Inspection on 30/11/05 for The Redhouse

This inspection was carried out on 30th November 2005.

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 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 21 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 03/01/07

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 30th November 2005 9; 15 Redhouse, The DS0000052210.V271131.R01.S.doc Version 5.0 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.V271131.R01.S.doc Version 5.0 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.V271131.R01.S.doc Version 5.0 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.V271131.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd August 2005 Brief Description of the Service: The Red house is a listed building, which used to be a hotel prior to becoming operational as a Care Home. The Red house 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. Redhouse, The DS0000052210.V271131.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and started at 9.15am and lasted 3 hours. There were no team leaders on duty as they had both gone out shopping with service users, and the staff on duty was not allowed to access the senior office or the files. The inspector therefore assessed some of the standards on this occasion and then returned to the home on 6th December for a period of 3 hours in order to complete the inspection. Therefore the inspection was undertaken over a two-day period. The inspector checked the previous requirements and recommendations made in the previous inspection report, and checked the key areas that were required to be assessed in a 12-month period. She examined care files and associated documents, and spent time speaking with staff members and service users. A tour of the house was undertaken and the health and safety records and checks of the building were examined. Time was spent observing service user and staff interaction. The Registered Manager of the home resigned a few months ago, therefore there is currently no manager working at the home. Three Team leaders are supporting the staff team, and a manager from another home visits the home regularly to provide managerial support. What the service does well: What has improved since the last inspection? The staff team now have a good understanding of the reason for the use of Incident Analysis charts, and stated that they had received guidance on this. Only the staff members that are deemed competent now administer medication. The Staff members only sign the Medication Administration Record (Mar chart) after they have administered the medication. Redhouse, The DS0000052210.V271131.R01.S.doc Version 5.0 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. Redhouse, The DS0000052210.V271131.R01.S.doc Version 5.0 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.V271131.R01.S.doc Version 5.0 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): EVIDENCE: These standards were not assessed on this occasion as they were assessed during the previous inspection visit Redhouse, The DS0000052210.V271131.R01.S.doc Version 5.0 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, and 9 The staff team have a good understanding of the service users support needs. Care plans covered all of the required areas. EVIDENCE: The inspector examined two care plans, and this standard continues to be met as the plans covered all of the required areas and some additional areas in accordance with service users aspirations. There was evidence in the files to support that the service users have been involved in the development of their plan. Service users showed a good understanding of their care plan in their discussions with the inspector. Although risk assessments have been completed there was limited evidence on the assessments to support the involvement and agreement of that particular service user. The inspector spoke with some of the service users during the inspection and many positive comments were received about living in this home and the quality of the support they receive. Service users comments included; the staff team are “friendly and supportive”, “its nice living here”. Service users confirmed that they are treated us with dignity and respect. Redhouse, The DS0000052210.V271131.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17 The meals in this home are good offering both choices, variety and catering for special diets. EVIDENCE: The inspector spoke with both the service users and the staff team about the provision of the meals. A staff member has recently reviewed and updated the three-week menus in consultation with the service users. Some of the service users have specified dietary requirements; therefore each service user has their own individual menu in accordance with their needs. The staff team spoken with had a good understanding of the service users dietary preferences and support needs. The staff records confirmed that 8 staff members are currently undertaking Food hygiene training, and that all other staff have already trained to this level. The service users confirmed that they support the staff team both to devise the menu and to assist in the weekly shopping to the local supermarket. The staff team stated that they encourage the service users to assist in the preparation of their meals Redhouse, The DS0000052210.V271131.R01.S.doc Version 5.0 Page 11 The inspector examined the record of the fridge and freezer temperatures. These have not been consistency completed and no temperatures had been recorded for the first three weeks of November 2005. Redhouse, The DS0000052210.V271131.