Care Home: Redclyffe

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What the care home does well Residents living at the home said "it`s really nice here", "they look after us very well" and "the food is good and you get a choice". One relative said "We cannot speak too highly of the staff, we have always found them caring and they always have time for you and any little queries you may have". The service benefits from a committed and caring staff team. The environment is homely and welcoming. What has improved since the last inspection? Documentation in all areas has improved significantly. The overall presentation of the home with more thought being given to the needs of the residents. Better communication, training and team work. More activities are being provided for the residents. CARE HOMES FOR OLDER PEOPLE Redclyffe 6/8 Aldrington Road London SW16 1TP Lead Inspector Davina McLaverty Key Unannounced Inspection 10:00 16 September 2008 th 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 Redclyffe DS0000010220.V366981.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. Redclyffe DS0000010220.V366981.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Redclyffe Address 6/8 Aldrington Road London SW16 1TP 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) 020-8769 6200 020 8769 6200 yvonne.wallace2@btinternet.com Richard Cusden Homes Ms Yvonne Wallace Care Home 22 Category(ies) of Dementia (22), Old age, not falling within any registration, with number other category (22) of places Redclyffe DS0000010220.V366981.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (CRH - PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP 2. Dementia - Code DE The maximum number of service users who can be accommodated is: 22 1st November 2007 Date of last inspection Brief Description of the Service: Redclyffe, is a residential care home for older people that is owned and operated by the voluntary organisation, Richard Cusden Homes (non profit provider) and is located in a leafy, residential area of Streatham. The property comprises of two attached, but formerly detached, large Victorian houses in their own grounds. A small car park is available. Public transport and local shops are nearby. The home is registered for twenty-two service users. Sixteen of the bedrooms have en-suite facilities. The atmosphere is homely and relatives are encouraged to visit and take part in the life of the home. At the time of this inspection the manager of the home reported that the weekly fees were £557.28 per week. Additional charges are made for toiletries, newspapers and some outings. Residents are made aware of the inspection report through individual discussion as well as a copy being displayed in the hallway. Redclyffe DS0000010220.V366981.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 2 stars. This means that the people who use this service experience good quality outcomes. This unannounced inspection took place on 16th September 2008 and was carried out by one regulation inspector over 7 hours. The manager and senior staff were available throughout the day. The inspector also spoke to six staff, and eight residents. Additional information has been gained from the inspection record for the home, the Annual Quality Assurance Assessment (AQAA), that the manager completed and surveys received from 9 staff, 2 residents and one health care professional involved with the service. Records looked at included care planning documentation, health and safety information, medication records and staff files. We also looked at the premises. All staff were helpful and friendly during the visit. What the service does well: What has improved since the last inspection? Documentation in all areas has improved significantly. The overall presentation of the home with more thought being given to the needs of the residents. Better communication, training and team work. Redclyffe DS0000010220.V366981.R01.S.doc Version 5.2 Page 6 More activities are being provided for the residents. 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. Redclyffe DS0000010220.V366981.R01.S.doc Version 5.2 Page 7 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 Redclyffe DS0000010220.V366981.R01.S.doc Version 5.2 Page 8 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): 1,3,4 & 6 People who use this service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service User Guide had been updated and now provides more up to date information for prospective residents and their advocates. Residents are assessed before admission, and where possible a visit to the home would take place. EVIDENCE: The Statement of Purpose had been updated since the last inspection. Copies of the Service Users Guide are given to residents on admission to the home. This document contains relevant information regarding living at the home and includes the organisations complaint procedure. The home is wanting to get accreditation by the RNIB and have been in consultation with Redclyffe DS0000010220.V366981.R01.S.doc Version 5.2 Page 9 them as regards the home meeting their standards/criteria. As a result a number of improvements have been made which will benefit all residents with a visual impairment. The majority of the residents residing in the home are placed by Wandsworth Social Services. Copies of Care Managers assessment reports were seen on two of the recent admissions files in