Inspection on 10/12/05 for Raby Hall

This inspection was carried out on 10th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Raby Hall 02/05/07

Raby Hall 29/06/06

Raby Hall 22/02/06

Raby Hall 21/01/05

Raby Hall 04/08/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Raby Hall Raby Hall Road Bromborough Wirral CH63 ONN Lead Inspector Beate Roth Unannounced Inspection 09:20 10 and 17 December 2005 th th Raby Hall DS0000018929.V271696.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Raby Hall DS0000018929.V271696.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Raby Hall DS0000018929.V271696.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Raby Hall Address Raby Hall Road Bromborough Wirral CH63 ONN 0151 334 7510 0151 334 1762 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) Wirral Autistic Society Mr Carl Joseph Kipling Care Home 27 Category(ies) of Learning disability (27) registration, with number of places Raby Hall DS0000018929.V271696.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st January 2005 Brief Description of the Service: Raby Hall is registered to provide personal care and accommodation to 27 adults who have a learning disability, specifically, autism. The home consists of four units. Old Hall, Respite Unit, The Courtyard and The Lodge. All service users are accommodated in single bedrooms and have access to sufficient communal bathroom and toilet facilities. Lounges and dining rooms are available for communal use. There is access to a domestic style kitchen within each of the units. The home is set within extensive grounds. Service users are accommodated in the unit of Raby Hall most suited to their needs and a programme of education, employment or training is provided as appropriate. The home is close to local shops and to public transport services. Parking is available. Raby Hall DS0000018929.V271696.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on two days and lasted 10 hours hours. During the inspection time was spent in the office examining records and policies and procedures. Service users were spoken with. The manager, team leaders and care staff were spoken with. A tour of the home was undertaken. Staff were observed delivering care to service users. What the service does well: What has improved since the last inspection? What they could do better: Some care plans need to be revised to ensure that the information available for staff around the support service users need in relation to their behaviour is clear and accurate. Requirements have been made around some health and safety matters that need attention. Two of the communal areas of the home should receive attention in order to make them more comfortable and homely for service users. The management arrangements at the home should be reviewed to ensure that there are clearer lines of accountability. Raby Hall DS0000018929.V271696.R01.S.doc Version 5.0 Page 6 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. Raby Hall DS0000018929.V271696.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Raby Hall DS0000018929.V271696.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 4 The needs of service users are fully assessed before they come to live at the home. Opportunities are provided for service users to visit the home to assess if the home is suitable for them. EVIDENCE: A separate statement of purpose and service user guide are available for Old Hall, The Courtyard and The Lodge. These documents contain all the required information regarding the home and the services provided. A statement of purpose and service user guide for the Respite Unit has not been completed. The statement of purpose for Old Hall should indicate that day care is provided in certain areas of the premises and any impact this has on residential service users. The service user guide and statement of purpose are available on request and are included in the information pack that is sent to local authorities and other persons who are looking towards making a placement at the home. Consideration should be given to making the service user guide more suited to the needs of the service users who live at the home. A sample of initial assessment records for new service users admitted to the home, since the last inspection were seen. These assessments are comprehensive, cover the information recommended in the National Minimum Standards for Care Homes for Younger Adults and provide a good basis for care planning. New service users are assessed by the manager for the home and by a representative from day services. The manager visits a prospective Raby Hall DS0000018929.V271696.R01.S.doc Version 5.0 Page 9 service user where they are living. Information is gathered from the service users’ carers, social worker and any other relevant agencies. An assessment is made if a service user moves to the home from another home within the Society to make sure that the service users needs can be met there. Introductions to the home are on an individual basis and designed to be specific to meet the needs of the service user. Some service users stay for an afternoon or just a meal, whilst some stay overnight. Family members are also encouraged to visit the service together with social workers from the funding authorities. The home does not take unplanned admissions. Raby Hall DS0000018929.V271696.