Inspection on 09/11/07 for The Redhouse

This inspection was carried out on 9th November 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Redhouse 03/01/07

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 The Redhouse Wharncliffe Road Ilkeston Derby Derbyshire DE7 5GF Lead Inspector Angela Kennedy Unannounced Inspection 9th November 2007 10:00 The Redhouse DS0000052210.V352221.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 Redhouse DS0000052210.V352221.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 Redhouse DS0000052210.V352221.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Redhouse Address Wharncliffe Road Ilkeston Derby Derbyshire DE7 5GF 0115 9447869 0115 9308160 Not given Voyagecare.com Voyage Ltd 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) Vacant Care Home 8 Category(ies) of Learning disability (8) registration, with number of places The Redhouse DS0000052210.V352221.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd January 2007. 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 £1,110.43 a week to £1680 a week. Items not covered in the fees include toiletries, transport and holidays. Service users give a contribution to trips out. The Redhouse DS0000052210.V352221.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and lasted approximately six hours. Key inspections take into account a wide range of information and commence before the site visit by examining previous reports and information such as any reported incidents. The site visit is used to see how the service is performing in practice and to meet with the people using the service. The inspection was focused on assessing compliance with defined key National Minimum Standards. The commission had requested the service to complete an Annual Quality Assurance Assessment, however as this document had only been received by the service the week of the inspection visit, it not been returned to the commission prior to this inspection visit. Six of the seven service users that lived at The Redhouse were met and were spoken with. All of the service users spoken with confirmed they were happy with the support and care they received at The Redhouse and all of the service users spoken with said they liked living there. Two of these service users were case tracked. Case tracking is a method used to track the care of individuals from the assessments undertaken before they are admitted to a service through to the care and support they receive on a daily basis. This includes looking at support plans and other documents relating to that persons care, talking to staff regarding the care they provide and if possible talking to the individual. Several members of staff were spoken with and lengthy discussions took place with two staff to ascertain their views on what it was like to work at The Redhouse. Both of the staff spoken with were very positive about the support they received from the manager and the training opportunities provided to them. Both staff confirmed that they enjoyed working at the Redhouse. What the service does well: Service users needs are assessed before admission is agreed. This indicates that a pro-active approach to admissions is undertaken to ensure the service is right for the individual and is able to meet their needs. Service users are actively encouraged to maintain their independence and enhance their daily living skills. The Redhouse DS0000052210.V352221.R01.S.doc Version 5.2 Page 6 Observations of staff with service users was positive a demonstrated a supportive and empowering approach was provided to service users by the staff team. All of the service users spoken with indicated that they were happy living at The Redhouse and confirmed that they were supported in their daily lives by a friendly and well-liked staff team. 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 summary of this inspection report can be made available in other formats on request. The Redhouse DS0000052210.V352221.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 Redhouse DS0000052210.V352221.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are able to make an informed choice about The Redhouse, as the information regarding the home is available in a variety of formats. To ensure individuals aspirations and needs can be met by the service a comprehensive assessment is undertaken, before admission to the home is agreed. EVIDENCE: At the last inspection it was noted that although the service user guide was available in a written format and on CD Rom, there wasn’t any other format for individuals who couldn’t access the written or the computerised version. The service user guide was seen at this inspection visit and a pictorial format was seen, this ensured that individuals who were unable to access written or computerised information were given pictorial information on the services and support provided by the staff team at The Redhouse. The Redhouse DS0000052210.V352221.R01.S.doc Version 5.2 Page 9 Of the two service users case tracked, one had moved into The Redhouse since the last inspection visit. Evidence was in place to demonstrate that a full assessment of this persons needs was undertaken prior to admission. This individual was not introduced to the service on a gradual basis such as a tea visit followed by overnight stays. The reason for this was that an introductory visit/s for this person would not have been beneficial to their well-being, and evidence was in place to support and demonstrate this. This service user was spoken with and confirmed that they liked living at The Redhouse and that they had received a copy of the service user guide. A detailed needs assessment was in place for the other service user case tracked, this person confirmed that they had visited The Redhouse on several occasions before they moved in, and confirmed that it had given them an opportunity to meet the staff and other service users before they came to live at The Redhouse. The Redhouse DS0000052210.V352221.