the home. The managers own assessment report was also seen. Where possible as part of the assessment process, potential residents are invited to visit the home to meet staff and residents and look at the service provided. Residents move in for an initial period of six weeks. Prior to the six weeks a review meeting is held between the resident, their relative/advocate, care manager and homes manager to review their stay and for the resident to decide if they want to stay. Intermediate care is not provided by the home. Redclyffe DS0000010220.V366981.R01.S.doc Version 5.2 Page 10 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 People who use this service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The residents’ needs are met through improved care planning that takes into account individual needs and preferences. EVIDENCE: Responses from residents indicate that they feel that they generally get good care and support from the care staff. Comments included “they work very hard to help us” “all are very kind and considerate” “the food is lovely I could not want for more” and “every thing is fine”. Three residents when asked about privacy and dignity said that staff usually responded appropriately and would knock on their doors, close doors when supporting them and allowed them to do as much for themselves as they were able. One survey stated that in response to the survey question ‘Does the care service respect individuals’ privacy and dignity as follows “ always” - “ lovely manner with clients- really care about residents”. Redclyffe DS0000010220.V366981.R01.S.doc Version 5.2 Page 11 Evidence was seen in the care plans of visits from various health care professionals including GP’S, opticians , chiropodists , and district nurses. The inspector spoke to a visiting community nurse who stated that she found this home to be very good in that she found the carers to be receptive and will do what is asked of them to ensure the well being of the resident. Nothing appeared to be too much trouble for them. Previously the home have struggled with care planning and a new system has recently been introduced which includes more relevant areas and would enable a new staff member to know residents level of functioning and what their care needs are. Staff are currently in the process of transferring information over to the new system.. Five care plans were looked at during this inspection and the majority of areas had been completed. The new system records time’s people like to get up and go to bed, what the person can do in respect of personal care tasks and what support they need. They also includes likes and dislikes as well as a life history of the person. However, where residents have dementia this area of the care plan need to be expanded upon with fuller assessments being carried out. Further dementia training would assist staff in this. The staff in the home would also benefit from training in care planning and risk assessments. Risk assessments were seen on the files examined but they were brief and lacked sufficient detail. Monthly reviews of care plans were seen and in one instance the wife of one of the residents had been involved. Risk assessments should involve more than one person and the resident themselves (if able), with all parties signing the document detailing the agreed level of risk. The medication for three residents was looked at. The home uses a monitored dosage system and the majority of medication is dispensed in this way. Where medication is not stored in a monitored dosage system it is clearly labelled with the name of the resident for whom it is prescribed and the date of opening is recorded. A fridge is available for the storage of medication which needs to kept at a low temperature e.g. eye-drops, antibiotics. A record is kept of the fridge temperature, however we saw three bottles of eye-drops for one resident, one was empty, and another was passed its expiry date to be used. Staff were also administering medication from one packet of medication instead of using resident’s individual packets. This was brought to the attention of the manager who said this practice would cease immediately. The inspector noted that residents were given lactulose from their own prescribed bottle. The Medication Administration record sheet (MAR) seen during the inspection detailed the medication coming into the home. There were no gaps in the medication being signed as given on the MAR sheets. However, the MAR sheet did not record whether the resident had any allergies or not. The staff member said that if resident have an allergy then it would be recorded on the sheet but Redclyffe DS0000010220.V366981.R01.S.doc Version 5.2 Page 12 agreed to ask the pharmacist to complete on all residents MAR sheets. There was a current photograph of the resident on the file. A sample of staff signatures was also seen. The record of staff medication training was not clearly seen on the files examined although staff spoken with said that they had all received medication training. This was not raised as an issue in any of the staff questionnaires received. The manager reported that medication training like all mandatory training is on going in the home. Redclyffe DS0000010220.V366981.R01.S.doc Version 5.2 Page 13 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 &15 People who use this service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Residents