Care Home: Redannick House

What the care home does well Redannick provides a safe and comfortable home for older people. Residents and their representatives stated that the home provides good quality care and accommodation. They made comments like, `lovely` and `They look after us too well`. Residents had confidence in the management and staff. The managers obtain detailed assessment information from Health and Cornwall Department of Adult Social Care for new residents where they are commissioning the service. They carry out a needs assessment for all prospective residents to ensure that they are able to meet their needs. All residents have written care plans which record in detail their needs and lifestyle preferences. Residents commented that their health needs were met, and medical advice and intervention were obtained promptly when needed. Residents felt that they were supported to make choices about their daily routine and that there was enough to do. There is a varied and stimulating programme of activities provided by the home and local community. Residents felt their visitors were welcomed to the home. They expressed satisfaction with the variety, quality and quantities of the meals provided. They reported that the home is well maintained, tidily decorated and clean and hygienic. Relatives were, in general, very satisfied with the care and accommodation provided and appreciated the range of activities. Staff and residents get to know each other well. Recruitment practice is fair and safe. Staff were positive about the training, supervision and support they receive to do their jobs and have confidence in the management team. Cornwall Care Ltd has a structured training programme which meets required standards and provides good training and personal development opportunities for staff. There are thorough and effective management arrangements which protect the well being and rights of residents. What has improved since the last inspection? The recommendations of the last report have been complied with. Additional staff have been employed and records are now kept of the interview scoring process. Maintenance in the home to include refurbishment is ongoing. A new conservatory has been brought into use, providing additional facilities for residents. What the care home could do better: Two recommendations are made as a result of this inspection. Where hand written entries are made to the medication administration records, these should be witnessed by two signatures. Evidence was provided to indicate that care plans are reviewed on a relatively regular basis. It is important to ensure that this process occurs at monthly intervals. CARE HOMES FOR OLDER PEOPLE Redannick House Redannick Lane Truro Cornwall TR1 2JP Lead Inspector Mike Dennis Unannounced Inspection 20th January 2009 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Redannick House DS0000009124.V373792.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Redannick House DS0000009124.V373792.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Redannick House Address Redannick Lane Truro Cornwall TR1 2JP 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) 01872 276889 01872 240903 Redannick.Home@cornwallcare.org Cornwall Care Ltd Mrs Linda Mary Delbridge Care Home 40 Category(ies) of Dementia (40), Mental Disorder, excluding registration, with number learning disability or dementia - over 65 years of of places age (40) Redannick House DS0000009124.V373792.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include one named person only out of the home`s category . 24th January 2007 Date of last inspection Brief Description of the Service: Redannick House is one of eighteen homes for which Cornwall Care Ltd is the registered provider. It is registered to provide accommodation and personal care to forty older people, with dementia or mental illness and over retirement age. Admissions are on a planned basis and emergency admissions are avoided whenever possible. Redannick is a purpose built care home situated close to the centre of Truro. Access to the main entrance of the home is level and suitable for wheelchairs. The accommodation is on one floor and this enables residents to access all areas. This is a non-smoking home. The grounds provide small flowerbeds around the building and a patio with seating to the rear. Car parking space at the front of the home is limited. The home has four wings, each with a sitting room, dining room, kitchenette and bedrooms. There is a large communal sitting and activity area. Meals are prepared in the main kitchen. All bedrooms are single and have a washbasin. There are accessible call bells in every room. The fees commence from £400 per week and increase according to dependency requirements. Redannick House DS0000009124.V373792.