This inspection was carried out on 6th March 2006.
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 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.
CARE HOME ADULTS 18-65
Ribble Valley Respite Service 12 Croasdale Drive Off Mayfield Drive Clitheroe Lancs BB7 1LQ Lead Inspector
Mrs Jennifer M Turner Unannounced Inspection 6th March 2006 09:00 Ribble Valley Respite Service DS0000040803.V264197.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 Ribble Valley Respite Service DS0000040803.V264197.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. Ribble Valley Respite Service DS0000040803.V264197.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Ribble Valley Respite Service Address 12 Croasdale Drive Off Mayfield Drive Clitheroe Lancs BB7 1LQ 01200 424394 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) Dianne.blackie@SSD.LancsCC.gov.uk Lancashire County Council Mrs Dianne Blackie Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Ribble Valley Respite Service DS0000040803.V264197.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. A maximum of 6 service users, requiring personal care who fall into the category of LD The registered provider must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 9th November 2005 Date of last inspection Brief Description of the Service: Croasdale Drive is situated within a residential area of Clitheroe about ten minutes walk from the town centre. There are local services and shops within easy reach of the home and access to public transport. The home is a two storey domestic property with six single bedrooms, a communal lounge and dining kitchen. A ramped area enables residents to access the garden and there is parking for several cars to the front of the house. There are two bathrooms and toilets. Ribble Valley Respite Service DS0000040803.V264197.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 6th March 2006. Information was obtained by talking with two members of staff, by examining a variety of records and walking around the home. Views were obtained from staff on a variety of topics and information was obtained by case tracking the four residents accommodated in the home the previous night. One resident spent time talking with the inspector and completed a residents comment card. Because there was no manager available the inspector had telephone contact with the District Service Manager. Views have been recorded collectively where the answers obtained were similar. Any specific or differing comments have been reported in the main body of the report. The inspector’s notes have been retained as evidence of the inspection. The inspector was informed at the inspection that the manager had resigned in January 2006. What the service does well:
The facility provides valuable and structured short term support, as part of a care package, to residents with a Learning Disability and their families. Staff induction training is carried out in line with the Skill for Care organisation. Staff rotas are adjusted to meet the needs of prospective residents. Residents continue to retain their social contacts during their period at the home. One resident commented, “a computer would be welcome for residents to play games or type on”. Ribble Valley Respite Service DS0000040803.V264197.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ribble Valley Respite Service DS0000040803.V264197.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 Ribble Valley Respite Service DS0000040803.V264197.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): NMS 1 and 2 were assessed at the previous inspection. There were no requirements or recommendations made. EVIDENCE: Ribble Valley Respite Service DS0000040803.V264197.R01.S.doc Version 5.1 Page 9 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): NMS 6:7:9 were assessed at the previous inspection. There were no requirements or recommendations made. EVIDENCE: Ribble Valley Respite Service DS0000040803.V264197.R01.S.doc Version 5.1 Page 10 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): NMS 12:13:15:16:17 were assessed at the previous inspection. There were no requirements or recommendations made. EVIDENCE: Ribble Valley Respite Service DS0000040803.V264197.R01.S.doc Version 5.1 Page 11 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): 20 Medication practices ensured protection for both staff and residents. EVIDENCE: From case files examined, medication administered had been appropriately recorded. At the time of the inspection no residents self medicated. Certificates indicated that some staff responsible for medication had carried out appropriate accredited training. Other staff were awaiting an appropriate course. Ribble Valley Respite Service DS0000040803.V264197.R01.S.doc Version 5.1 Page 12 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 A clear Complaints policy was available although it did not make reference to the Commission for Social Care Inspection. There was a robust policy relating to the Protection of Vulnerable Adults. EVIDENCE: There was a complaints procedure that was a corporate document. This procedure was also evident in the Statement of Purpose. The procedure was also available on a Video and DVD format. Lancashire County Council had compiled a corporate leaflet in 2002 titled “We care about what you think of us”. This contained a complaints process but it required to be reviewed, as there was no reference to the Commission for Social Care Inspection. A complaints book that dealt with minor issues on a day-to-day basis was viewed. Written comments made by relatives indicated that they were aware of the complaints procedure. Various letters of thanks to the staff were seen on the notice board. A robust adult protection procedure had been developed, which included the Lancashire County Council’s “No Secrets” documentation. There was also a Whistle Blowing policy with a credit card type addition that contained useful numbers. Staff spoken with had received “Protection of Vulnerable Adults” training. Some members of staff were awaiting places in respect of this training. Allegations of abuse would be recorded and staff spoken with were aware of their obligations to inform relevant bodies. Ribble Valley Respite Service DS0000040803.V264197.R01.S.doc Version 5.1 Page 13 