have the opportunity to be involved in some in- house activities, though improvements are needed to ensure all residents have the choice to be involved through more variety of activities. EVIDENCE: Care plans now seek social activities/ interests of residents and activities should expand to enable some activities and interests of people to continue whilst living in the home. The manager stated that the services of two free lance people are used. One comes every week and plays the piano and staff and residents enjoy a good old fashion sing song. The other person who comes does reminiscence and holds discussions with residents on a variety of topics. The home also has contact with a local project whereby residents are collected and taken to a local hall for activities. One resident who goes regularly spoke Redclyffe DS0000010220.V366981.R01.S.doc Version 5.2 Page 14 of the variety of activities she in involved in. The home has organised trips to the coast, parks and local theatres. The manager and staff are keen to expand the number of activities they offer. During the inspection we saw staff engaging in a ball throwing exercise, dominos, and and one to one chats . Newspapers were also available The activities book was seen and staff are using the book more and we saw details of one to one trips out, in house activities in the garden e.g. coffee on the patio, ice cream and drinks in the garden as well as video evenings singing and dancing. One resident spoken to said there has to be more to do all we do is sit and eat”. This was not seen to be the case and on looking at this persons file it seemed likely that due to their dementia they failed to remember what the were involved in as their care notes identified a number of activities. The manager in her AQAA has stated that the home is “ providing training in activities for people with dementia for all care staff” Staff spoken with and in their questionnaires said that they would like to have more activities for residents. The manager is aware of this and a one staff member has particular responsibilities to develop this area further in the home. One relative in her survey stated that they are aware of activities in the home that they are invited to although it’s not always possible to attend. Birthdays are celebrated ( if the person wants) with at least a cake. We saw positive interaction between residents during this inspection with one resident actively encouraging conversation and sing- a- longs. Staff were also seen to engage appropriately with residents. Lunch was observed and seen to be a relaxing event with low level music being played. Individual tables were appropriately set out. Condiments were available for residents to help themselves. A choice of meals is offered and on the day of the inspection residents appeared to enjoy their meal, however deserts were seen to be given to at least three residents before they had finished their first course. This practice should cease . Staff offered appropriate support and encouragement to residents during lunch. Staff were seen in the morning asking residents what meal they would like for lunch. All residents spoken with said that they liked the food. One relative stated “My relative does not eat red meat or poultry. Her diet of fish and vegetables are well catered for. I have seen lunches and they are well presented and the taste is good!!”. Redclyffe DS0000010220.V366981.R01.S.doc Version 5.2 Page 15 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): 16 &18 People who use this service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure and guidelines regarding protecting of Vulnerable adults. These systems minimise risks to residents. EVIDENCE: The home has a complaints procedure which residents are given a copy of in their Service user guide. The procedure is also displayed on various notice boards around the home. Since the last inspection no complaints have been made. At least four of the residents spoken to were aware of the procedure if they wanted to make a complaint, although one person did say that things would have to be pretty bad before they complained as they were wary that it would have repercussions for them continuing living there. A relative said that they were aware of the complaints procedure but said that any issues they had when raised with the manager or any staff member it was immediately addressed Redclyffe DS0000010220.V366981.R01.S.doc Version 5.2 Page 16 Survey responses from staff indicated that staff had a good awareness of what to do if they received a complaint. Staff spoken to during the inspection had a good understanding of what they should do should there be suspicion of abusive practice taking place and they were aware of the ‘whistle blowing procedures’. In discussion with the manager she stated that most staff have received training in Safeguarding of Vulnerable adults and that training is on going. Individual staff records must be available at inspection. A copy of Wandsworth Safeguarding of Vulnerable adults (SOVA) leaflet was displayed on the homes notice board in the hallway and office. The manager reported that all staff had recently received updated Safeguarding training from an independent organisation. Certificates of this training was shown to inspectors. Inspectors advised the manager that the home accesses the Wandsworth Training on SOVA as this will enable staff to become familiar with Wandsworth reporting procedures. Redclyffe DS0000010220.V366981.