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two star.This means the people who use this service experience good quality outcomes. This was a planned unannounced key inspection. The purpose of the inspection was to focus on the key national minimum standards as identified by the commission. The report for the last inspection dated 24th. January 2007 set four recommendations and the provider has met these. We were on the premises for approximately 7 hours. The methods used were discussion with the deputy manager, staff, residents, and their relatives, inspection of records and documents, observation of the daily life of the home and inspection of the premises. This included case tracking the records for four residents selected using the criteria of their age, disability, and gender. The Registered Manager completed the Annual quality assurance assessment prior to this inspection. What the service does well: Redannick provides a safe and comfortable home for older people. Residents and their representatives stated that the home provides good quality care and accommodation. They made comments like, ‘lovely’ and ‘They look after us too well’. Residents had confidence in the management and staff. The managers obtain detailed assessment information from Health and Cornwall Department of Adult Social Care for new residents where they are commissioning the service. They carry out a needs assessment for all prospective residents to ensure that they are able to meet their needs. All residents have written care plans which record in detail their needs and lifestyle preferences. Residents commented that their health needs were met, and medical advice and intervention were obtained promptly when needed. Residents felt that they were supported to make choices about their daily routine and that there was enough to do. There is a varied and stimulating programme of activities provided by the home and local community. Residents felt their visitors were welcomed to the home. They expressed satisfaction with the variety, quality and quantities of the meals provided. They reported that the home is well maintained, tidily decorated and clean and hygienic. Relatives were, in general, very satisfied with the care and accommodation provided and appreciated the range of activities. Redannick House DS0000009124.V373792.R01.S.doc Version 5.2 Page 6 Staff and residents get to know each other well. Recruitment practice is fair and safe. Staff were positive about the training, supervision and support they receive to do their jobs and have confidence in the management team. Cornwall Care Ltd has a structured training programme which meets required standards and provides good training and personal development opportunities for staff. There are thorough and effective management arrangements which protect the well being and rights of residents. What has improved since the last inspection? What they could do better: Two recommendations are made as a result of this inspection. Where hand written entries are made to the medication administration records, these should be witnessed by two signatures. Evidence was provided to indicate that care plans are reviewed on a relatively regular basis. It is important to ensure that this process occurs at monthly intervals. Redannick House DS0000009124.V373792.R01.S.doc Version 5.2 Page 7 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. Redannick House DS0000009124.V373792.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Redannick House DS0000009124.V373792.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of prospective service users are assessed so that they can be assured that the home can provide adequate care. EVIDENCE: Managers from the home visit prospective residents and complete a needs assessment. Cornwall Care Ltd uses a standard format for assessment and care planning. When completed in sufficient detail, this record covers the assessment issues specified in the standard and the diverse needs of prospective residents. All the residents’ records case tracked contained needs assessments completed by the home’s managers. These assessment records recorded their assessed needs in detail and included their views and preferences. The home’s assessments do not always make clear who was Redannick House DS0000009124.V373792.R01.S.doc Version 5.2 Page 10 present at the assessment. This would provide evidence that the prospective resident and their family, or representatives, were involved in the assessment to ensure that their diverse needs were recorded. Relatives did, however, feel that the home involved them in the resident’s care arrangements. The records for a resident whose care was commissioned by Cornwall Department of Adult Social Care included essential commissioning and admission information. Appropriate information is given to perspective residents and their relatives. Contracts and/or a Statement of Terms and Conditions is provided to each resident. People have the option of visiting the home prior to admission to enable an informed choice to be made. Redannick House DS0000009124.V373792.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Written care plans direct and inform staff about the residents’ health and personal care needs so that these can be consistently met. The healthcare needs of residents are monitored and addressed so that their needs are met. The arrangements for the management of medicines protect service users. EVIDENCE: All the residents case tracked had written care plans. Cornwall Care Ltd has introduced the Standex System for care planning. At the present time staff are in the process of transferring information from the old to new system. These care plans were dated and signed. At the time of the inspection there was no clear evidence to indicate that reviews of the four care plans case tracked had occurred since last October. We have recently communicated with the Redannick House DS0000009124.V373792.R01.S.doc Version 5.2 Page 12 manager, who has provided evidence to suggest that in fact these care plans have been reviewed. The documentation had not transferred to the new care planning system. Each resident has a key worker. The care plans directed and informed care staff in detail in meeting the health, personal and social