000052210.V292223.R01.S.doc Version 5.1 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. Redhouse, The DS0000052210.V292223.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Redhouse, The Address 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) The Redhouse Wharncliffe Road Ilkeston Derby Derbyshire DE7 5GF 0115 9447869 0115 9308160 Not given Voyage Limited Vacant Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Redhouse, The DS0000052210.V292223.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th November 2005 Brief Description of the Service: The Redhouse is a listed building, which used to be a hotel prior to becoming operational as a Care Home. The Redhouse was registered on the 18th September 2003 by National Care Standards Commission, and is owned by Voyage Ltd. The home has been refurbished and is managed as a smaller family type unit. The home was first registered for seven people, but following an application to vary the registration the home is now registered for 8 individuals with a learning disability between the ages of 18 - 65 years old. The home is situated close to the centre of Ilkeston and the shops and facilities are within walking distance. Information about the service is provided in the Statement of Purpose and Service User Guide; both of these documents are made available to individuals and their families/representatives. The current fees for this service commence from £1,110.40 a week. Items not covered in the fees include toiletries, transport and holidays. Redhouse, The DS0000052210.V292223.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, carried out by one inspector, which lasted 7 hours. A review of the evidence available prior to the site visit was undertaken, for example, the pre inspection questionnaire, resident surveys (6 surveys received) and notification of incidents, are used to identify areas to be examined during the site visit. Records such as care plans (as part of the case tracking process, which is used to help determine how the home meets the needs of individual residents) were examined during this inspection. Time was spent talking with 5 service users and 4 staff members who were on duty and the daily routines were observed. Some bedrooms were viewed during this visit and a brief tour of the building was undertaken. Other records such as medication records, and staff files were also examined. An assessment was also made of the progress by the registered persons to address the requirements made at previous inspections. The service has not had a permanent manager for over a year and during the interim period various acting managers have provided managerial support. A new manager has been recruited and has worked at the service since August 2006. This acting manager intends to process her application to register with the CSCI and assisted the inspector during this visit. The previous acting manager completed and returned the pre-inspection questionnaire. What the service does well: What has improved since the last inspection? The medication practices have been improved to make the systems are easier to understand for the staff team and therefore ensuring service users receive their medication as prescribed. Redhouse, The DS0000052210.V292223.R01.S.doc Version 5.1 Page 6 The areas identified for redecoration have been addressed therefore making the environment more homely for the service users to enjoy, however more repairs are required. The newly employed staff members have access to an induction programme therefore enabling them to gain relevant skills and knowledge to fulfil their responsibilities, and to support service user appropriately. 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. Redhouse, The DS0000052210.V292223.R01.S.doc Version 5.1 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 Redhouse, The DS0000052210.V292223.R01.S.doc Version 5.1 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): 1, 2, and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The support and care needs of individuals are assessed to ensure that their aspirations are planned for and that this service is right for them. EVIDENCE: In the discussions with the people that live at The Redhouse it was confirmed that they had previously received copies of the Service user guide to enable them to be informed about the services available. The Statement of purpose has been updated to reflect the new acting manager in place and details her experience. Both the Statement of purpose and Service user guide are available in a written format and on CD Rom but not in any other format for individuals who cannot access the written or the computerised version. The inspector examined two files, one of which was for an individual who had recently moved into the service. There was evidence in both files to support that an assessment of their needs had been undertaken by their Care manager and by a designated staff member for the service. There was limited written evidence to support that trial visits had been undertaken, but one individual confirmed that these were undertaken, and the following comment was made: “it was nice to visit here and meet the staff and other individuals living here”. Redhouse, The DS0000052210.V292223.R01.S.doc Version 5.1 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, 8, and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care files did not reflect individual aspirations and needs, and how these needs should be supported. Therefore staff do not have the required information to delivery care that meets individuals needs. EVIDENCE: One of the files examined was for an individual who has resided at this service for a period of time. Although the file contained information about the individual’s personal and healthcare needs, there was limited evidence to support that the care plans had been reviewed within the last 6 or 12 months. Some of the plans did not have dates recorded on them therefore it was difficult to ascertain when they were implemented, and some plans were dated June 2004 and September 2005. Although the plans had written information attached to them recording the continued progress of the individual, it was difficult for the inspector to ascertain if each plan had been reviewed as recommended by the National Minimum Standards. There was evidence of formal reviews undertaken by the individuals care manager reviewing their placements within this service. Redhouse, The DS0000052210.V292223.R01.S.doc Version 5.1 Page 10 The file for the individual who had recently moved into The Redhouse did not contain detailed care plans, therefore providing limited information for the staff team to follow, other than the pre-admission information. This individual had transferred