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, 20,21,22,23,24,25 & 26 People who use this service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The environment is welcoming, relaxed and clean. The furnishings are of a good standard which makes it a nice place to live. EVIDENCE: The premises are well maintained and provides a comfortable and homely environment for the residents. Maintenance of the home is on going. The home is wanting to be accredited to RNIB and have had an initial assessment carried out by the organisation which has resulted in more thought going into any redecoration particularly the colour schemes. Since the last inspection more contrasting colours have been used to identify different areas, this will enable someone with a sight difficulty find their way around the home more easily. Redclyffe DS0000010220.V366981.R01.S.doc Version 5.2 Page 18 The lounge area seen was light and was clean. A large flat screen television, piano and music equipment was available as well as a small stocked bookcase. Chairs were seen to be against the walls , but given the shape of the room it is difficult to arrange them differently. There is a small seating area off the main dining area which can be used for small group meetings or quite time with certain residents. The dining room consists of several small tables to encourage conversation over lunch and this room leads out onto a patio area and the garden. Both areas again were well maintained . The manager stated that the garden has been landscaped to make it more user friendly. Residents spoke of their use of the garden when it warm. A laundry area is available of the ground floor as are a few of the bedrooms. A small lift is available although where able residents are encouraged and supported to use the stairs. A sample of 14 bedrooms was looked at over the three floors. Bedrooms seen were all clear and personalised reflecting individual’s choice and personality. Furniture in the rooms were of a good standard. Bathrooms and toilets within the home were all clean with paper towels and liquid soap. Various support aids and hoists were available.. Lunchtime was seen to be calm affair, with music playing quietly and those residents needing assistance being supported by staff. Staff however, must ensure that residents are not given their dessert before they have finished their first course as seen on the inspection day. Redclyffe DS0000010220.V366981.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): People who use this service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The staff team support each other and share skills and knowledge to provide a good service to people. Staff roles and responsibilities are clearly defined with residents being protected by the organisations recruitment procedures. Staff have access to training appropriate to their roles. EVIDENCE: Redclyffe has a consistent staff team , some of whom have worked at the home for over twenty years . Staff reported that they are confident that the service they provide promotes the well –being of the residents. This was confirmed by residents spoken to and from surveys received where again comments were generally positive, with staff being described as caring, understanding and kind. The home aims to have four staff morning and afternoon shifts and three waking night. The manager is supernumerary but will work shifts during times of illness and holidays. In the AQAA the manager has stated “ We assess the needs of the resident group to ensure that sufficient staff are on duty to be Redclyffe DS0000010220.V366981.R01.S.doc Version 5.2 Page 20 able to provide adequate care. We provide adequate waking night staff to ensure that residents are well cared for during night hours.” Files of five staff were examined and appropriate information was seen in respect of recruitment. The staff files were much better organised , enabling relevant information e.g. application forms, record of interview, references and Criminal Bureau checks to be found. However , the files lacked clear evidence that inductions had taken place on the two new staff members files examined. Although talking to one of the staff she confirmed that she had had a two week induction programme, which she had found very helpful and had provided her with a good grounding into the home and the residents. Current appraisals were also missing. In feedback to the manager she stated that written inductions do occur with both parties signing the documentation. Appraisals had fallen behind with and would give priority. She stated that the system for appraisals had recently been reviewed and that the organisation had decided that instead of doing it at the end of every financial year it would now be carried out on the anniversary of the date the employee had started. All files contained a training record and the manager endeavours to ensure that all staff undertake mandatory training which is updated. All senior staff are required to take the full First Aid training whereas support staff undertake a “Save a life” first aid course. The manager stated in her AQAA that “Care staff have either completed or are in the process of completing NVQ training relevant to their post. The home intends to increase its level of training over the next twelve months with further courses on Dementia care, Loss and Bereavement as well as the Capacity Act., health issues and activities for older people. The home had Wandsworth Local Authority training bulletin which contained a number of courses which the home was eligible to apply for. Staff meetings are taking place more regularly and notes taken at these meetings were seen. Redclyffe DS0000010220.V366981.