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9 In general, care planning reflects the assessed and changing needs of service users. EVIDENCE: A sample of service user plans were examined and contained detailed and clear information to enable staff to provide appropriate support around day-to-day living and personal goals. Care plans are prepared by the manager, the homes’ social work team and any other professional involved in their care i.e. speech and language therapist, psychiatrist and GP. In general, a review of the care plan had taken place within the last 6 months. The documentation available from reviews indicated that the service user, their relatives, social worker and other relevant individuals are invited to contribute to reviews. The care plan for a service user who had moved to Old Hall from another home within the Society contained care-planning information that was relevant to their last home and not to Old Hall. The plan for the management of this service users behaviour did not reflect the actual support being provided by staff. Raby Hall DS0000018929.V271696.R01.S.doc Version 5.0 Page 11 An examination of the service user plans indicated that service users’ rights to live as independently as possible, in accordance with their abilities, is promoted by the home. Risk assessments are available which indicate why service users’ rights need to be limited in order to safeguard their wellbeing. A risk assessment for a service user identified with the manager did not provide clear guidelines around the support staff are to provide to minimise risk of challenging behaviour toward other service users and staff in the home and when using transport. Reactive plans, which detail behaviour management strategies are also available. These indicate that as a last resort physical intervention is used. A sample of the records made following an incident of physical intervention were seen and were satisfactorily maintained and indicate that physical intervention is not used frequently. A behaviour management plan for a service user identified with the manager at this inspection needs to provide clearer information on the nature of the physical intervention staff are to use to support this service user when administering medication to manage their behaviour. Staff are trained in behaviour management strategies such as supportive holds and breakaway techniques as part of their induction. Raby Hall DS0000018929.V271696.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13 and 16 Service users are able to take part in appropriate activities that provide opportunities for their educational, social and personal development. Links with the local community are good. The daily routines ensure that the preferences of service users are provided for. EVIDENCE: The majority of service users attend day services from Monday to Friday, where they are provided with opportunities for social, educational and communication support and development. Daily living skills are taught at the day services by appropriately trained staff, and by care staff within the home on a daily basis. Staff give encouragement and support within a risk management framework. The home accesses Speech and Language Therapy services. The home uses a picture system, Makaton and Sign Language to communicate with service users as appropriate for those who do not have verbal communication skills. Service users have the opportunity to demonstrate individual preferences for a range of activities within day services subject to risk assessments. Some of the opportunities available are horticulture, craftwork, community work experience, drama and physical Raby Hall DS0000018929.V271696.R01.S.doc Version 5.0 Page 13 education. Service users are provided with work experience opportunities and attend local college courses in accordance with their wishes and abilities. There are opportunities for service users to become involved in the local community and staff assistance is given to promote this. For example, the service users visit local shops, go to the gym, cinema, bowling and participate in community life through attendance at college courses. Where necessary risk assessments are available around community outings. Discussions with the staff and observations confirmed that the home’s routines are flexible as much as possible. The weekday routines are generally dictated by the day services and work placements. Many of the service users benefit from a structured lifestyle and it is understood that some service users do not relate well to change. Most service users develop their own routines. Choices are offered, although some of these may be limited and service user specific. Weekends are more flexible and fewer routines are in place at this time. The records inspected indicated the support service users need in their daily lives in order to make decisions and encourage independence. Where possible, service users were asked about life at the home. A service user said “ I am happy, I have lots of things to do here, I go out more and go to clubs, the food is good, I have put on weight.” Raby Hall DS0000018929.V271696.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 The personal care and health needs of service users are well met. Service users are protected by the home’s policies and procedures for handling and administering medicines. EVIDENCE: There is clear information available for staff on service users personal care routines that indicate service users preferences. Consistency and continuity of support for service users is provided through the key worker system. Staff receive training on promoting privacy and dignity during their induction. Observations of staff indicated that the privacy of service users is respected. All service users are accommodated in single bedrooms. The home has an ‘Intimate Care’ policy, which is issued to all care staff. Records indicated that service users have access to medical/health care professionals as needed. Service users are supported to attend health care appointments. Service users are supported and facilitated to take control of and manage their own healthcare in accordance with their abilities. A revised medication procedure is available which provides clear guidance. Observations of staff administering medication indicated that they are following this procedure. Medication is stored securely. Members of staff interviewed Raby Hall DS0000018929.V271696.R01.S.doc Version 5.0 Page 15 reported that they have been trained in the administration of medication. A selection of medication administration record sheets and corresponding medication were inspected in Old Hall and The Courtyard and found to be in order. Any service users who self – administer their own medication do so in accordance with a risk assessment. Raby Hall DS0000018929.V271696.