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;26:30 Some environmental issues still need to be addressed to ensure safe and homely surroundings for residents. EVIDENCE: The premises are in keeping with the local community. The Lancashire County Council Property Group is responsible for the upkeep of the premises and repair documentation was kept in a “maintenance” file. Contractors were addressing the dampness in the downstairs extension bedroom. Lockable facilities were still required in residents’ bedrooms. Room audits had been carried out to identify the facilities available in residents’ rooms. Bedrooms did not have wash hand basins installed. There was evidence that residents brought personal items with them during their stay. Because of the amount of electrical equipment that residents can bring into the home with them it is recommended that a minimum of two double electric sockets are supplied in each bedroom. Suitable bedroom door locks had been fitted and radiators were suitably covered. Aerial tracking was fitted into one downstairs bedroom. Ribble Valley Respite Service DS0000040803.V264197.R01.S.doc Version 5.1 Page 14 At the time of the inspection it was observed that the home was clean and hygienic. There were no offensive odours. The sluice had been resited. Ribble Valley Respite Service DS0000040803.V264197.R01.S.doc Version 5.1 Page 15 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): 34;35 Staff records were not examined as they were locked away. A variety of training opportunities were continually available to staff. This ensures a competent workforce. EVIDENCE: Staff files were locked away and could not be accessed. Staff explained the recruitment process. The inspector spoke by telephone to one of the service managers who explained the recruiting procedure. Criminal Record Bureau information was retained centrally. Staff indicated that their training needs were identified during their supervision session. Records showed that a variety of training was offered. Staff indicated that the department’s induction training was carried out in line with the requirements of the Skills for Care organisation and the Learning Disability Award Framework. Staff confirmed that they received support from Community Nurses. Ribble Valley Respite Service DS0000040803.V264197.R01.S.doc Version 5.1 Page 16 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 needs of the residents were identified through various quality assurance methods. The authority produces corporate documents. These should be written for, and relevant to, the individual home. This would ensure that staff had access to documentation relevant to the home. EVIDENCE: Due to restructuring within the department, the inspector was informed that the registered manager had moved from the home. Written confirmation was received following the inspection. Arrangements are in place to recruit another manager. Staff said that they had access to the policies, procedures and codes of practice. There was an annual Development Plan for the home in the form of a Service Performance Plan. Staff that the line manager visited the home monthly and carried out a quality audit. According to the homes Service History the CSCI was not always informed of this visit under Regulation 26 (5)(a). Staff at the home attended an advisory forum group where quality issues were discussed. Feedback about the service provided was sought from
Ribble Valley Respite Service DS0000040803.V264197.R01.S.doc Version 5.1 Page 17 residents and their families at focus group meetings. The results of these were available. Staff at the home attended meetings at the day centre and feedback on quality issues was sought from stakeholders. Corporate documents were in place. Documentation showed that health and safety policies had not been reviewed since 2003. Some policies referred to the home. Many of the aspects covering the health, safety and welfare of residents and staff were covered by the use of staff training and procedures. There was information regarding infection control. Environmental risk assessments were carried out and individual risk assessments were carried out for the residents. Other documentation seen satisfied the requirements of the Commission for Social Care Inspection. Due to a new method of recording accidents, the inspector was not able to carry out an audit trail of accidents that had occurred since the previous inspection. Ribble Valley Respite Service DS0000040803.V264197.R01.S.doc Version 5.1 Page 18 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 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X 2 X 2 X X 2 X Ribble Valley Respite Service DS0000040803.V264197.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 1 YA23 18 (1) (c) The registered person must 30/06/06 ensure that all staff receive training in respect of the Protection of Vulnerable Adults. 2 YA37 8.9.10 The registered provider shall 30/06/06 appoint an individual to manage the care home. 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 2 3 4 5 6 7 Refer to Standard YA20 YA22 YA24 YA24 YA26 YA34 YA39 Good Practice Recommendations Staff should continue to complete accredited training in relation to the administration of medication. The registered person should ensure that all documentation available to residents and their families contains up to date information. The dampness in the downstairs extension bedroom should continue to be addressed. Lockable facilities should be provided in residents’ bedrooms. A minimum of two double electric sockets should be supplied in each bedroom. Although staff records are retained in the home arrangements should be in place for them to be made available for inspection. The registered person must ensure that copies of the visits
DS0000040803.V264197.R01.S.doc Version 5.1 Page 20 Ribble Valley Respite Service 8 YA42 carried out under Regulation 26 are forwarded to the CSCI on a monthly basis. A central accident record, stating the date and initials of the resident concerned, should be maintained in order for accidents to be monitored. This would remain Data Protection compliant. Ribble Valley Respite Service DS0000040803.V264197.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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