Care Home: Redcroft

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What the care home does well People only move into the home following a full assessment of their individual needs and aspirations in order to be assured that the home has the staff and skills to meet their needs. People are supported to make decisions about their own lives. People who use the service are encouraged and supported to take risks as part of an independent lifestyle. Redcroft DS0000065720.V377582.R01.S.doc Version 5.3 People living in the service are able to take part in activities which interest them in the local community and are encouraged to participate in a variety of leisure activities. People are able to maintain relationships with their family and friends as they wish. Individual person centred plans ensure that people are able to make decisions about their own lives. People are encouraged to be involved in maintaining a healthy diet. People tell us they are listened to and any concerns are acted upon. Staff who work in the home are trained to understand how to protect people from harm. There is a system in place to enable people to have a voice in how the home develops. What has improved since the last inspection? At the end of the inspection in July 2008 there were four requirements and seven recommendations. Care plans have improved and contain accurate information about each person’s health care needs and the interventions needed to support them. This ensures that support staff are clear on the action they need to take to respond to health needs safely. All support staff who work in the home have had the necessary checks completed as part of a robust recruitment process. All support workers employed to work in the home have completed induction training which meets the common induction standards as issued by Skills for Care. Support workers receive specialist training to ensure they understand the needs of people who use the service. There has been improvement to goal setting with evidence of how people are being enabled to progress in their goals. Care plans are specific in detailing the information support staff need to meet people’s needs. People who work in the service have had training in administering medication and their practice is regularly observed. Redcroft DS0000065720.V377582.R01.S.doc Version 5.3 Repairs in the home are completed and clearly recorded. Support staff who work in the home are supported to complete NVQ qualifications in care. Regular audits of the home are completed by management to ensure that the service is meeting the national Minimum Standards. What the care home could do better: At the end of this inspection there are no requirements and two recommendations. Where equipment is broken or damaged it should be replaced as it has the potential to harbour infection. Once accidents and incidents have been recorded and audited the information should be stored in the individuals file to maintain confidentiality. Key inspection report CARE HOME ADULTS 18-65 Redcroft 255 Belle Vue Road Southbourne Bournemouth Dorset BH6 3BD Lead Inspector Tracey Cockburn Key Unannounced Inspection 29th September 2009 10:40 Redcroft DS0000065720.V377582.R01.S.doc Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Redcroft DS0000065720.V377582.R01.S.doc Version 5.3 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Redcroft DS0000065720.V377582.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Redcroft Address 255 Belle Vue Road Southbourne Bournemouth Dorset BH6 3BD 01202 428158 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) info@applehouse.co.uk Apple House Limited Mrs Romaine Estelle Lawson Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Redcroft DS0000065720.V377582.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Learning Disability (Code LD) The maximum number of service users who can be accommodated is 8. Date of last inspection 15th July 2008 Brief Description of the Service: Redcroft opened as a residential care home in December 2005. It is one of two homes run by Apple House Limited. It is a detached house situated in the Southbourne area of Bournemouth. The property is in-keeping with the neighbourhood. The home is registered to provide accommodation and support for up to eight adults who have a learning disability. There is a lounge, kitchen / dining room, a small utility area and a large garden to the rear of the house. Accommodation is provided on three floors. There are currently two bedrooms on the ground floor and five bedrooms on the first floor, two of which have an en-suite facility. The second floor of the home comprises a studio flat with ‘kitchenette’ facility suitable for a person who wishes to gain more independence. Five people who use the service share bathroom facilities in the home. The home is staffed on a 24-hour basis. There is an area for parking at the front of the property. Local shops are within walking distance and a bus route into the neighbouring towns of Christchurch, Boscombe and Bournemouth is close by. At the time of the inspection the basic fee for the service was £735 per week. General guidance on fees and fair terms in care homes contracts may be obtained from the Office of Fair Trading whose website can be found at www.oft.gov.uk . Redcroft DS0000065720.V377582.R01.S.doc Version 5.3 Page 5 Redcroft DS0000065720.V377582.R01.S.doc Version 5.3 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience Good quality outcomes. This inspection was carried out by one inspector but throughout the report the term ‘we’ is used to show that the report is the view of the Care Quality Commission. This was an unannounced key inspection of the