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 The practices at the home provide protection for service users. EVIDENCE: A copy of Wirral Borough Council’s adult protection procedure was available at the 4 units. A shorter and more accessible version of the adult protection procedure has been made available by Wirral Borough Council and was available for staff to refer to. All staff are given training in the prevention of abuse during their induction training. Training in the prevention of abuse is part of Wirral Autistic Society’s compulsory training. The training includes identification of the different types of abuse and how to recognise the signs of it occurring. Members of staff interviewed were clear about what to do in the event of a suspicion of abuse. From discussion with members of staff and from an examination of the financial records, the home’s policies and practices with regards to service users’ money and financial affairs safeguard service users. Raby Hall DS0000018929.V271696.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 30 In general, the home provides a comfortable, pleasant and safe environment for service users. Some communal areas are not homely and should receive attention. Attention is needed to some matters that pose a possible risk to the welfare of service users. EVIDENCE: The home consists of four units, Old Hall, Respite Unit, The Courtyard and The Lodge. A tour of these units was undertaken. In general, the premises provide a comfortable environment to service users and are well maintained. There was evidence of maintenance and decorative works having been undertaken since the last inspection. A sample of bedrooms were seen at the units. Bedrooms are furnished and personalised, in accordance with the service users’ preferences, needs and risk assessments. The Lodge, The Courtyard and the Respite Units have access to communal lounges/dining areas and kitchens that appear homely and were well maintained. Each flat at Old Hall has access to a communal kitchen, which is domestic in appearance. There are communal dining areas and three lounges Raby Hall DS0000018929.V271696.R01.S.doc Version 5.0 Page 18 at Old Hall. Some of the communal areas at Old Hall did not appear homely. The panelled lounge on the ground floor, has dark wooden panelling on the walls giving the room a dark appearance and has seating around the edge of the room. The manager reported that work is planned to make this room more welcoming. The lounge on the first floor contained small, brightly coloured plastic sofas that did not appear age appropriate for the service users, did not appear comfortable and did not make this room homely. A member of staff reported that these sofas are being replaced. The decoration in this room could also be enhanced for the benefit of the service users. It is understood that this room used to be an activity room but is now used as a lounge to relax in and watch television or listen to music. A few doors are in use at Old Hall and The Courtyard, which open in two sections. These doors are not domestic in appearance. A risk assessment around the use of these doors needs to be made available. This needs to cover the circumstances in which these doors are used, physical risks presented, for example, risk of trapping fingers and the risk that privacy may not be fully promoted by the use of these doors. The Lodge is situated near to the main road. The garden has a gap in the hedging. This requires attention in order to promote the security of the home and to fully promote the well-being of service users. In the meantime steps must be taken at all times to ensure the well-being of service users. In the meantime a risk assessment is needed detailing how the welfare of service users is to be safeguarded. A tour of the home showed that the home was clean. There are procedures for staff to refer to about hygiene and infection control. Raby Hall DS0000018929.V271696.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 and 35 Service users are supported by the number of staff available and the training staff receive. EVIDENCE: The staff files were not inspected at this unannounced inspection. Staff spoken to stated that they had been provided with a job description and were aware of their own responsibilities. Separate day staff are available for Old Hall, Respite Unit, The Courtyard and The Lodge. The rota’s for each unit were seen. The rotas, a sample of service user records and a discussion with staff indicated that there are sufficient levels of staff being provided. Where service users have 1:1 staff support this is clearly indicated in the rota. At night The Lodge and the respite unit have their own staff team. Old Hall and The Courtyard share night staff. Two waking and 1 sleeping-in staff are provided. There is also a senior member of staff on-call. The records made by night staff were seen and a discussion with staff who perform night time duties took place. In general, the staff reported the staffing levels to be sufficient. A discussion with the manager indicated that the staffing levels are kept under review and additional staff would be made available if required. There is a core staff team employed at the units. Bank staff are used to cover absences. Bank staff have been recruited to work for Wirral Autistic Society to Raby Hall DS0000018929.V271696.R01.S.doc Version 5.0 Page 20 cover absences in the homes if needed or to provide support within the day care service. A discussion with staff and records showed that bank staff who are familiar with the units and the needs of the service users are deployed. A comprehensive induction and foundation training programme is provided to staff. This includes training around how to support individuals with autism, communication, promoting dignity and health and safety training. Steps have been made to encourage bank staff to attend this training so as to ensure that they are appropriately trained should they need to be deployed. The induction and foundation training programmes have been developed in accordance with the National Training Organisation training targets. There was evidence that training is provided to meet the specific needs of service users. Observations indicated that staff are respectful and supportive of the service users. Raby Hall DS0000018929.V271696.