care needs of residents. Care plans clearly set out the care need, the objective and the intervention required. The Personal Routines and Preferences records detail residents’ lifestyle preferences and choices, their dietary preferences and needs, and their religious beliefs. There were good examples of individual care planning. Some residents said that they were aware of their care plans. All residents’ records case tracked had a moving and handling assessment. Cornwall Care use a standard format for this. These assessments had been reviewed regularly. There was a separate risk assessment for residents at risk of falling. The managers record an analysis of falls as part of the strategy to reduce their incidence. The daily records for residents detailed the care delivered and health care matters. They also made reference to other daily activities allowing the reader to establish a life pattern. Consistent and informative daily records demonstrate the accountability of the provider and protect the well being and rights of the residents. Staff keep separate records in respect of bathing, and other specific individual care needs. The contents of the residents’ records met regulatory requirements. Residents are registered with local GP practices. Residents felt that their health care needs were monitored and attention obtained promptly when needed. Care staff record each resident’s medical contacts and appointments. There are also written plans where required for eye care, foot care and dental and oral care. Residents are weighed regularly. Medicines are stored in a locked medicines trolley and a locked cupboard in a secure medicines room. The cupboards and trolley were tidy and well organised. There is a small medicines refrigerator and the temperature is checked daily. The monitored dosage system is in use. Cornwall Care has a corporate policy and procedure on the handling of medicines, which includes guidance on the use of homely remedies. Residents sign an agreement to the administration of medicines. Residents who self-administer are provided with a lockable storage area in their room, although no one is self medicating at this time. Specific named staff, managers and care coordinators, complete training and have responsibility for the administration of medicines. The administration records were well maintained. Two staff check in stocks of medicines delivered from the pharmacist. A second worker checks the hand written medication records, drawn up, for example, when residents are admitted for respite, but does not currently sign to confirm this. The home has a controlled drug register and each administration is signed and witnessed. A check of stock of one drug against the record showed this to be accurate. A Redannick House DS0000009124.V373792.R01.S.doc Version 5.2 Page 13 record is kept of medicines returned to the pharmacist. The pharmacist has visited and provided guidance. Residents and their relatives made positive comments on the skills and caring qualities of staff. Residents felt well cared for and reported that staff delivered care sensitively, respected their privacy and dignity and listened to their concerns. Residents said that staff were “lovely” and “kind”. Residents felt safe when staff assisted them with personal care. Examples of staff providing skilled and sensitive care were observed during the inspection. Residents found it difficult to identify any area where the home could improve. Redannick House DS0000009124.V373792.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported in a lifestyle which accords as far as possible with their own expectations and preferences. A range of activities takes place which meets residents’ social, religious and recreational interests. The diet provided is varied and nutritious with attention to individual preferences. EVIDENCE: Residents felt that they had control over their daily lives and were supported to make choices about their routines and activities. They felt that there was enough to do. A number of relatives were very satisfied with the range of activities offered. There is a notice board displaying information and events. The residents’ care plans detail their social and activity interests. The home provides a range of planned activities. This includes a Christian service, a lively music and drama session, hairdressing and ‘fitness 4U’. Residents were involved in other activities – reading the paper, playing games, doing jigsaw Redannick House DS0000009124.V373792.R01.S.doc Version 5.2 Page 15 puzzles, and receiving visitors. Residents and visitors reported that they found the visiting arrangements open and flexible. They felt that visitors were made welcome. Residents choose where they meet their guests. The Deputy Manager reported that the manager is no longer appointee for any residents for their benefits. Residents’ finances are managed with informal assistance from relatives or through Power of Attorney arrangements. Residents can bring in possessions and furniture at admission by agreement with the provider. The staff record an inventory of belongings at admission. Many residents and their families had personalised their bedrooms. Cornwall Care has introduced the ‘appetite for life’ initiative for residents to receive a varied and appealing diet in a relaxed atmosphere. Each resident’s preferences and choices are recorded. The four wings have their own separate dining areas. Residents were positive about the quality of food provided, reporting that the meals were very good with wholesome choices and sufficient portions. Breakfast can be taken in one of the dining areas or in the resident’s room and residents were very happy with the choices available. There are two main choices each day for lunch, with further options available. Tea is a choice of savouries and home made cakes. Daily menus are on the dining tables and staff approach residents individually for their choices. The food was appetising and well presented. Residents were relaxed and unrushed with staff providing sensitive support in a pleasant manner. Staff knew residents’ likes and dislikes. The kitchen provides residents with soft meals and diets for residents with diabetes as required. Hot and cold drinks are served between meals. Redannick House DS0000009124.V373792.