service. The inspection took place over one day and an evening. The aim of the inspection was to evaluate the home against the key National Minimum Standards for adults and to follow up on the requirements made at the last key inspection in July 2008. During the inspection we were able to meet some of the people who use the service and observe interaction between them and staff. Discussion took place with the Registered Manager, Romaine Lawson, and some members of staff in the home including the manager in day to day charge. A sample of records was examined including some policies and procedures, medication administration records, health and safety records, staff recruitment and training records and information about people who live at the home. Recruitment and training records were looked at on a separate day at the providers head office in Christchurch. Surveys were given to the home before the inspection for distribution among people who live in the home and those who have contact with the service. We received five surveys from people who use the service, seven surveys from staff who work in the home and three surveys from health and social care professionals. We received the home’s Annual Quality Assurance Assessment when we requested it which gives us some written information and numerical data about the service. What the service does well: People only move into the home following a full assessment of their individual needs and aspirations in order to be assured that the home has the staff and skills to meet their needs. People are supported to make decisions about their own lives. People who use the service are encouraged and supported to take risks as part of an independent lifestyle. Redcroft DS0000065720.V377582.R01.S.doc Version 5.3 Page 7 People living in the service are able to take part in activities which interest them in the local community and are encouraged to participate in a variety of leisure activities. People are able to maintain relationships with their family and friends as they wish. Individual person centred plans ensure that people are able to make decisions about their own lives. People are encouraged to be involved in maintaining a healthy diet. People tell us they are listened to and any concerns are acted upon. Staff who work in the home are trained to understand how to protect people from harm. There is a system in place to enable people to have a voice in how the home develops. What has improved since the last inspection? At the end of the inspection in July 2008 there were four requirements and seven recommendations. Care plans have improved and contain accurate information about each person’s health care needs and the interventions needed to support them. This ensures that support staff are clear on the action they need to take to respond to health needs safely. All support staff who work in the home have had the necessary checks completed as part of a robust recruitment process. All support workers employed to work in the home have completed induction training which meets the common induction standards as issued by Skills for Care. Support workers receive specialist training to ensure they understand the needs of people who use the service. There has been improvement to goal setting with evidence of how people are being enabled to progress in their goals. Care plans are specific in detailing the information support staff need to meet people’s needs. People who work in the service have had training in administering medication and their practice is regularly observed. Redcroft DS0000065720.V377582.R01.S.doc Version 5.3 Page 8 Repairs in the home are completed and clearly recorded. Support staff who work in the home are supported to complete NVQ qualifications in care. Regular audits of the home are completed by management to ensure that the service is meeting the national Minimum Standards. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Redcroft DS0000065720.V377582.R01.S.doc Version 5.3 Page 9 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 Redcroft DS0000065720.V377582.R01.S.doc Version 5.3 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Detailed assessments are completed prior to people moving in, to ensure that staff are able to meet people’s needs. EVIDENCE: We looked at the care records for one person who recently moved into the service. Documentation from the local authority on their needs was on file and there was evidence that the home had also carried out their own assessment. Areas covered by the assessment included personal care, eating and drinking, behaviour, medication, health care, community access, social needs, literacy and safety. The annual quality assurance assessment says they plan to do the following over the next 12 months: “To plan a review of our assessment and contract tools.” Redcroft DS0000065720.V377582.R01.S.doc Version 5.3 Page 11 Redcroft DS0000065720.V377582.R01.S.doc Version 5.3 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are given opportunities to be independent, make choices and decisions about their lives and achieve their goals. EVIDENCE: There was one recommendation made in this outcome area at the last key inspection regarding goal setting and the need to clearly document progress. We found this had improved. We looked at the goals for one person and found very good information on how the person is being supported to achieve their goal including being realistic about how it will be achieved. There was evidence that staff were supporting the person to consider various aspects of what needed to be in place before moving on to the next stage. The recording was clear and had timescales. Redcroft