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was the potential for service users changing needs to remain unidentified, as support plans did not reflect that needs were regularly assessed. EVIDENCE: At the time of this inspection visit person centred plans were in the process of being developed using the information provided on service users support plans and other records held. There was evidence to demonstrate within the person centred plans seen that staff were involving service users and their representatives such as family, in providing information to ensure a person centred approach to care was further developed. Once this system is fully implemented a more detailed and individualised approach to the support and aspirations of each service user will be in place. The support plans for both service users case tracked were looked at and provided good detail of each persons support needs and their preferred The Redhouse DS0000052210.V352221.R01.S.doc Version 5.2 Page 11 methods of support. Support plans included a pictorial format to ensure they could be understood by the service user. However not all of the support plans seen had evidence in place to demonstrate that they had been reviewed on a regular basis. This was discussed with the manager who confirmed that the support plans in place were being up dated with new forms that contained sections to demonstrate that support plans had been reviewed. A copy of the new forms was seen. Although support plans were written from the service users viewpoint, these support plans had not been signed by the service user, and therefore did not clearly demonstrate that service users had been involved in the implementation of their support plans and were in agreement with them. Discussions with the manager confirmed that some service users would be unable to sign in agreement, therefore it is suggested that if this is the case a statement to confirm this is in place on support plans. 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. One of the service users risk assessments had evidence in place to support that they had recently been reviewed. However the records held for the other service user indicated that twelve risk assessments had not been reviewed since October 2006. Risk assessments should be reviewed on a regular basis to ensure any changing needs and support can be identified, within a risk managed framework. Some risk assessments seen cross-referenced to other risk assessments in place, such as ‘community behaviour’ linked with ‘ accessing money’. This ensured that staff were provided with sufficient information as to the potential risks whilst out in the community and how these risks were to be minimised and managed. Service users spoken with confirmed that they were encouraged to be independent in their lives and that staff consulted them about their care and about the running of the home. All of the services users spoken with stated that they liked living at the Redhouse and one service user said, “ the staff are lovely, they are all very good” Staff observation with service users demonstrated a friendly and positive rapport. The Redhouse DS0000052210.V352221.R01.S.doc Version 5.2 Page 12 The Redhouse DS0000052210.V352221.R01.S.doc Version 5.2 Page 13 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. 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 were supported in developing their skills and independence and were able to engage and maintain appropriate leisure activities and relationships with family and friends. EVIDENCE: On the day of this inspection visit, all of the service users spent time away from home either attending the local college or accessing the local community. Five of the seven service users did not undertake day opportunity placements such as day service or college. Two of the service users attended college on a regular basis. Individuals were supported by their designated Key worker to complete a weekly planner of their preferred activities. The Redhouse DS0000052210.V352221.R01.S.doc Version 5.2 Page 14 Activities and trips out were promoted and encouraged by the staff team. The majority of service users went out for lunch on the day of inspection with staff support, and spent some time chatting with the inspector on their return. One service user showed the inspector several pieces of woodwork that they had created and they were clearly very proud of their creative achievements, which were very good. One service user showed the inspector an award that they had won for services within the local community. This service user, although extremely modest regarding their services to the community, was clearly very proud to have been given this award. Staff through discussions and observations demonstrated that they were supportive of each persons needs and actively encouraged and promoted personal development and independence. One of the service users case tracked was being supported by staff to develop their confidence in accessing community facilities, and on the day of inspection, staff had encouraged and supported this person to access the local facilities with a member of staff. On their return this service user confirmed that they had enjoyed their trip out. From observations throughout the day it was clear that routines within the home were flexible and service users were supported and encouraged to maintain their independence and choices within their daily life. Contact with family and friends was maintained and some of the service users spent time with their family and on a regular basis. Discussions took place with the service users regarding their opinion of the quality and choices of meals at the home. Service users confirmed that they all discuss their preferred meal choices and then meals were planned to ensure everyone’s choices were included throughout the week. Service users said they were able to go shopping with the staff to purchase the food, although it was stated that some people didn’t like food shopping and chose not to go. Staff spoken with said that service users were encouraged and supported to help with meal preparation. One of the service users case tracked was observed making a cake on the day of this inspection and a member of staff was seen supporting this person to do this. The Redhouse DS0000052210.V352221.R01.S.doc Version 5.2 Page 15 The Redhouse DS0000052210.V352221.R01.S.doc Version 5.2 Page 16 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. 