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure that would ensure that complaints are listened to and acted upon. There are arrangements to protect service users from abuse. EVIDENCE: Cornwall Care Ltd has a corporate complaints procedure which complies with the standard and regulation. Residents and representatives had confidence that they could approach the managers with any concerns. Cornwall Care Ltd has a corporate adult protection policy and procedure. The policy and procedure have been revised since the last inspection to comply with the Cornwall Multi-Agency Adult Protection Code of Practice. Staff receive training in adult protection following their induction and as part of their NVQ level 2. The registered manager will continue to nominate staff for the Cornwall multi-agency adult protection training. Some staff have completed the ‘Alerter’s Training’. The home had a copy of the Cornwall Multi-Agency Adult Protection Guidance and the Alerters’ Guidance. Staff were aware of their responsibilities to report concerns about the protection of vulnerable adults. Redannick House DS0000009124.V373792.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is accessible, well maintained and safe. The premises are clean and hygienic providing a pleasant environment and reducing risks to residents. EVIDENCE: Redannick is situated in a residential area of Truro fairly close to the town centre. There is limited car parking space. The main entrance is accessible for wheelchair users; there is a small threshold. The home is on one level. Cornwall Care Ltd continues to maintain and refurbish the home’s décor and Redannick House DS0000009124.V373792.R01.S.doc Version 5.2 Page 18 furnishings. New carpets, for example, have been provided. There is a large shared central sitting room and activity area which has been divided into smaller seating areas. The accommodation is arranged in four wings, all with their own bathroom, toilets, sitting room and dining area. The premises are generally in good decorative order. Furniture is of good quality and in good condition. Residents and their representatives commented that the home is kept clean, fresh and well presented. The home has central heating and felt warm in the current cold weather conditions. The grounds are fairly small, but were tidy and accessible to residents. There is a small patio, with seating for good weather. Residents reported that their rooms were comfortable and kept clean and hygienic. The majority of bedrooms are relatively small and are for single occupation. The home has a sluice on each wing. The laundry complies with the standard. The washing machines and tumbler driers are industrial standard. Clothes and linen for laundry is transported through the home in sealed red bags or covered containers. Residents and their representatives were satisfied with the laundry service. Residents’ clothes appeared well cared for. The bathing and toileting facilities in the home comply with the standard with an assisted bath on each wing. Toilet and bathroom doors have signs and suitable locks. Hot water was supplied at a safe temperature. Toilets are situated throughout the home. All the bathrooms and toilets inspected were half tiled, in good decorative order, and clean and hygienic. Facilities for staff hand washing, with sterilising rub, hand wash, and paper towels, were situated throughout the home. Staff reported that there were good supplies of gloves and aprons. Equipment and adaptations were in place to assist with mobility and transfers. The day centre on the lower ground floor has been taken out of service. This accommodation is to be used as a supported living flat. A new conservatory has been constructed and brought into use to improve facilities for residents. Redannick House DS0000009124.V373792.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staffing and training arrangements ensure that the needs of residents are met. There is a good level of qualified staff. Recruitment procedures support and safeguard the residents. EVIDENCE: The staffing compliment consists of the Registered Manager, deputy manager, 3 care coordinators, care assistants, cooks, laundry, domestic and maintenance personnel. There is also an activities coordinator who provides activities for a small number of day care clients and of course the residents. A physiotherapist, employed by the company makes regular visits. A written roster details the deployment of staff. Six care staff are on duty during the day, one on each wing with 2 floating workers who assists where needed. There are two domestic staff who assist with meals and drinks, and a worker in the laundry. There are two cooks and ancillary kitchen staff. A senior member of staff is on duty during the day