DS0000065720.V377582.R01.S.doc Version 5.3 Page 13 The annual quality assurance assessment says they are planning to improve by: “To commence a service user forum to gain peoples views on the risk management process from a service user perspective. We plan for this work to take place from the end of 2009 for a period of 8 months and to cover and gain peoples views on how the risk assessment process can achieve its goal of expressing individuality and taking reasonable risks.” There was information on the notice board for people about speaking up groups, bullying and harassment and where to go for support. We saw evidence of residents’ meetings taking place in the home. Minutes of meetings showed that people had been enabled to discuss activity and holiday choices. The home had also involved people in a recent recruitment campaign, requesting service users’ involvement on the interview panel and in thinking of questions they would like asked. People’s care plans showed that some relevant risks to each person had been assessed, for example in relation to cooking, use of sharp instruments, using the stairs, going out in the community and money-handling. Risk assessments offered guidance to staff about the action they need to take to minimise risks, for example, to avoid certain crowded places if they are likely to raise service users’ anxiety levels. It was evident from observing people in the home and talking to them about their lives that their independence is promoted and that the home enables people to take risks in order for them to lead an ordinary life. During our visit we observed people being about to make their own snacks and drinks. There was also evidence that people are being supported to be responsible for their own actions and decision making. One person was being supported to consider the responsibility in being the owner of a pet as part of achieving her goal. All staff sign to say they have read and understood the care plan and any changes. Redcroft DS0000065720.V377582.R01.S.doc Version 5.3 Page 14 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): This is what people staying in this care home experience: People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are enabled to lead a lifestyle that is positive, gives them opportunities to develop skills and independence and have the support of their family and friends. They are supported to lead an ordinary life. EVIDENCE: A social care professional wrote under the heading “what does the service do well” “ homely environment with large rooms, wide range of social activities to suit individual needs” One person who lives in the home is responsible for the three chickens in the garden, but he said that other people who live in the home help with their care. The chickens arrived in June. Each person who lives in the home has a diary which has a sheet recording their one to one hours. The total agreed and what activities they have done in Redcroft DS0000065720.V377582.R01.S.doc Version 5.3 Page 15 this time. Each person who lives in the home also has a communication book. This contains information on ‘things you need to know to support me’ such as my understanding, how I make choices, my eyesight and hearing, how I communicate. The activities for one person we looked at included; athletics, riding and dance and relaxation. We looked in the care files for three people and could see information on their faith and cultural needs and thought had gone into how they could support people to maintain important aspects of their culture at a pace they were happy with. The manager told us they were being guided by the individual as to how this progressed. We observed people participating in their chosen hobbies and interests when we visited in the evening. People who use the service told us in surveys that they could do what they wanted to do during the day, in the evenings and at weekends. We noted from records and from talking to people who use the service and staff that they are enabled to engage in activities that are meaningful to them as individuals. Care plans detail individual choices and interests and how people can be supported to undertake their hobbies in the community. One person told us about the holiday they had been on and how much they had enjoyed it. We observed that, where appropriate, people are enabled to make themselves drinks and snacks using the kitchen facility and help with cooking. People are involved in deciding what they eat and are supported to make healthy choices. The fridge was stocked with a variety of foods, we noted that a packet of ham had been opened and the date written on. All meals are recorded. Redcroft DS0000065720.V377582.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive the support they need in the way they prefer, there are systems in place to ensure their health and emotional needs are met. There is a system in place to ensure that medication is administered safely. EVIDENCE: At the last inspection there was one requirement in this outcome area. Individual care plans needed to contain accurate information to ensure care workers knew what to do. Three recommendations were made in this outcome area at the last key inspection, more clarity in care plans, ensuring that health care professionals were given all the information they needed on which to base their interventions and appropriate training for staff on administering medication. One health care professional commented: Redcroft DS0000065720.V377582.R01.S.doc Version 5.3 Page 17 “ the service needs better understanding of communication with people with learning disability often too long and complex in interactions with little awareness” We looked