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): 31,33,35 and 38 People who use this service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The management team is committed to progressing the service for the benefit of the residents. EVIDENCE: In the survey sent to staff , they were asked to comment on what they feel the service does well. Some of these responses are as follows: “We are supported by our manager”. “We provide a very good service our residents are happy and we are all very friendly and this reflex’s on the visitors who always comments on it”. “Provision of a balanced diet” Redclyffe DS0000010220.V366981.R01.S.doc Version 5.2 Page 22 “ The home is a small home and we provides a family atmosphere” and “provide better care for the users” Staff spoken to said that the management does well at communicating important information and promoting team work. There are three daily verbal handovers as well staff ensuring that important issues with residents are written down . Staff reported that generally communication in the home had improved. When asked where the service could improve, to staff said that there needed to be more activities offered to residents, one survey said that the home needed more lifting equipment. In discussion with the manager she stated that the home des not have any mobile hoisting equipment and that when resident falls they would check them over or call for an ambulance. All staff receive moving and handling training, however, discussions should take place with an Occupational Therapists re mobile hoists. The manager said that despite being the manager she remains hands on and will regularly spend time on the floor getting to know residents and work with staff. The manager has over 30 years experience of working in a care setting, and prior to being appointed as the manager at Redclyffe was the deputy for seven years. She has completed the Registered Managers award. The manager stated that there has been no changes to the homes quality and assurance system which the management committee takes responsibility for organising. Views of residents, relatives and other stakeholders are sought and responses are collated by the chair of the management committee who would write a development plan for the home. Currently this is overdue. Monthly Regulation 26 visits were seen to be taking place with the home being supported by the Responsible person. The home continues to support residents manage their money, if there is no relative who is able to do this on their behalf. Senior staff are responsible for handing out money, records are maintained of all transactions. The service maintains records to demonstrate that appropriate health and safety checks are carried out on the fire system and equipment, electrical installation, gas safety and Portable appliance testing etc. Systems checked were found to be in order. Inspectors saw a copy of the most recent Environment Health inspection in which the kitchen had been designated three stars (good). The home is working on recommendations to increase this level. Redclyffe DS0000010220.V366981.R01.S.doc Version 5.2 Page 23 Redclyffe DS0000010220.V366981.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 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Redclyffe DS0000010220.V366981.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. 1 2. Standard OP7 OP9 Regulation 15(1) 13(2) Requirement The care plans must be include more detail on dementia assessments . The Responsible person must ensure that: the allergy section on the Medication Administration chart is completed for all residents - prescribed medication is not shared between residents The service must provide a varied programme of activities that caters to the needs of all the residents Timescale for action 01/10/08 01/10/08 3. OP12 16(2) (m) (n) 30/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Redclyffe DS0000010220.V366981.R01.S.doc Version 5.2 Page 26 No. 1 Refer to Standard OP1 Good Practice Recommendations Consideration should be given to producing the Statement of Purpose and Service User guide in different formats which would better meet the needs of the users of the service. Staff would benefit from external training in Care planning and Risk Assessments. Risk assessments should detail who was involved in drafting them with assessments and the reviews being signed by all parties. Staff should ensure that deserts are not served until the resident has finished their first course. The home should access the local authorities Safeguarding of Vulnerable adults training to ensure that all staff are familiar with the procedures. All staff should have an annual appraisal. All staff should have a induction and a record be maintained. 2 3 4 5 6 7 OP7 OP9 OP9 OP15 OP18 OP28 OP30 Redclyffe DS0000010220.V366981.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Redclyffe DS0000010220.V366981.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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