Inspection on 22/02/06 for Raby Hall

This inspection was carried out on 22nd February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 14 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 10/12/05

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 Lynn Sharples Unannounced Inspection 22nd February 2006 09:00 Raby Hall DS0000018929.V284135.R01.S.doc Version 5.1 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.V284135.R01.S.doc Version 5.1 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.V284135.R01.S.doc Version 5.1 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.V284135.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th December 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.V284135.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The organisation did not know about the visit it lasted eight hours. The inspector spent time in the office examining records and policies and procedures. Service users, the team leader 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: The risk assessments should be looked at to ensure that the service users are safe. The physical intervention techniques need revising to ensure that service users and staff are safe. There should be a record kept of the stock of paracetamols. Staff should not be given paracetamols from the stock. The risk assessments around the environment must ensure the safety and well being of the service users. Staff must receive formal supervision which should be at least six times a year and this should be recorded. The safe working practices for service users and staff must be recorded. Raby Hall DS0000018929.V284135.R01.S.doc Version 5.1 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.V284135.R01.S.doc Version 5.1 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.V284135.R01.S.doc Version 5.1 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): 1,2,4,5 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 statement of purpose and service user guide is 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 could not be found. 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. The service user guide could be presented in a format that would be understood by the service users. 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.V284135.R01.S.doc Version 5.1 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. In the service user files sampled all contained a statement of terms and conditions with the home. Raby Hall DS0000018929.V284135.R01.S.doc Version 5.1 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): 6,7,9 There is a clear care planning system in place to adequately provide staff with the information they need to satisfactorily meet service users needs. The risk assessments are not clear and could place service users at risk of harm. 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. In some of the files there was a decision making form, this included information about self administration of medication, managing own finances, going out on your own, staying in without staff, bring allowed to cook without staff, choosing who I want to come to my reviews, having my own set of keys. The service user, staff member and parent/guardian sign this document. This Raby Hall DS0000018929.V284135.R01.S.doc Version 5.1 Page 11 document should be included all service users files and be expanded upon. There was limited evidence that service users make choices with assistance. This was discussed with the member of staff on duty. 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. Some risk assessments did not clearly identify exactly what staff should do in certain circumstances. Some guidelines were not dated and it could not be found if these had been reviewed. 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 completed. Some of the behaviour management plans for service users are not clear about the nature of the physical intervention used. The incident forms completed were not clear about how staff intervened with service users and the consequence to the behaviour with one service user was punitive. One behaviour management plan was not clear about the instructions to staff and could be misinterpreted. This was discussed with the team leader. Raby Hall DS0000018929.V284135.R01.S.doc Version 5.1 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): 12,13,14,15,16,17 Links with the community are good and support and enrich service users’ social and educational opportunities. The daily routines ensure that the preferences of service users are provided for. Dietary needs of service users are well catered for with a balanced and varied selection of food available. Service users have limited choice over what they eat. 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 Raby Hall DS0000018929.V284135.R01.S.doc Version 5.1 Page 13 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 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. The daily diaries of some service users were inspected, there were some gaps were staff had not written in them and some of the language used was not appropriate, this was discussed with the team leader who agreed and said that these issues would be addressed. Where possible service users maintain contact with their families and this was evidence in the personal files. If appropriate the service user can see their family in the privacy of their own room or left in private in a lounge. The menus in the four units were examined and found to be nutritious, the inspector discussed offering choices of evening meals using communication aids, to improve choice making. This would be greatly improved if the flats in Raby Hall and the Respite Unit had appropriate cooking facilities. Raby Hall DS0000018929.V284135.R01.S.doc Version 5.1 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): 18,19,20 Personal support is offered in such a way as to promote and protect service users’ privacy and independence. The health needs of some of the service users are not met. The systems for the administration of medication could be improved. 