Inspection on 29/06/06 for Raby Hall

This inspection was carried out on 29th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 9 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 22/02/06

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 Key Unannounced Inspection 29th June 2006 10:45 Raby Hall DS0000018929.V292513.R01.S.doc Version 5.2 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.V292513.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V292513.R01.S.doc Version 5.2 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.V292513.R01.S.doc Version 5.2 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. The fees at the home range from £905 - £2074 per week. Raby Hall DS0000018929.V292513.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home did not know about the visit and took seven hours. The inspector spoke with the service users, manager and staff about the home. Files and other documents relating to the home were read. The inspector looked round the home. What the service does well: What has improved since the last inspection? What they could do better: Raby Hall DS0000018929.V292513.R01.S.doc Version 5.2 Page 6 The home could greatly improve communication with service users and ensure that communication aids are made available to service users to assist with the decision making process, this would also, assist the inspector to communicate effectively with the service users and ascertain their views. Service users should be consulted about the running of the home and have opportunities to make major life decisions as well as everyday choices. Risk assessments should be written clearly and identify exactly what staff should do in certain circumstances. The behaviour management plan for service users should be clear about the exact physical intervention strategy to use and the instructions to staff must be clear. Only staff that are trained in current physical intervention should work with the service users who require it. The physical intervention is safe and does not place the service user at risk. There should be a risk assessment around the use of the doors that open in two sections. There should be hot water in service users’ bedrooms and toilets. Staff should receive formal supervision at least six times a year and this should be recorded. 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.V292513.R01.S.doc Version 5.2 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.V292513.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose is adequate and provides sufficient information for prospective service users and their representatives to be clear about the services the home provides to meet their needs. EVIDENCE: All four homes had a Statement of Purpose and Service User Guide. The Statement of Purpose in the Old Hall now indicates that day care is provided in certain areas of the premises. 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, were read. These assessments are comprehensive 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 service user where they are living. Information is gathered from the service users’ carers, social worker and any other relevant agencies. An Raby Hall DS0000018929.V292513.R01.S.doc Version 5.2 Page 9 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.V292513.R01.S.doc Version 5.2 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): 6,7,8,9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is a clear care planning system in place to adequately provide staff with the information they need to satisfactorily meet service users’ care needs. Service users have limited involvement in making decisions, choices and are not consulted in the running of the home. This leaves service users without the information, assistance and communication support they need to make decisions about their own lives. Some reactive strategies and risk assessments used with the service users are not clear and do not protect the service users from harm. EVIDENCE: The service user plans examined 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 Raby Hall DS0000018929.V292513.R01.S.doc Version 5.2 Page 11 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 document should be included all service users files and be expanded upon. There was limited evidence that service users make choices with assistance. The lack of communication aids such as storyboards and pictorial information leaves the service users without adequate information to make choices and make decisions about their own lives. The home does not use an independent advocacy service that could also help with informed decision making. The service users spoken with said that they enjoyed living at the home and identified staff they enjoyed working with. The home does not have residents meetings or consult with service users in changes to the statement of purpose, or involve them in staff meetings. Policies and procedures are not presented in a suitable format for service users. This means that service users are denied opportunities to make major life decisions as well as everyday choices. 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. The risk assessments were not extensive and could leave the service user at risk of harm. 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. Raby Hall DS0000018929.V292513.R01.S.doc Version 5.2 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 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 according to their assessed requirement. However, 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. The staff team give encouragement and support within a risk management framework. Service users have the opportunity to demonstrate individual preferences for a range of activities within day services subject to Raby Hall DS0000018929.V292513.R01.S.doc Version 5.2 Page 13 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, some service users visit local shops, go to the gym, cinema, bowling and participate in community life through attendance at college courses. 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 homes 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.V292513.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal support is offered in such a way as to promote and protect service users’ privacy and independence. Service users’ individual health, personal and social care needs are clearly recorded. This provides care staff with the information they need to meet the service users care needs. 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. There was evidence of health care professionals being visited and social workers visiting service users. Some staff are now trained to cut toe nails and some service users visit the podiatrist. . Raby Hall DS0000018929.V292513.R01.S.doc Version 5.2 Page 15 Medication of Raby Hall is stored centrally in a locked cabinet. Home remedies are provided and a separate sheet is completed, it would be beneficial if a record of the stock of home remedies were kept. At some homes service users self medicate and this has been risk assessed. The staff are trained to administer medication and this is done with two staff. Raby Hall DS0000018929.V292513.R01.S.doc Version 5.2 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): 22,23 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The staff team have a 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: The home has a complaints procedure and CSCI has not received any complaints since the last inspection. A copy of Wirral Borough Council’s adult protection procedure was available at the 4 homes. 