from another service and their file contained the support plans from that service. There was no evidence to support that this information had been reviewed following their admission to this service. It was difficult for the inspector to access up to date information in both files due to the amount of information contained within them. The inspector was advised that the files were due to be organised due to the amount of information they contain and that person centred plans were due to be developed. The acting manager has implemented a new daily recording of events, and this information is now organised into specific sections, the staff team stated: “they are a lot better than the previous system”, and have welcomed its implementation. Both files contained a variety of risk assessments that indicated key areas of concern and ways in which staff could minimise or eliminate any problems arising from these risks. There was evidence to support that these assessments had recently been reviewed. The files also contained information concerning the behaviours that each individual could present, which could be deemed as challenging to the service and the staff team. The staff team complete behaviour analysis forms to record this information when significant incidents occur, and these records are then analysed in order to highlight patterns of behaviour so that strategies can be implemented. The acting manager has made contact with a behaviour therapist and requested training for the staff team around the specific needs of the current client group. The people living at The Redhouse confirmed that they are actively encouraged to be independent in their lives and that they are consulted on a daily basis concerning aspects about their care and about the running of the home. Individuals confirmed that the staff members offer them choices and respect their replies in accordance with their needs. Individuals spoken with made the following comments “I like living here”; “the staff are friendly and supportive”. During the course of the day the inspector did observe some friendly banter between individuals and the staff members. Redhouse, The DS0000052210.V292223.R01.S.doc Version 5.1 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, and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals have access to varied opportunities, and life experiences in order to develop independent living skills. Opportunities were tailored to individual interests and abilities to enable all people to have fulfilling lifestyles within the service. EVIDENCE: The individuals who spoke with the inspector stated that they felt the staff team assisted them to develop their skills, including social, emotional, communication, and independent living skills. They also commented that they are enabled to access positive life experiences and various community provisions. One of the individuals living at this service attends college, and all other individuals are being supported by their designated Key worker to complete a weekly planner of their preferred activities and aspirations. One of the files examined contained a revised planner but this had not been dated or signed by the service user or their key worker. Redhouse, The DS0000052210.V292223.R01.S.doc Version 5.1 Page 12 It was evident from the discussions and observations that the daily routines of the service are flexible and promote people’s independence, choice, and freedom of movement, in accordance with their individual support needs. Individuals confirmed that contact with family and friends is supported and encouraged by the staff team. The inspector was invited to have an evening meal with the people at the home. Each individual has their own designated menu based on a four-week rolling programme, and individuals did state that they are consulted about the choices and meals available. The staff team cooked the evening meal and all staff joined the residents to eat their meals creating a social and relaxing environment. Generally all individuals stated that they were satisfied with the meal provision but some individuals did state that some improvements could be made. Improvements are required to the recording of temperatures in respect of the food that is cooked in accordance with Food safety legislation. Redhouse, The DS0000052210.V292223.R01.S.doc Version 5.1 Page 13 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, and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The records did not fully identify the support individuals required in order to ensure that their healthcare needs are met. EVIDENCE: The files examined confirmed that individuals are supported to attend health care appointments by the staff team, and information was provided about the outcomes of these visits. Information was also recorded about some specific medical conditions. However it was difficult to access some of these records due to the volume of information contained in the files, and there were limited updated plans in place underpinning the support individuals required with their medical conditions. The inspector noted gaps in the recording of an individuals weight and there were limited monitoring tools in place. There was limited information about individuals preferences in respect of the way they would like to be supported in personal care tasks, and about their routines in respect of rising and retiring times. Individuals who spoke with the inspector did state that the staff team supported them in their personal care tasks in a manner, which is in accordance with their individual preferences. Individual cultural requirements are recorded, if a need is identified and would be implemented as part of their Redhouse, The DS0000052210.V292223.R01.S.doc Version 5.1 Page 14 support plan, although there are currently no individuals at the home who are from a minority ethnic background. The observations and discussions held with the staff team confirmed that they are aware of the need to treat individuals with respect and to consider dignity when delivering personal care. People who use the service are happy with the way that the staff team deliver their care and respect their dignity. The medication practices and storage was examined and improvements have been made to the management of these. The acting manager has implemented a new colour coded system in consultation with the local pharmacy. The staff team felt that this system was easier to follow. There was information about individual’s medical needs and allergies and photos were on the new medication charts and on the storage boxes for the homely remedies, which reduces the risks when administering medication. All medication had been administered as prescribed and the records were satisfactory. All