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. Some of the records examined indicated that service users were not accessing all the health appointments, some service users had not been to the dentist or opticians for over twelve months and no reason for this was recorded. One service user was taking medication that meant that a dentist, due to a possible side effect being overgrowth of the gums, should see him. There was evidence of social workers visiting service users. The staff cut the service users toenails and are not Raby Hall DS0000018929.V284135.R01.S.doc Version 5.1 Page 15 trained to do so, this practice must cease and the organisation should either train the staff or seek alternative arrangements. Medication of Raby Hall is stored centrally in a locked cabinet, the inspector discussed with the team leader having the medication stored in a locked cabinet each of the flats, they agreed this would be easier. Home remedies are provided and a separate sheet is completed, the team leader explained that if a service user were receiving a lot of the same home remedy they would seek advice from the GP. There is a stock of paracetamols used for PRN, there is no record of how many tablets have been dispensed a stock book should be started. There is also a record of staff who are given paracetamols for their own use, this practice should stop. At the Lodge, some service users self medicate and this has been risk assessed, examination of the records, did not indicate that a service user was visiting relatives and that was why there was no medication in the cabinet. The staff are trained to administer medication and this is done with two staff, however, there have been some instances were medication has been administered wrongly. The inspector discussed with the team leader ensuring that this is improved upon and talking with the Wirral Autistic trainer. Raby Hall DS0000018929.V284135.R01.S.doc Version 5.1 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 Staff have good knowledge and understanding of Adult Protection issues, which protects service users from abuse. Arrangements for using physical intervention with service users are not satisfactory placing them at possible risk of harm. 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. Staff are trained in behaviour management strategies such as supportive holds and breakaway techniques as part of their induction. The trainer is not accredited with the British Institute of Learning Disabilities (BILD) and some of the holds were not safe, placing both service users and staff at risk of injury. From next month a new trainer will be used who is an accredited trainer with BILD. The inspector discussed not using some of the old techniques and to discuss with the trainer alternative arrangements as a matter of urgency. The inspector also discussed regularly practising the physical intervention techniques to ensure that the staff had up to date knowledge of the techniques. Raby Hall DS0000018929.V284135.R01.S.doc Version 5.1 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): 24,25,26,30 The home provides a comfortable environment for service users. Attention is required to some issues 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. Samples of bedrooms were seen at the units. Bedrooms are furnished and personalised, in accordance with the service users’ preferences, needs and risk assessments. In one bedroom a man had a duvet cover that was not age appropriate and it was not his choice. The team leader agreed with this and said they will speak with the staff team. 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 Raby Hall DS0000018929.V284135.R01.S.doc Version 5.1 Page 18 presented, for example, risk of trapping fingers and the risk that privacy may not be fully promoted by the use of these doors. This remains outstanding from the last inspection. 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 a risk assessment is needed detailing how the welfare of service users is to be safeguarded. This remains outstanding from the last inspection. A tour of the home showed that the home was clean. The staff spoken with indicated that it was sometimes difficult to attend to service users morning routines and then clean each of the flats. The flats would benefit from more domestic assistance, instead of relying on care staff to complete these tasks. Raby Hall DS0000018929.V284135.R01.S.doc Version 5.1 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): 32,34,35,36 The arrangements for the induction and on going training of staff are good with the staff demonstrating a clear understanding of their roles. The recruitment practices are adequate and appropriate checks are carried out. The lack of supervision leaves the staff without appropriate direction. EVIDENCE: Wirral Autistic Society has a staff trainer and an NVQ trainer, an examination of the training record indicated that most staff have either an NVQ level 2 or level 3 or are completing the training. Observation of and discussion with the staff demonstrated that they interact appropriately with service users and have a good understanding of service users with autistic spectrum disorder. An examination of a sample of staff records indicated that all staff had two references, enhanced CRB checks, statements of terms and conditions on their personnel file. 