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. Some staff are trained in behaviour management strategies such as supportive holds and breakaway techniques; the trainer is accredited with the British Institute of Learning Disabilities (BILD). The home still uses some old techniques as well as the new supportive holds and some of the old holds were not safe, placing both service users and staff at risk of injury. The home should be clear that only staff who are trained in the new technique work with the Raby Hall DS0000018929.V292513.R01.S.doc Version 5.2 Page 17 service users who are subject to this form of physical intervention. The use of two methods of physical intervention could be confusing for the staff team, leaving them at risk of harm as well as service users. The reactive strategies are not written clearly and pose a risk to service users. One service users was subject to a physical intervention technique that was potentially dangerous and this technique should be discussed with the accredited trainer and involve other professionals to ensure that it is safe. The reactive strategies should be very clear and detailed. Raby Hall DS0000018929.V292513.R01.S.doc Version 5.2 Page 18 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 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 hall consists of four homes, 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. The Old Hall is also used for day services and some service users attend who do not live at Raby Hall. It was a very noisy and chaotic environment. The home are hoping to move the majority of the day service to another building. The bedrooms were seen at the home and these are furnished and personalised, in accordance with the service users’ preferences, needs and risk assessments. In one of the flats in the Old Hall, some of the hand wash basins in the bedrooms did not have hot water, the home should ensure that the Raby Hall DS0000018929.V292513.R01.S.doc Version 5.2 Page 19 water piped to these bedrooms is hot enough to wash. This was also evident in one of the toilets. A door used at Old Hall opens in two sections, this door is not domestic in appearance. A risk assessment around the use of this door needs to be made available. This needs to cover the circumstances in which this door is 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. This remains outstanding from the last inspection. The gap in the hedges has now been fixed. 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.V292513.R01.S.doc Version 5.2 Page 20 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): 32,33,34,35,36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The recruitment practices are adequate and appropriate checks are carried out. The arrangements for the induction of staff are good with the staff demonstrating a clear understanding of their roles. The lack of supervision leaves the staff without appropriate direction. EVIDENCE: The staff team spoken with were able to demonstrate a good understanding of the autistic spectrum disorder and all commented about how much they enjoyed their job. Staff were observed interacting positively with service users. They said that the manager was supportive and would listen to any concerns raised. The majority of staff have completed the NVQ 2 or NVQ 3. The rotas indicated that there were sufficient staff team to support service users needs. Each home has regular staff meetings that are recorded. 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. Raby Hall DS0000018929.V292513.R01.S.doc Version 5.2 Page 21 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. However, staff do not receive five paid training days a year. The records indicated that staff have received training in autistic spectrum disorder, but in some cases this was several years ago. There was a discussion with the manager and the trainer about ensuring that the staff team are kept up to date with any developments autistic spectrum disorder. 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. The manager said that they found it very difficult to supervise staff at least six times a year. The records showed that staff have received some supervision but not six a year. The manager should raise this issue with the responsible person to ensure that the staff team are appropriately formally supervised, to ensure that they can monitor the work of staff with individual service users and provide support and professional guidance. Raby Hall DS0000018929.V292513.R01.S.doc Version 5.2 Page 22 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management arrangements could be improved to ensure that there are clearer lines of accountability. The record of self-review by the registered provider provides the home with adequate quality assurance. EVIDENCE: The manager has worked at the home for several years and has experience of working with people with autistic spectrum disorder, they has a management qualification. The manager is registered with CSCI 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. This been documented in past Raby Hall DS0000018929.V292513.R01.S.doc Version 5.2 Page 23 inspections and the registered manager said that this has been discussed with their manager. The responsible individual has nominated someone to visit the hall on a monthly basis and self monitor, there is evidence this is done as CSCI has received copies of the report. 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. A sample of safety check records were examined for the gas, electricity and fire drills and detection systems and were found to be in order. Raby Hall DS0000018929.V292513.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 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 3 23 2 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 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 2 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 3 3 X 3 X 3 X X 3 X Raby Hall DS0000018929.V292513.R01.S.doc Version 5.2 Page 25 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 YA7 Regulation 12 Requirement The registered person must ensure that communication aids are made available to service users to assist with the decision making process. The registered person must ensure that service users are consulted about the running of the home and have opportunities to make major life decisions as well as everyday choices. Timescale for action 27/07/06 2. YA8 12 27/07/06 2. YA9 13 The registered person must 27/07/06 ensure that the risk assessments are written clearly and identify exactly what staff should do in certain circumstances.(This requirement remains outstanding 22/02/06). 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 only staff that are trained in current physical DS0000018929.V292513.R01.S.doc 3. YA9 13 27/07/06 4. YA23 13 27/07/06 Raby Hall Version 5.2 Page 26 intervention work with the service users who require it. 5. YA23 13 The registered person must ensure that the physical intervention is safe and does not place the service user at risk. 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 ensure there is hot water in service users bedrooms and toilets. The registered person must ensure that staff are appropriately formally supervised and that this is recorded. 27/07/06 6. YA24 12,13 27/07/06 7. YA26 12 24/08/06 8. YA36 18 24/08/06 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 service users have access to an independent advocacy service. DS0000018929.V292513.R01.S.doc Version 5.2 Page 27 2. 3. YA7 YA7 Raby Hall 4. 5. YA20 YA35 A locked cabinet should be made available in each of the flats in Raby Hall, for service users medication. It is recommended that all staff receive at least 5 paid training and development days (pro rata) per year. Raby Hall DS0000018929.V292513.R01.S.doc Version 5.2 Page 28 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.V292513.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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