at the care records for three people and found in one file very clear instructions on how staff need to communicate effectively with one person. We spoke to the manager about communication and we observed staff, while we were observing we found staff were clearly following guidance in care plans especially around communication. The annual quality assurance assessment says: “We provide individualised support that assists people to improve their independence and gain new skills. Personal support is provided in private and with respect. The health of the people we support is continually assessed and the guidance of relevant professionals is sought when appropriate. We work as a team with a diverse range of people and communicate well with others in keeping up to date.” We examined a sample of care plans in relation to information about people’s health care needs. People’s appointment records that we looked at indicated the home liaises with various health care professionals to meet their individual needs. The annual quality assurance assessment also says: “All staff are currently completing an in-house medication pack provided by Boots who will be marking the completed packs and providing a certificate on completion. We work very closely with Boots who always offer support all staff are confident in the protocol when it come to medication. Staff have also completed a Vision eye and hearing course.” We looked at the care plan for one person, which contained detailed information on their health condition and the support and action staff need to take, this care plan was written with the support of the community nurse. We looked at individual records on health care appointments and found that there was information on the outcome of the appointment and action staff needed to take. We observed medication being dispensed during our visit in the evening, one member of staff completed this task. We also looked at the medication administration records and found there were no signature gaps and the sample we looked at was correct. There were no controlled drugs being stored in the home at the time of the visit. Redcroft DS0000065720.V377582.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are listened to and systems are in place to respond to their concerns and complaints. Procedures are in place to protect people from harm. EVIDENCE: There is a complaint procedure in place, with a clear timescale. All the people who responded in the survey said they knew who to speak to if they were unhappy or wanted to complain. The complaint procedure is written in an easy read style which is accessible for people. All support staff who work in the home receive training in protecting vulnerable adults. There have been no safeguarding investigations since the last key inspection. A social care professional wrote: “very rapid and thorough response to any adult protection issues” The annual quality assurance assessment says: “We listen to others. We act on and value people’s feedback and we try to convey this to the people we support and work with.” Redcroft DS0000065720.V377582.R01.S.doc Version 5.3 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Redcroft provides a homely, comfortable and clean environment for people to live in. EVIDENCE: One recommendation was made in this outcome area at the last key inspection, the toilet needed to be repaired promptly. We asked the person if their toilet was now working and they said “Yes” In the hall there is a large collection of photographs of the people who live at Redcroft and the variety of activities they have done over the summer such as the arrival of the chickens, baking, decorating cakes, sitting out in the sun enjoying the new decking area. Redcroft DS0000065720.V377582.R01.S.doc Version 5.3 Page 20 One member of staff who returned a survey form thought under the heading ‘What could the home do better’? “Some of the maintenance of the house” The annual quality assurance assessment says: “The lounge carpet has been replaced since the last inspection. There has been further re decoration of the lounge and communal areas. The appearance of the home is smart and homely. The garden is well maintained and tended to by some people who use the service and by professional gardeners All staff now have designated roles within their time on shift and complete weekly/monthly checks of the environment.” Since the last key inspection the home has also: “We have a lovely decking area where the service users like to spend their time and enjoy a cup of tea or just to relax” We were told that the laundry room will be refurbished; we found that the tap in the hand basin was dripping and that some of the paint on the walls was peeling. We found that there were some stains on the stair carpet on the first few steps, which the manager was aware of. There is a large lounge, large kitchen with a big table that everyone can sit round. All the communal areas of the home are accessible to the people living there. We looked in several people’s rooms and found them to be personalised and comfortable. We looked in one bathroom and noted that the bath seat being used had exposed metal work which was rusting and needed to be replaced which we drew to the attention of the manager. All the bathrooms had liquid soap, paper towels and pedal bins which aid in infection control. Redcroft DS0000065720.V377582.R01.S.doc Version 5.3 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who work in the home are competent and receive the training they need to do their job well. Recruitment practice ensures that people are protected. EVIDENCE: There were three requirements in this outcome area at the end of the