and on call at night. Three Redannick House DS0000009124.V373792.R01.S.doc Version 5.2 Page 20 waking care staff are on duty at night. Residents were positive about the skills, kindness and caring qualities of the staff team. Posts are advertised through the Job Centre, local press and the Cornwall Care Website. Cornwall Care Ltd has standard corporate recruitment procedures including an equal opportunities policy and procedure. The records for two recently recruited members of staff showed that the required employment checks had been properly completed. The staff records for established staff contained the required documents and information. The company issues all staff with a statement of terms and conditions of employment. Cornwall Care Ltd provides a structured corporate training programme for staff which covers induction, NVQ qualification and other required training. Staff and the employer sign up to a Contract for Training and Development. Records detailed that recently appointed staff had received an induction to the Skills for Care standard. Individual staff training records showed that longer established staff had completed training in moving and handling, first aid, dementia care, health and safety and other required areas. Nearly 80 of care staff have completed their NVQ in care at level 2. The Cornwall Care Ltd training structure ensures that all new staff are registered promptly for their NVQ training. Staff made positive comments about the company’s opportunities for training. Redannick House DS0000009124.V373792.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 to 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an experienced and qualified registered manager who has a sound understanding of her responsibilities. The provider operates a clear system for safeguarding residents’ spending money. The health and safety of residents and staff are promoted and protected. EVIDENCE: The registered manager Mrs Linda Delbridge exceeds the experience requirement in caring for older persons and has completed her Registered Redannick House DS0000009124.V373792.R01.S.doc Version 5.2 Page 22 Managers Award. The Care Coordinators each have identified areas of responsibility and there are clear lines of accountability from the registered manager. Managers and staff were positive about the support and supervision that they received from the registered manager. Residents had confidence in the registered manager and felt that she would listen to and address any concerns that they might have. The registered manager does not act as agent or appointee for any resident in the collection of benefits. Cornwall Care Ltd has a corporate policy and procedure for the safekeeping of small amounts of residents’ money. A standard format for each resident details the payments in and out, and a running balance. Each resident’s balance is not held as an individual amount of cash as this would amount to a large total sum to hold. The home runs a specific bank account with a cash float available for daily transactions. Receipts are retained for all transactions. The registered manager carries out regular checks on the records. Cornwall Care Ltd has previously sought the views of residents and their representatives, and other stakeholders through questionnaires. The returns of the last survey were positive. A further quality assurance survey will be due in the near future. The registered manager holds residents’ meetings on each wing and has found that the small group encourages people to join in. There are regular staff meetings. Relatives are invited to care plan reviews, and the registered manager makes herself available to relatives and visitors. The Maintenance person completes a regular check on the premises and equipment. The records showed that staff receive regular supervision And annual appraisals. Staff reported that informal and formal supervision supported them to do their jobs well and they had confidence in the management. Staff felt that the home provided a very high quality of care and they worked well as a team to achieve this. Cornwall Care Ltd has comprehensive policies for health and safety. The Annual Quality Assurance Assessment, returned to the CSCI detailed required maintenance and safety records. A sample were checked against the original records and found to be accurate. Staff have attended relevant health and safety training. The accident record for residents was inspected. The home maintains an additional record to analyse all falls. The records showed regular tests of the fire alarm system and the emergency lighting. The home’s fire risk assessment has been completed, amended as directed by the fire service and reviewed. There are records of fire drills and fire safety training, with question and answer sessions for staff. Redannick House DS0000009124.V373792.R01.S.doc Version 5.2 Page 23 Redannick House DS0000009124.V373792.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Redannick House DS0000009124.V373792.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action 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 OP9 Good Practice Recommendations Where hand written entries are made to the Medication Administration Records, these should be accompanied by two signatures. Redannick House DS0000009124.V373792.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Redannick House DS0000009124.V373792.R01.S.doc Version 5.2 Page 27 - 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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