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Improvements are required to the medication practices in order to safeguard service users. EVIDENCE: The inspector examined the medication cabinet and associated documentation. There was evidence of gaps in a couple of the Medication Administration Record (Mar Charts), which had not been explained. A service users medication dose was still in the blister pack and there was no explanation on the Mar Chart as to why this medication was not administered. Handwritten medication instructions were not checked and countersigned by two staff members to ensure the instructions are accurate. Discussions with staff members confirmed that not all of them that have a responsibility to administer medication are fully aware of the medication procedures. The Mar chart for a service user did not correspond with the medication blister pack. The records indicated that on a particular day the service user refused their medication, however the medication dose was in the blister pack on a different day therefore the records did not correspond with the medication practices. The medication procedures at the home require updating, as they do not cover all of the required areas. Redhouse, The DS0000052210.V271131.R01.S.doc Version 5.0 Page 13 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 Improvements are required to ensure that the complaint and adult protection procedures safeguard service users. EVIDENCE: An accessible complaints procedure and recording system is in place. From discussions with the service users it was evident that they are aware of the procedure and informed the inspector that they would not hesitate to raise any concerns they had with the staff team. The inspector checked the complaint recording system and there was one complaint recorded, which was made by a service user. However the complaint record had not been completed therefore the outcome is not recorded or the timescales in which the investigation was completed. The home has the required Vulnerable Adults policy in place, and a copy of the Derbyshire Adults Protection procedures. There has been one adult protection incident since the previous inspection visit. The inspector examined the training records and identified that 13 staff members including the team leaders require Adult protection training. The inspector examined the records and the money held in safe keeping for four service users. The money was held separately and the balances crossreferenced to the transaction sheets for all of the service users whose money was checked. Redhouse, The DS0000052210.V271131.R01.S.doc Version 5.0 Page 14 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 Service users would benefit from some redecoration in the communal areas and some additional heating in order to provide a comfortable environment. EVIDENCE: The inspector checked the communal areas of the home. Majority of these areas are decorated to a satisfactory standard. The dining area would benefit from being redecorated, as there are stains on the wall. The passage leading to the dining area and kitchen was very cold on the day of the inspection and would benefit from the provision of additional heating. The kitchen door would benefit from being repaired as the frame around it was split. Redhouse, The DS0000052210.V271131.R01.S.doc Version 5.0 Page 15 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): 34, 35 and 36 The recruitment procedures do not fully safeguard service users from potential risk. EVIDENCE: The inspector examined two staff files, both of these were for new employees. All of the required information was not contained in these files. For example both files did not contain a full employment history and the required documentation. There was evidence that both staff members had received a Pova or Criminal Record Check before the commencement of their employment. There was no evidence to support that the new employees have commenced on an induction other than the service specific induction. There was some evidence in the staff files to confirm that they had received some supervision from the team leaders who divided the responsibility for this. The staff-training matrix identified that the staff require mandatory training. For example none of the staff had received Fire training since Oct 2004. An immediate requirement was issued in relation to this, as the training is outdated. There are 17 staff members who require First Aid training, 13 staff require Abuse training. There is no induction training in place that meets the Sector Skills Council specifications. In the absence of a manager the 3-team leaders have divided the managerial responsibilities between them and provide the staff team with daily support in Redhouse, The DS0000052210.V271131.R01.S.doc Version 5.0 Page 16 their roles. The staff team also receive support from a Registered Manager from another home belonging to the same organisation who visits twice a week. Redhouse, The DS0000052210.V271131.