Inspection on 28/11/05 for Rivacre House

This inspection was carried out on 28th November 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Rivacre House 28/11/08

Rivacre House 14/08/06

Rivacre House 26/04/05

Rivacre House 18/11/04

Rivacre House 10/06/04

Rivacre House 13/01/04

Similar services:

Sunny Bank (P.R.S.) Ltd

Ashwood Court Unit 1

Thornton Lodge

Griffin Lodge

Pathways North West

Grove Lodge Care Home

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

CARE HOME ADULTS 18-65 Rivacre House 47a Seymour Drive Ellesmere Port South Wirral Cheshire CH66 1LZ Lead Inspector Jayne Telfer Unannounced Inspection 28th November 2005 10:00 Rivacre House DS0000006670.V268244.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Rivacre House DS0000006670.V268244.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Rivacre House DS0000006670.V268244.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Rivacre House Address 47a Seymour Drive Ellesmere Port South Wirral Cheshire CH66 1LZ 0151 356 9299 0151 355 2693 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) Making Space Care Home 12 Category(ies) of Learning disability (1), Mental disorder, registration, with number excluding learning disability or dementia (9), of places Mental Disorder, excluding learning disability or dementia - over 65 years of age (3) Rivacre House DS0000006670.V268244.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Maximum number of 12 people with mental disorder (MD) to be accommodated Within the maximum of 12 service users, no more than 3 people aged over the age of 65 may be accommodated Within the maximum of 12 service users, 1 named person with a learning disability can be accommodated 26th April 2005 Date of last inspection Brief Description of the Service: Rivacre is a purpose-built care home for people who have mental health needs. Opened in 1992, it is run by the charity Making Space. The home is a twostorey building is located within a mile of Ellesmere Port town centre, and is in close proximity to a range of local shops and other facilities including a bus route and a railway station. Accommodation for service users comprises 12 single bedrooms located on both the ground and first floor. There is a large lounge/dining area and separate conservatory on the ground floor, and a training kitchen/small lounge area on the first-floor. This service seeks to provide support and care to service users over a medium-to-long-term period and a number of former service users have moved on successfully to independent (or semi-independent) living in the community. Service users are encouraged to participate fully in the formulation and subsequent reviews of their individual care plans, as well as in the running of the home, generally; they are also supported by staff to make use of community facilities and amenities for shopping, recreation, education and healthcare. Rivacre House DS0000006670.V268244.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over 4.5 hours on the 28th November 2005. 5 residents and 3 members of staff were spoken with. Standards which were not assessed during the last inspection were looked at. A tour of the Home was undertaken, 3 care plans read and a range of policies and procedures examined. Staff and residents were both observed and spoken with. Since the last inspection a deputy manager has been acting up as Manager and the post has now been advertised. There have been no new admissions to Rivacre since early 2003. What the service does well: What has improved since the last inspection? Rivacre House DS0000006670.V268244.R01.S.doc Version 5.0 Page 6 The Home has increased its focus on rehabilitation, with residents having opportunities to shop, budget, cook and participate in the household chore rota. The vacant posts in the home are being filled, and the Manager vacancy has been advertised. 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. Rivacre House DS0000006670.V268244.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rivacre House DS0000006670.V268244.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 5 Rivacre has appropriate information available for prospective residents. Each resident has clearly written, user-friendly agreements with the home, setting out the terms and conditions of residence. EVIDENCE: The Statement of Purpose and Service User Guide were up to date, clearly displayed and contained appropriate information. All residents had a signed agreement with the Home and these were kept on their individual files. Rivacre House DS0000006670.V268244.R01.S.doc Version 5.0 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): The residents at Rivacre are supported to participate in all aspects of life in the Home and are consulted about the way the Home is run. Residents are aware that all personal information held by Rivacre is handled in an appropriate and confidential way. EVIDENCE: The Manager has a weekly rota for household chores, and residents are given jobs to do. Residents said that they discuss their jobs and other issues at the regular resident meeting. These meetings are clearly advertised in the hallway. Residents are able to access the kitchen to help themselves to food and drink as needed. Residents are supported by staff to launder their own clothes, and this was observed. The Manager has organised a regular visit from an advocate and residents said that they were able to see her in private. Residents knew where and what information was kept about them and also said that they were able to talk to the staff in private whenever they wanted to. Staff had a good understanding of confidentiality, including when to break confidences if they thought a resident was at risk. The policy in the Home Was clear, although it did need to state incidents when confidentiality could be broken. Rivacre House DS0000006670.V268244.R01.S.doc Version 5.0 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): 11, 14, 15 A good variety of leisure and social activities are well managed at Rivacre. Personal and family relationships were encouraged and maintained appropriately. The Home provides a rehabilitation programme to the residents within their individual care plan. EVIDENCE: Leisure activities were both organised in terms of group outings and on an individual basis, such as ‘going swimming and to aerobics’. Residents said that they had plenty to do and there was a lot of information available regarding activities in the community. The Home is organising a Garden Fete to raise money for social events. Relatives of residents have contributed and offered to participate