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 can not be reassured that personal support is provided in the way they wish, as the care plans lacked validity. Service users health care needs were met and the medication practices in place ensured that services users welfare was maintained. EVIDENCE: Service users spoken with confirmed that staff supported them in the way they preferred with their personal care needs. The support profiles seen addressed the personal care needs of individuals and provided good detail to staff on how these needs were to be supported, however as stated in standards 6 to 10 not all of the support profiles seen had been signed and dated, making it difficult to ascertain the validity of these support profiles. Healthcare records were in place within both service users files seen. These records demonstrated that service users were supported to access healthcare professionals and facilities, such as G.P and hospital appointments and The Redhouse DS0000052210.V352221.R01.S.doc Version 5.2 Page 17 assessments from psychologists, speech and language therapists and psychiatrists. The medication practices of the home were looked at and the systems in place demonstrated that safe working practices were in place. Medication administration records and storage boxes for homely remedies included a photograph to identify each individual. Information on service users preferences on where medication was to be administered and how they would like it to be given was in place Records were maintained of medication received into the home and medication disposal. A weekly audit system was undertaken in-house, and a six monthly audit was provided by a community pharmacist, to monitor the amount of medication in stock and to monitor all of the systems in place. A record of fridge temperatures was maintained for medication that required cold storage. Medication training was provided by South East Derbyshire College and at the time of this inspection six members of staff had undertaken medication training. The manager discussed plans for the rest of the staff team to undertake medication training with a local pharmacy and confirmed that four members of staff were awaiting finance approval to commence this training. The Redhouse DS0000052210.V352221.R01.S.doc Version 5.2 Page 18 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. 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. The views of service users were taken seriously and acted upon and the systems in place ensured service users were protected from abuse. EVIDENCE: Service users spoken with were confident that if they had any worries these would be dealt with by the staff team and confirmed that they would speak to staff if they had any concerns. A copy of the complaints procedure was displayed and service users received a copy within their Service user guide. No complaints had been received by the service since the last inspection. No safeguarding referrals or investigations have been made in relation to the service. The majority of the staff team had undertaken training in Safeguarding Adults and two members of staff were awaiting dates to attend this training. Staff spoken with had a good understanding of safeguarding (adult protection) issues and there were several notices seen around the home promoting the safeguarding of services users. The Redhouse DS0000052210.V352221.R01.S.doc Version 5.2 Page 19 The monies and financial transaction records of the service users case tracked was checked and the monies held corresponded with the records seen. Receipts were obtained for all purchases made on behalf of the people who live at The Redhouse, and two signatures were recorded on the transactions sheets, which is good practice. Monies were checked and signed for at each staff handover, again this demonstrates that safe working practices are in place to safeguard service users financial interests. The Redhouse DS0000052210.V352221.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Redhouse provides a clean, comfortable and homely environment for the service users. 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. A tour of the communal areas of the building was undertaken. A maintenance person was employed at The Redhouse and the maintenance department was used for any maintenance work that could not be undertaken by the maintenance person employed in-house. A renewal plan was in place and since the last inspection the following refurbishment had taken place; The Redhouse DS0000052210.V352221.R01.S.doc Version 5.2 Page 21 New sofas have been purchased for the sitting room and these were attractive and comfortable. Service users spoken with said they were much nicer than the previous furniture. The sitting room had also recently been redecorated. New carpets had been purchased for the dining room along with new dining chairs and table. The manager discussed plans that were in place to look at providing a ramp to the front entrance of the building. This will provide access for any persons with mobility problem. At the last inspection it was noticed that some of the panelling in the corridors had been damaged. The manager stated that these areas had been repaired but had since been damaged again, and confirmed that as the house was a listed building the panelling could not be removed or covered, therefore continuous maintenance takes place in this area. The general standards of hygiene at The Redhouse appeared to be of a good standard. Service users spoken with were happy with the décor and standards of hygiene maintained at their home and a relaxed and comfortable atmosphere was noted throughout the inspection. The Redhouse DS0000052210.V352221.