CARE HOMES FOR OLDER PEOPLE
Riccall House 78 Main Street Riccall York North Yorkshire YO19 6QD Lead Inspector
Denise Rouse Unannounced Inspection 13th March 2006 10:50 X10015.doc Version 1.40 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 Riccall House DS0000007669.V283125.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 Older People. 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. Riccall House DS0000007669.V283125.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Riccall House Address 78 Main Street Riccall York North Yorkshire YO19 6QD 01757 248586 01757 248123 riccallhouse@aol.com 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) Mrs Gillian Mary Conroy Mr John Anthony Conroy Mrs Diane Moughan Care Home 18 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (18) of places Riccall House DS0000007669.V283125.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Service Users to include up to 18 (OP) and up to 18 (DE(E)) up to a maximum of 18 Service Users 1 named service user under the age of 65. This condition will cease when the named service user reaches 65 or leaves the home. 6th December 2005 Date of last inspection Brief Description of the Service: Riccall House is registered to provide personal and social care and accommodation for 18 older people who may have additional dementia care needs relating to their age. The home is located on the main street in the village of Riccall, four miles from the market town of Selby and eight miles from the City of York. The village is on a main bus route to both of these locations. The home consists of a two storey Georgian building with a newer, purpose built ground floor extension. Twelve of the fifteen bedrooms are for single accommodation. None of these have en-suite facilities. One of the three double rooms has an en-suite facility. The home has no passenger lift but has a stair lift. Riccall House DS0000007669.V283125.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The unannounced inspection took place over one hour thirty minutes, following a day’s preparation. A tour of the building was undertaken which included bedrooms, communal areas, and laundry and treatment room. A team leader and the administrator assisted with the inspection process. A feedback session was held at the end of the inspection with the team leader, administrator and regulatory inspector. What the service does well: What has improved since the last inspection?
The registered provider has undertaken an unannounced visit to the home, to check on the quality of service being provided. This visit was documented in a report and a copy was sent to the Commission of Social Care Inspection. This process should be maintained. Riccall House DS0000007669.V283125.R01.S.doc Version 5.1 Page 6 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. Riccall House DS0000007669.V283125.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Riccall House DS0000007669.V283125.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not inspected on this visit. EVIDENCE: Riccall House DS0000007669.V283125.R01.S.doc Version 5.1 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 7 9 10 Service users have an individual plan of care, however further review and reassessment was required for one service user in relation to new needs. EVIDENCE: Service users had an individualized plan of care. There was evidence available to ascertain that on the whole care profiles for service users were reviewed at least monthly. Service users were seen to be treated with respect by the staff. Service users privacy was maintained. Double rooms had screens provided within them. Staff were seen to address service users by their preferred names. One service users file was reviewed after a Regulation 37 form had been received by the Commission of Social Care Inspection relating to a fall that had been sustained. The care documentation had not been reviewed during February and new care plans and risk assessments had not been created as required. Also an incident had occurred relating to a new need, the service user had no care plan or risk assessment for this new need. This was pointed out to the team leader and administrator, who examined the documentation,
Riccall House DS0000007669.V283125.R01.S.doc Version 5.1 Page 10 and stated that this would be rectified immediately and be in place by the end of the day. Standard 9 was not fully inspected but it was noted that the study door was propped open and a sachet of movicol was left on the worktop. Service users could have easily gained access to this area and this was pointed out to the team leader who immediately rectified this situation. Riccall House DS0000007669.V283125.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not inspected on this visit. EVIDENCE: Riccall House DS0000007669.V283125.R01.S.doc Version 5.1 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not inspected on this visit. EVIDENCE: Riccall House DS0000007669.V283125.R01.S.doc Version 5.1 Page 13 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 26 The home was clean, pleasant and hygienic, however access to the laundry was possible by service users, and 2 walls required redecoration. EVIDENCE: The home was pleasant, clean and free from any malodour. Laundry facilities were sited away from the kitchen and food areas. Hand washing facilities were available throughout the home. The washing machine was suitable for sluicing and was of an industrial size. The laundry may be accessed by service users; the door was heavy and hard to open. Access must be restricted to staff only. Cleaning chemicals were stored within the laundry and service users may have been able to access these items if they had gained entry. Two of the laundry walls had plaster and paint peeling off them. The necessary repairs must be made to ensure that the laundry walls remain impermeable and can be easily cleaned to prevent possible cross contamination. Dust in the downstairs bathroom fan must be removed.
Riccall House DS0000007669.V283125.R01.S.doc Version 5.1 Page 14 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not inspected on this visit. EVIDENCE: Riccall House DS0000007669.V283125.R01.S.doc Version 5.1 Page 15 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 38 Service users safety was maintained, however sterident was accessible within one bathroom. EVIDENCE: Standard 38 was not fully inspected, however it was noted during the inspection that a tube of sterident had been left unattended in the downstairs bathroom. The team leader stated that this did not usually occur, and it was immediately removed. Access to the building was difficult; it took the inspector 5 minutes to gain entry. This was pointed out to the staff on duty at the time of the inspection. Service users safety was well maintained in regard to this. Riccall House DS0000007669.V283125.R01.S.doc Version 5.1 Page 16 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 X 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X 1 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 2 Riccall House DS0000007669.V283125.R01.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 (2) (a) (b) 13 (2) 23 (b) 13 (4) (a) Requirement Service users must have their care profiles, care plans and risk assessments updated at least monthly or as their need change Medications must be stored securely. Service users must not be able to gain access to the laundry. Laundry walls must be repaired to ensure they are impermeable and can be easily cleaned. Sterident must be stored securely. Dust from the downstairs bathroom fan must be removed. Timescale for action 13/03/06 2 3 OP9 OP26 13/03/06 30/03/06 4 OP38 13 (c) 13 (4) (a) 13/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Riccall House DS0000007669.V283125.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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