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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 The appointment of a new manager will benefit service users by providing consistent support, leadership and direction to the staff team. EVIDENCE: The home does not currently have a manager in place, and the staff team are working together in order to ensure the home continues to function and meet the service users needs. There are three team leaders sharing the managerial responsibility, who have specified roles to complete. However this can lead to inconsistencies as each team leader works in a different way and has different ways of responding to issues. Although a Registered Manager visits from another home, she does not necessary undertake an audit of the areas the team leaders are responsible for, in order to ensure they are fulfilling their roles. This has led to some deterioration in some of the systems within the home, as there is no manager to oversee all aspects of the running of the home. The inspector examined the report completed following the recent service user consultation about living at the home. All service users, their representatives Redhouse, The DS0000052210.V271131.R01.S.doc Version 5.0 Page 18 and other stakeholders were consulted in November and the outcomes were contained in the annual report. The inspector checked some of the health and safety systems in place at the home. As previously mentioned certain mandatory training is out of date. The gas and electrical installations certificates were up to date. Checks on the water temperatures and checks required to prevent legionella were undertaken on August 2005. The electrical appliances were PAT tested in December 2005. The required insurance cover is in place and up to date. Redhouse, The DS0000052210.V271131.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X x Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X x 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Redhouse, The Score X X 2 x Standard No 37 38 39 40 41 42 43 Score 2 X 3 X X 2 x DS0000052210.V271131.R01.S.doc Version 5.0 Page 20 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA9 Regulation 13 (6) Requirement Timescale for action 01/02/06 2. YA17 16 (2) 3 YA20 13(2) 4. YA20 18 (1) (i) 5. YA20 18 (1) (i) The Registered Person must ensure that were possible risk assessments are completed with the involvement of the service user and are signed by that service user. (j) The Registered Person must ensure that the temperatures of the Fridge and Freezer are checked and recorded twice daily. The Registered Person must ensure that a record is kept of medication administration or a coded reason for nonadministration. (Previous timescale of 31/11/05 not met) (c ) The Registered Person must ensure that only competent and trained staff administer medication in accordance with the homes polices and procedures. (Previous timescale of 31/11/05 not met) (c ) The Registered Person must ensure that when medication discrepancies occur the staff members responsible; receive additional training to improve their practices. An assessment of DS0000052210.V271131.R01.S.doc 01/01/06 01/02/06 01/02/06 01/02/06 Redhouse, The Version 5.0 Page 21 6 YA20 18 (1) (c) (i) 17 (1) (a) 7 YA20 8 YA20 17 (1) (a) 9 YA22 22 10 YA23 13 (6) 11 12 YA24 YA24 23 (2) (b) 23 (2) (p) 13 14 YA24 YA34 23 (2) (b) 19 (b) (i) 15 YA34 19 (b) (i) 19 YA35 23 (4) (e) competence should then be repeated to ensure their practice has improved. (Previous timescale of 31/11/05 not met) The Registered Person must ensure that all handwritten instructions are checked and countersigned by two people. The Registered Person must ensure that the Medication Administration Records cross reference to the Medication administered on that day. The Registered Person must ensure that the medication procedures cover all of the required areas. The Registered Person must ensure that all complaints and the outcomes are recorded appropriately. The Registered Person must ensure that staff x 13 attend Adult protection training and are made aware of the Derbyshire Vulnerable Adults protocols The Registered Person must ensure that the dinning area is redecorated. The Registered Person must ensure that additional heating is installed in the passage area leading to the dining area and kitchen. The Registered Person must ensure that the Kitchen door is fixed. The Registered Person must ensure that the recruitment files contain all of the required information The Registered Person must ensure that a full employment history is obtained for all new employees. The Registered Person must ensure that all of the staff team have been booked onto Fire DS0000052210.V271131.R01.S.doc 01/02/06 01/02/06 01/03/06 01/02/06 01/03/06 01/04/06 01/02/06 01/04/06 01/02/06 01/02/06 13/12/06 Redhouse, The Version 5.0 Page 22 20 YA35YA42 19 (5) (b) 21 YA35 19 (5) (b) 22 YA37YA36 8 Training. (Immediate Requirement issued) The Registered Person must ensure that all of the staff team complete all of the required mandatory training. The Registered Person must ensure that an induction training programme is in place that meets the requirements of the Sector Skills Council specifications. The Registered Person must appoint a manager. This manager must seek registration with the Commission for Social Care Inspection. 01/04/06 01/04/06 01/02/06 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. Refer to Standard YA20 Good Practice Recommendations The Registered Person should ensure that the staff member responsible for medication, undertakes regular audits of all the systems in place, and takes appropriate action when practices are not in accordance with the homes policies and procedures. The Registered Person should ensure that all staff responsible for medication, understand all of the medication systems including the re-ordering of the medication The Registered Person should ensure that each service users doctor is consulted concerning what homely remedies the individual can take depending on their prescribed medication. The Registered Person should consider implementing some support to be given to the staff team in response to the recent adult protection incident. The Registered Person should consider giving all staff access to the office. 2. YA20 3. YA20 4 5 YA23 YA24 Redhouse, The DS0000052210.V271131.R01.S.doc Version 5.0 Page 23 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.V271131.R01.S.doc Version 5.0 Page 24 - 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. 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