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 Raby Hall DS0000018929.V284135.R01.S.doc Version 5.1 Page 20 the National Training Organisation training targets. There was evidence that training is provided to meet the specific needs of service users. There is training programme in place that includes: -health and safety, food hygiene, first aid, manual handling, fire awareness, drug administration, epilepsy, report writing, etc. The records of supervision were not available as the registered manager was not on site. However, the team leader supervises staff, it would be beneficial if they could have access to the relevant staff files as such they are not stored correctly. The team leader and the staff spoken with said that supervision was not regular. The team leader said that they were looking to address this. There are procedures in place for dealing with physical aggression towards staff and the staff spoken with said they felt supported by their line managers. The staff are offered de-briefing sessions if they are physically assaulted and this is adapted to suit each individual member of staff. Raby Hall DS0000018929.V284135.R01.S.doc Version 5.1 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): 37,39,42 The management arrangements could be improved to ensure that there are clearer lines of accountability. The lack of a record of self-review by the registered provider leaves the home without adequate quality assurance. EVIDENCE: 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. Both managers are of an equal status and the registered manager does not supervise the manager of the other services he is responsible for. The management arrangements at the home should be reviewed to ensure that there are clearer lines of accountability. The registered provider has nominated the head of residential services to visit monthly and record their findings. These could not be found and a copy of this should be made available to CSCI every month. The inspector discussed with Raby Hall DS0000018929.V284135.R01.S.doc Version 5.1 Page 22 the team leader having advocates for service users to provide feedback to the organisation, they said they would look into this. 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 responsibility 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 in some areas. 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.V284135.R01.S.doc Version 5.1 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 Standard No Score 1 2 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 1 ENVIRONMENT Standard No Score 24 2 25 3 26 2 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 X X 2 X Raby Hall DS0000018929.V284135.R01.S.doc Version 5.1 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 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 the risk assessments are written clearly and identify exactly what staff should do in certain circumstances. The registered person must ensure that the behaviour management plan for service users are clear about the exact physical intervention strategy to use and the instructions to staff must be clear. The registered person must ensure that the service users have access to regular visits to the dentist and opticians. The registered person must ensure that the staff are trained to cut service users toenails or make alternative arrangements. The registered person must ensure that a record is kept of the stock of paracetamols. Staff should not be given paracetamols from the stock. DS0000018929.V284135.R01.S.doc Timescale for action 27/03/06 2 YA9 13 27/03/06 3 YA9 13 27/03/06 4 YA19 12 17/04/06 5 YA19 13 17/04/06 6 YA20 13 27/02/06 Raby Hall Version 5.1 Page 25 7 YA20 13 8 YA23 13 9 YA24 12,13 10 YA24 13 11 YA36 18 12 YA39 26 13 YA42 23 The registered person must ensure that staff record when service users are away overnight and that there medication is with them. The registered person must ensure that physical intervention training is BILD accredited. All physical intervention used should be safe. The registered person must document the risk assessment around the use of the doors that 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. (This requirement remains unmet timescale 24/12/05) 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. (This requirement remains unmet timescale 24/12/05). The registered person must ensure that staff receive formal supervision at least six times a year and that this is recorded The registered person must ensure that their monthly visits are recorded and a copy be made to CSCI. The registered person must ensure that the records for the tests of emergency lighting are available for inspection. (This DS0000018929.V284135.R01.S.doc 27/02/06 27/03/06 27/02/06 27/02/06 27/03/06 27/03/06 27/02/06 Raby Hall Version 5.1 Page 26 14 YA42 23 requirement remains unmet timescale 17/12/05). 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. (This requirement remains unmet timescale 17/12/05). 27/02/06 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. Records should indicate the choices made by each service users. It is recommended that staff practice the physical intervention techniques with appropriately qualified staff on a regular basis. A locked cabinet should be made available in each of the flats in Raby Hall, for service users medication. The organisation should consider the number of errors made in administering medication and provide further training. It is recommended that service users have age appropriate bedding. It is recommended that the organisation look into using advocacy services were appropriate to ensure that service users can provide independent feedback to the organisation. 2 3 4 5 6 7 YA7 YA9 YA20 YA20 YA26 YA39 Raby Hall DS0000018929.V284135.R01.S.doc Version 5.1 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. 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