last inspection. One was regarding appropriate checks on agency staff and two in relation to training, induction and specialist. One recommendation was made in this outcome area at the last inspection that all staff should be working towards NVQ in care at least at level two. A member of staff wrote, “They manage challenging behaviour very well” The annual quality assurance assessment says: Redcroft DS0000065720.V377582.R01.S.doc Version 5.3 Page 22 “We now employ permanent bank staff thus reducing the agency to a bare minimum. This has proved to be an asset to staff and service users alike. We have an effective staff team that is sufficient to meet the needs of the people we support. We have a good skills mix to ensure a high level of care is delivered across the service. Regular staff meetings take place.” At the last key inspection, the home employed very few of its own staff preferring at the time to have an arrangement with an agency who supplied all support staff and provided training. This has now changed and all staff are recruited to work in the home by the registered provider. The registered provider is also responsible for sourcing, arranging and providing all training for the staff it employs. We looked at the recruitment records for a number of staff who work in the home, we found the records were in good order, written references were in place and all Criminal Records Bureau checks and Pova1st checks were completed before anyone started work in the home. There is a training matrix in place for each person working in the home which provides a clear record of the courses they have been on and when refresher training is due. The registered providers have sought advice and guidance from an experienced training provider and have sourced a variety of training courses for their staff including epilepsy, physical intervention and medication. We observed both during the day and in the evening working with people who live in the home. People told us they get on well with staff and we observed activities taking place which were the individual’s choice. In the evening one person was learning how to play cards with a member of staff. The staff rota is on the notice board in the kitchen and has photographs of the staff on duty on each shift, morning, afternoon and evening. It also covers the following day so people know who will be supporting them the following morning. Redcroft DS0000065720.V377582.R01.S.doc Version 5.3 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service is run with the interests of the people who live there at the centre of the homes objectives. A system is in place to ensure that the views of the people in the home form the basis of its development. The health, welfare and safety of people living in the home is promoted and protected. EVIDENCE: One recommendation was made at the last key inspection in this outcome area that regular audits of records and procedures in the home should take place. Redcroft DS0000065720.V377582.R01.S.doc Version 5.3 Page 24 The annual quality assurance assessment says: “The manager is approaching the end of her NVQ4 and RMA qualifications. The staff have received training in Epilepsy and Fire training.” They also tell us: “We have booked Breakaway training for all staff for September 09. We have invested in our recruitment and training of all staff.” We spoke to the manager in day to day charge who told us that her application to registered with the commission will be submitted in the next few weeks, it had been rejected several weeks ago because some of the information was out of date. There is a system in the home for listening to the views of the people who live there are using that information to form the basis of the services development. Portable appliance testing was last done on 17/06/09. The fire risk assessment for the home was reviewed in July2009. The gas safety check was completed on 05/08/09. Fridge and freezer temperatures are regularly checked, all items opened in the fridge were dated on the day of opening with a signature. All staff who work in the home complete the mandatory training such as infection control, food hygiene, moving and handling and first aid. All substances which could be hazardous to health were stored securely. All staff who work in the home receive induction training. We looked at the accident and incident records which are all kept together in one book and suggest that they are stored in individual files to improve confidentiality once an audit has been completed. Redcroft DS0000065720.V377582.R01.S.doc Version 5.3 Page 25 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 CONCERNS AND COMPLAINTS CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score Standard No 22 23 Score 3 3 3 3 X 3 X ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000065720.V377582.R01.S.doc LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Redcroft Score 3 3 3 X X X 3 X X 2 X Version 5.3 Page 26 Are there any outstanding requirements from the last inspection? No 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 YA30 Good Practice Recommendations The registered manager should ensure that where equipment such as bath seats have cracked and broken coverings they should be replaced as they could potentially harbour infection. The registered manager should ensure that once all accidents and incidents are reported the forms are then stored in individual files and not stored collectively. 2 YA42 Redcroft DS0000065720.V377582.R01.S.doc Version 5.3 Page 27 Care Quality Commission Care Quality Commission Southwest Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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