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were supported by a competent and trained staff team and the recruitment practices in place empowered service users and enhanced their protection. EVIDENCE: At the last inspection a requirement was left for the staff team to access the Learning Disability Award Framework training in order for them to gain a basic knowledge of the service user group. The manager confirmed that the staff team had completed this training programme and due to a registration error were waiting for this work to be marked. The deputy manager had achieved a National Vocational Qualification (NVQ) at level 4 and was at the time of the inspection undertaking the Registered Managers Award training. The Redhouse DS0000052210.V352221.R01.S.doc Version 5.2 Page 23 Six staff had achieved a National Vocational Qualification (NVQ) at level 3 in care and a further two staff were registered to commence this training in the near future. Five members of staff were waiting to commence NVQ level 2 training. The recruitment records were looked at for three members of staff. There was evidence to support that checks had been undertaken in respect of references and Criminal record checks, all files contained information in respect of staff identification and full employment histories. Service users were encouraged to participate in the staff recruitment process and one service user discussed with the manager his participation in interviews that were due to take place within the near future. The training provided to staff has much improved since the last inspection and the training certificates seen demonstrated that mandatory training was kept up to date and training specific to service users needs was also undertaken, such as epilepsy awareness and training relating to specific syndromes. The staff team was accessing a new electronic learning training programme and the staff spoken with were very positive regarding this method of training. Evidence was in place within the staff records seen of supervision that had taken place. Staff spoken with stated that supervision was undertaken every 6 to 8 weeks and appraisals took place on a six monthly basis. Staff were complimentary regarding the managers skills in supporting them. The Redhouse DS0000052210.V352221.R01.S.doc Version 5.2 Page 24 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. 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 was well managed and service users were supported in expressing their views to enable them to make decisions regarding how their home is run. The health and safety practices in place ensure the welfare of service users, staff and visitors to the home is promoted and protected. EVIDENCE: The manager has had many years experience within the learning disability field and has been in management post previously. The manager has achieved an NVQ at level 4 and has completed the Registered Manager Award. The Redhouse DS0000052210.V352221.R01.S.doc Version 5.2 Page 25 The manager confirmed that she had completed the registered managers application form and was awaiting funds from the provider to enable her to send her application in to the commission. Staff were very complimentary regarding the managers ability to run the home and stated that she provided an ‘open door’ policy for staff and service users. Observations of the manager with both staff and service users was noted throughout the day and demonstrated an open and positive relationship was in place. The quality assurance systems in place at the service were looked at. Records were held of service user meetings that were held on a monthly basis, and an agenda sheet was provided to service users prior to these meetings to ensure everyone had an opportunity to discuss any issues they had. Questionnaires were sent out to service users every three months and the most recently returned questionnaires were looked at. These questionnaires were audited and any actions taken following the results of these questionnaires were recorded on separate comments sheets. Annual questionnaires were sent out to visiting professionals every year to ascertain their views of the service. These questionnaires were not looked at during this inspection visit. Some of the health and safety records were looked at, such as the gas safety certificate, portable electrical tests, the electric wiring certificate and weekly fire tests and weekly water temperature checks. All Health and Safety records seen were satisfactory and in date. The guidance regarding care homes providing first aid has recently been amended and allows services to undertake a first aid risk assessment specific to their individual service. Information pertaining to the factors that can be taken into account and the criteria for who can be regarded as a qualified first aider were provided at this inspection visit. However if a risk assessment is not in place the Commission will require that someone who has undertaken a suitably approved first aid at work qualification be on duty at all times. As stated in standards 31 to 36 all mandatory training was updated as required. The Redhouse DS0000052210.V352221.R01.S.doc Version 5.2 Page 26 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 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 2 X 3 X X 3 X The Redhouse DS0000052210.V352221.R01.S.doc Version 5.2 Page 27 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 Support plans should be developed in consultation with the individuals who should be encouraged to sign their plan in agreement. (Previous timescale of 01/03/07 expired) Support plans must be reviewed on a six monthly basis or sooner if service users changing needs dictate. Risk assessments must be reviewed on a six monthly basis or sooner if service users changing needs dictate to ensure any risk identified can be minimised. Support plans regarding service users preferred method of support in personal care needs must be reviewed a six monthly basis or sooner if service users changing needs or preferences change. The acting manager must seek registration with the Commission for Social Care Inspection. Timescale for action 31/03/08 2. YA6 15 (1) 31/03/08 3 YA9 13 (4) 31/03/08 4. YA18 15 (1) 31/03/08 5. YA37 8 31/03/08 The Redhouse DS0000052210.V352221.R01.S.doc Version 5.2 Page 28 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 YA6 Good Practice Recommendations 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. 2. 3. YA9 YA23 Individuals should be consulted about the risk assessments and sign the assessment in agreement with the contents. The acting manager should attend training in the Derbyshire safeguarding adult’s procedures. The Redhouse DS0000052210.V352221.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Redhouse DS0000052210.V352221.R01.S.doc Version 5.2 Page 30 - 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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