medication was signed in and a returns book was in place. An audit system was in place in order to monitor the amount of medication in stock and to monitor all of the systems in place. The acting manager intends to complete an assessment of the staff member’s competency in this area, and confirmed that only staff that have received training currently administer the medication. Redhouse, The DS0000052210.V292223.R01.S.doc Version 5.1 Page 15 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 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Satisfactory complaints and adult protection procedures are in place in order to safeguard individuals. EVIDENCE: All individuals spoken with confirmed that they are aware of the complaints procedure and stated that they would not hesitate to speak with the staff or the acting manager about any issues they may have. A copy of the complaints procedure is displayed and individuals receive a copy within their Service user guide. The Pre-inspection questionnaire stated that there had been 2 complaints since the previous inspection, and these were logged in the complaints record. However only one of the complaints had been signed off and the second complaint has been closed but no information of the outcome had been recorded, as the previous acting manager had dealt with the issue. The CSCI received a complaint from a neighbour and they were referred back to the provider to discuss the issue. The inspector was informed that the issue has now been resolved. The acting manager could not locate the Safeguarding Adults policy for Derbyshire but a copy was in place for Nottinghamshire. The acting manager confirmed that she has undertaken some training provided by the provider in safeguarding adults and was aware of the action to take in the event of a disclosure being made. Some of the staff team have attended training in safeguarding adults and further training has been planned for four staff members, however there are 10 staff members who have not yet accessed any training in this area. The acting manager informed the inspector that as far as Redhouse, The DS0000052210.V292223.R01.S.doc Version 5.1 Page 16 she is aware there have not been any safeguarding adult incidents that have occurred since commencing her employment at the service. The inspector examined the records and the money held in safe keeping for three individuals. The money was held separately and the balances crossreferenced to the transaction sheets for all individuals. Receipts are obtained for all purchases made on behalf of the people who live at The Redhouse, and two signatures are recorded on the transactions sheets, which is good practice. Redhouse, The DS0000052210.V292223.R01.S.doc Version 5.1 Page 17 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, 25, and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the environment is comfortable and safe, repairs are required to make it a homely setting for service users to enjoy. EVIDENCE: The Redhouse is a grade 2 listed building and has access only by stairs to the three floors and basement. Therefore the individuals that live here are independent in their mobility. Since the acting manager has commenced employment she has moved the position of the office to the ground floor, making it more accessible to both the staff team and the service users. Improvements have been made to the kitchen area creating an open plan environment, which is more accessible to all individuals. There has been some redecoration of areas, in the past 12 months, and the acting manager intends to develop a renewal plan once she receives her budget. The inspector did note some areas that required attention and in particular areas that have been damaged such as the panelling in the corridors and some pictures which, would benefit from being replaced as they have been torn. The furnishings in the lounge area are looking worn and would also benefit from being recovered or Redhouse, The DS0000052210.V292223.R01.S.doc Version 5.1 Page 18 replaced. The building was found to be generally clean and free form any odours. The inspector was invited to look at some bedrooms by the respective individuals. The bedrooms was personalised to reflect their interests and preferences. All individuals are offered the choice of having a key to their room, and confirmed that staff “always knock before entering”. Redhouse, The DS0000052210.V292223.R01.S.doc Version 5.1 Page 19 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, and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A fully trained staff team does not support people living at The Redhouse, so there are no guarantees that service user needs will be met. The recruitment procedures in place do not fully protect individuals from potential risk. EVIDENCE: During the discussions with the people who lived at the home they confirmed that they felt that adequate staffing levels were maintained although they did state that at times there had been periods of short staffing, and agency staff have been used resulting in some inconsistent practices. Comments were also made about the number of staff that have left employment and the new staff employed and one individual commented: “I need to get used to the new ones”. The inspector spoke with some of the staff members who were clear about their roles and responsibilities and had a satisfactory knowledge of individuals support needs and their aspirations. The staff members commented on the difficulties faced due to the many changes in the managerial support, which has resulted in inconsistent approaches and different styles of leadership, which has caused some confusion and concern. The staff members commented that the staff morale is now starting to improve following the employment of Redhouse, The DS0000052210.V292223.R01.S.doc Version 5.1 Page 20 the new acting manager who is now providing support and leadership to them in their roles. The inspector examined three personnel files to examine the recruitment processes of the home. There was evidence to support that checks had been undertaken in respect of references and Criminal record checks, however the files did not contain all of the information required in respect of staff identification and full employment histories. The acting manager is aware that the files are missing some records and is in the process of obtaining the required information. There was evidence in the files to support that two of the three staff had undertaken an induction. In discussions with the staff team they did state that the training has not been provided as frequently as it used to be and the training records reflected this. There are several gaps in the records and many staff has not undertaken training in the