in this event. Residents said that they were able to invite friends and family to the Home whenever they wanted. Staff assisted by driving residents to visit relatives and friends. One resident is supported by staff to visit his sister regularly and this has a positive impact on his mental health. Although no residents spoken with were engaged in intimate relationships, one regularly sees an ex-partner. Rivacre House DS0000006670.V268244.R01.S.doc Version 5.0 Page 11 The Home provides a basic rehabilitation programme on an individual basis, this includes a household chore rota, going shopping, laundry, budgeting and cookery. The Manager said that the ultimate aim was to increase individual independence. Rivacre House DS0000006670.V268244.R01.S.doc Version 5.0 Page 12 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): These standards were not inspected at this time. EVIDENCE: Rivacre House DS0000006670.V268244.R01.S.doc Version 5.0 Page 13 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 Residents views are listened to and they are fully aware of the complaint procedure. Systems are in place to protect residents from abuse neglect and self-harm. EVIDENCE: Rivacre has a clearly written, user-friendly complaints procedure which residents are aware of and make use of. Residents also make use of the Manager’s ‘open door’ policy and said that they could ‘speak with Glynn’ if they had any concerns and were confident that any problems would be ‘sorted out’. The Complaint procedure needs to include a time scale for response. Staff have a clear knowledge of the procedures to be followed with regard to allegations of abuse. The local authority procedures were clearly displayed in the Home, ensuring that the procedures are accessible. Rivacre’s procedures need to include the local authority procedures, giving detailed actions to be taken should abuse be alleged or suspected. Rivacre House DS0000006670.V268244.R01.S.doc Version 5.0 Page 14 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): 28 Shared spaces are fully accessible, safe and provide residents with space, both for shared activities and private use. EVIDENCE: Rivacre has a good range of shared space which are accessed by residents. A small lounge with television and kitchen facilities is on the first floor. A large lounge/dining area is on the ground floor, as is a conservatory, which is used as a smoking area. The kitchen is accessed by residents via the lounge and a large serving hatch opens onto the dining area, making food preparation and meal times an open and shared activity. These spaces were clean and well maintained and residents were observed to make use of the areas. Rivacre House DS0000006670.V268244.R01.S.doc Version 5.0 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, 36 Rivacre has a thorough recruitment procedure which ensures the protection and support of residents. Staff are well supported and supervised through both formal and informal discussions. EVIDENCE: Two members of staff were in the process of being recruited and all appropriate checks were being completed. Good practice was noted as residents were fully involved in the recruitment process. Residents take responsibility, in the recruitment procedure, for showing potential staff around, asking their own questions, sitting on the interview panel and taking part in the decision process. Both staff and residents were positive about the recruitment process. Agency staff were used at Rivacre. The Manager stated that only 5 individuals were used from agencies as these people had gone through the Home’s induction and in-house training. One Agency staff member was on duty and confirmed that he had attended training sessions. He was seen to interact well with residents. A formal supervision procedure was in place at Rivacre, with meetings taking place every 6 weeks. Notes were kept on these sessions and these were linked to the appraisal process and to training. This meant that staff had the opportunity to develop, discuss concerns and learning needs, so benefiting Rivacre House DS0000006670.V268244.R01.S.doc Version 5.0 Page 16 residents who have access to a contented, motivated and developing staff team. The recommendation from the last inspection that vacant posts be filled had been achieved. Rivacre House DS0000006670.V268244.R01.S.doc Version 5.0 Page 17 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): 39 Rivacre has extensive and appropriate quality assurance, review and development systems in place which are underpinned by the views of residents. EVIDENCE: Rivacre uses a formal quality assurance procedure, developed by the provider (Making Space). Questionnaires are sent to residents, relatives, staff and any other person involved with Rivacre or its residents. Information is collated by the Manager and any issues are addressed. An annual development plan is produced using this information. The Manager stated, and it was observed that the response to the questionnaire was usually poor. It is recommended that other methods of gathering information are explored. In addition, only negative issues are examined, and it is recommended that positive practice is also highlighted through the quality assurance process. Rivacre House DS0000006670.V268244.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X X X 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X 3 X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X 3 X X LIFESTYLES Standard No Score 11 3 12 X 13 X 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 4 X 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Rivacre House Score X X X X Standard No 37 38 39 40 41 42 43 Score X X 3 X X X X DS0000006670.V268244.R01.S.doc Version 5.0 Page 19 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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. Refer to Standard YA10 YA22 YA23 YA39 YA39 Good Practice Recommendations It is recommended that the confidentiality policy should include incidents when confidentiality could be broken. It is recommended that the complaint procedure include timescales for responses. The Procedures for protecting vulnerable adults should include that local authority procedures. The Manager should explore other ways of information gathering for the quality assurance procedure. The Quality Assurance procedure should highlight positive practice as well as issues of concern. Rivacre House DS0000006670.V268244.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 Rivacre House DS0000006670.V268244.R01.S.doc Version 5.0 Page 21 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!