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 and 39 The management arrangements could be improved to ensure that there are clearer lines of accountability. EVIDENCE: The registered manager is currently working towards NVQ at level 4 and this training is due to be completed in the very near future. He is an experienced manager who has developed his knowledge of autistic spectrum disorders through on going training and working with the service users over a number of years. The manager is registered with CSCI as the responsible person for Old Hall, the Respite Unit, The Lodge and The Courtyard but in effect only manages Old Hall. Another manager is currently managing the Respite Unit, The Lodge and The Courtyard. The staff spoken with, were not fully aware that the registered manager has overall responsibility for the services at Raby Hall. The registered manager raised the concern that he is currently responsible for four units whilst he only directly manages one. Both managers are of an equal status and the registered manager does not supervise the manager of the Raby Hall DS0000018929.V271696.R01.S.doc Version 5.0 Page 22 other services he is responsible for. The management arrangements at the home should be reviewed to ensure that there are clearer lines of accountability. Training around safe working practices such as manual handling, fire safety, infection control and first aid is made available to staff as part of their induction. There is a rolling programme of training opportunities provided and staff can access this when required. There are a range of policies and procedures available that promote safe working practices. Wirral Autistic Society has a health and safety advisor who is available to provide advice and who has responsibilty for promoting a safe environment within the homes. There was evidence of a safe environment being provided at the home. The water throughout the home is regulated to ensure it does not exceed 43 degrees centigrade. Records of thermometer temperature checks of hot water are undertaken. A risk assessment has taken place of the windows at the home and restrictors have been put in place. Risk assessments of the radiators have been undertaken. As a consequence radiator guards have been provided in some areas of the home. A sample of safety check records were inspected for the gas, electricity and fire drills and detection systems and were found to generally be in order. The records for the tests of emergency lighting could not be located. The records showed that fire safety training has not been provided to a number of staff in the last 6 months. The manager reported that the fire drill is an additional method of providing fire instruction to staff. The names of the staff that took part in the drills were not recorded. A record of who is involved in the fire drill needs to be documented as this provides evidence that staff have received fire safety training at intervals recommended by the fire service of every 6 months for day staff and every 3 months for night staff. Raby Hall DS0000018929.V271696.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 X 3 X Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 X X X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Raby Hall Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 2 X X X X 2 X DS0000018929.V271696.R01.S.doc Version 5.0 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 4, 5 Requirement The registered person must provide a statement of purpose and service user guide for the respite unit. The registered person must ensure that behaviour management plans reflect the actual support currently required by service users and provide clear information on the nature of the physical intervention staff are to use, if necessary, to support service users when administering medication to manage their behaviour. The registered person must ensure that where necessary, risk assessments detail the support staff are to provide to minimise risk of challenging behaviour toward other service users and staff in the home and when using transport. The registered person must document the risk assessment around the use of the doors that DS0000018929.V271696.R01.S.doc Timescale for action 17/01/06 2 YA9 15 17/12/05 3 YA9 15 17/12/05 4 YA24 12, 13 24/12/05 Raby Hall Version 5.0 Page 25 open in two sections. This must detail the circumstances in which these doors are used, risks to privacy and to physical wellbeing. Action is to be taken to address any risks identified. 5 YA24 13 The registered person must give attention to the gap in the hedging of the garden at The Lodge. This requires attention in order to promote the security of the home and to fully promote the well-being of service users from the risks presented by the main road. In the meantime a risk assessment is needed detailing how the welfare of service users is to be safeguarded. 24/12/05 6 YA42 23 The registered person must 17/12/05 ensure that the records for the tests of emergency lighting are available for inspection. The registered person must ensure that fire safety training is provided to day staff on a 6 monthly basis and night staff on a 3 monthly basis. 17/12/05 7 YA42 23 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 YA1 Good Practice Recommendations Consideration should be given to making the service user guide more suited to the needs of the service users who live at the home. Raby Hall DS0000018929.V271696.R01.S.doc Version 5.0 Page 26 2 YA1 The statement of purpose and service user guide for Old Hall should indicate that day care is provided in certain areas of the premises and any impact this has on residential service users. The sofas in the first floor lounge should be replaced with a more suitable alternative. The decoration in this room could be improved for the benefit of service users. It is recommended that the panelled lounge at Old Hall receive attention to make it more welcoming for service users. The management arrangements at the home should be reviewed to ensure that there are clearer lines of accountability. 3 YA24 4 YA24 5 YA37 Raby Hall DS0000018929.V271696.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Raby Hall DS0000018929.V271696.R01.S.doc Version 5.0 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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