mandatory areas. Although new staff members are undertaking an induction that meets Skills for care specifications, staff are not currently accessing Learning disability Award Framework training, which provides underpinning knowledge that is specific to working with the client group the service is registered for. The acting manager did state that she is now focusing on training as a matter of urgency and planned training is booked for the next 3 months to cover the mandatory areas. Staff confirmed that supervision and team meetings are now being held on a regular basis. The inspector was informed that 6 staff members have completed a National Vocational Qualification (NVQ) at Level 3 or equivalent and one staff member is currently working towards this. One staff member has also competed NVQ level 4. Redhouse, The DS0000052210.V292223.R01.S.doc Version 5.1 Page 21 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, and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The acting Manager has a good understanding of the areas, which need to be developed within the home. Processes of consultation have now been implemented so that the views of the people living at the home are obtained and will be acted upon. EVIDENCE: The acting manager has had many years experience working in this capacity and with this client group. She has spent time with the individuals living at the service in order to develop a good knowledge of their needs and aspirations and the inspector observed good relationships between her and the service users. The acting manager is working with the staff team to imbed a culture whereby the staff encourage and enable individuals to be self managing and to promote their independence in their daily lives in accordance with their needs. Redhouse, The DS0000052210.V292223.R01.S.doc Version 5.1 Page 22 The acting manager has an open door policy and the staff stated that she is open, approachable and responsive to their needs. The acting manager has recently facilitated a meeting with the service users and intends to plan these on a regular occurrence. A quality assurance survey will be sent to all stakeholders later on in January 2007. There was no evidence to support that a survey was undertaken during 2006. The acting manager confirmed that a delegate of the provider visits the home regularly and completes detailed reports of these visits in accordance with regulation 26. Copies of the reports completed up to October 2006 were available for inspection in the service. Random samples of the health and safety systems were checked and although some of the paperwork could not be located the acting manager contacted the provider’s head office and information was faxed through so that it could be examined. The acting manager is in the process of setting up systems and files for all of the required documentation as these were not previously in place upon her arrival. As mentioned during the previous section not all of the staff team have undertaken all of the required mandatory training including moving and handling, fire, food hygiene, First aid and infection control. However some training has now been organised. The acting manager is aware that the night staff must undertake fire training twice a year. Redhouse, The DS0000052210.V292223.R01.S.doc Version 5.1 Page 23 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 3 2 3 3 3 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 2 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 X 3 X X 2 3 Redhouse, The DS0000052210.V292223.R01.S.doc Version 5.1 Page 24 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 YA6 Regulation 15 (1) Requirement A care plan must be developed following the admission of an individual into the service, which covers all of the areas as outlines in National Minimum Standards 2. This plan must e kept under review Care plans should be developed in consultation with the individuals who should be encouraged to sign their plan in agreement. Monitoring tools and assessments must be completed following an individual’s admission and reviewed regularly. The staff x 10 must attend safeguarding adults training (repeated from previous report timescale of 01/03/06 not met) A renewal programme must be developed and repairs undertaken in the home. The staff recruitment files must contain all of the required information and any gaps in employment must be explored and a written explanation DS0000052210.V292223.R01.S.doc Timescale for action 01/03/07 2 YA6 15 (1) 01/03/07 3 YA19 17 (1) (a) 01/03/07 4 YA23 13 (6) 01/05/07 5 6 YA24 YA34 23 (2) (b) 19 (b) (i) 01/03/07 01/03/07 Redhouse, The Version 5.1 Page 25 7 YA35 18 (c) (i) 8 9 YA37 YA42 8 19 (5) (b) provided. (repeated from previous report timescale of 01/02/06 not met) Staff must access the Learning disability Award Framework training in order to gain underpinning knowledge of the service user group. The acting manager must seek registration with the Commission for Social Care Inspection. The staff team must undertake training in all of the required mandatory areas: (repeated from previous report timescale of 01/04/06 not met) 01/04/07 01/04/07 01/04/07 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 Refer to Standard YA1 YA3 YA6 Good Practice Recommendations The Service user guide should be available in an accessible format. Information concerning the trail visits undertaken should be recorded. All documentation should be signed and dated by the person completing the record. Care files should be cleared of any old information that is not relevant. Individuals should be consulted about the risk assessments and sign the assessment in agreement with the contents. Staff should record the temperature of the food in accordance with the food safety legislation. Individual’s preferences, routines, likes and dislikes should be recorded in their support files. An assessment of the staff member’s competency in administering medication should be undertaken. All complaints should have the outcomes recorded and DS0000052210.V292223.R01.S.doc Version 5.1 Page 26 4 5 6 7 8 YA9 YA17 YA18 YA20 YA22 Redhouse, The 9 YA23 should be closed when the investigation has been undertaken. The acting manager should attend training in the Derbyshire safeguarding adult’s procedures. A copy of the Derbyshire safeguarding adult’s procedures should be obtained and staff should be made aware of these. Staff files should contain evidence of the training undertaken by them. Records should be available in the service of all of the health and safety records and certificates. 10 11 YA34 YA42 Redhouse, The DS0000052210.V292223.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Redhouse, The DS0000052210.V292223.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!