CARE HOMES FOR OLDER PEOPLE
Rivelin Residential Care Home 17/21 Albert Road Cleethorpes North East Lincs DN35 8LX Lead Inspector
Theresa Bryson Unannounced Inspection 13th November 2007 09:15 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 Rivelin Residential Care Home DS0000002844.V354958.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 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. Rivelin Residential Care Home DS0000002844.V354958.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Rivelin Residential Care Home Address 17/21 Albert Road Cleethorpes North East Lincs DN35 8LX 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) 01472 692132 P/F01472 692132 J and LD Hayes Limited Vacant Care Home 42 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (42) of places Rivelin Residential Care Home DS0000002844.V354958.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home can accept specified service user CH under the age of 65 years and this will apply until they reach the age of 65 years or they terminate the contract with the home if prior to that date. 17th November 2006 Date of last inspection Brief Description of the Service: Rivelin Residential Care Home is situated in the centre of the attractive seaside town of Cleethorpes, close to all local amenities. These include a library, post office, local shops and the seafront promenade. Local buses provide frequent services to all areas of the town and also to Grimsby town. The home provides residential care for up to forty- two service users in the category of older people. The accommodation consists of four adjoining houses covering three floors and serviced by two passenger lifts. There are communal bathrooms, shower rooms and separate WC facilities situated on each of the three floors. The service users have the use of four lounges (one of which is a smoking room) and a large dining room, all of which are located on the ground floor. There is a small courtyard to the rear of the building and three small car parks. Parking is also available on the road. Weekly fees are: £329 reviewed annually. Additional charges are made for the following: toiletries, newspapers/magazines, hairdressing and chiropody. Information on the service is made available to prospective and current service users via the statement of purpose, service user guide and inspection report. Documents are made available prior to and following admission, copies are available on request. Rivelin Residential Care Home DS0000002844.V354958.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This site visit took place over one day in November 2007. Prior to this a number of surveys were sent out to relatives and staff and a large number returned. The service history was checked on CSCI records and some staff contacted by telephone who work for the local Social Services Department. The Company returned the completed AQAA form and also submitted copies of a number of documents during the course of the site visit. 13 staff were spoken to at the site visit, 10 people resident in the home and 2 relatives. Other documents and records were checked. The Acting Manager and Responsible Person for the Company were present throughout the site visit. What the service does well: What has improved since the last inspection?
Rivelin Residential Care Home DS0000002844.V354958.R01.S.doc Version 5.2 Page 6 The new Company, which had only taken over 5 months before this inspection and have started to make large improvements in the refurbishment and redecorated of the building. Most of the communal areas had been redecorated and new carpets purchased as well as most sitting rooms and the dining room. Easy chairs had been purchased for all lounges and some bedrooms had also been refurbished and decorated. This is ensuring that people are living in a more comfortable environment. Information for prospective service users had been revised and was on display in the form of the Statement of Purpose and Service Users’ Guide. This ensures people can make informed choices about moving into the home. The staffing levels with in the home had been reviewed and job allocations reviewed. This will ensure there are sufficient staff on duty to fulfil the needs of people at all times. Staff personal files had also been audited and evidence produced to ensure they are safe to work with the people in the home. All induction training had taken place using the new Company’s documentation and all staff asked to complete this process to enable the management team to have a good base line to work with for staff future training. This will enable staff to have the skills to enhance the delivery of care to people living in the home. All polices and procedures had been reviewed and the new Company format put into place. This will ensure staff have processes to work to and ensure the care they deliver is safe and the home is being maintained to a good standard for people’s safety. What they could do better:
The care plan documentation kept on each individual is very basic and needs to be expanded to ensure that all needs are recorded accurately and evidence is produced that care has been delivered. This must be evaluated regularly to ensure current needs are addressed and people are free from harm. This must also include the safe administration of medicines. Where changes occur there must be accurate recording and all items stored in a clean and tidy environment. Failure to do so could put people at risk from incorrect dosages being given and risk to health with dust particles in equipment used. The home offers some social activities and is beginning to make links with the local community to ensure the social, cultural and religious needs of individuals can be met. These events need expanding upon to ensure individual expectations can be met taking into consideration a person’ s medical history. The new Company has made great improvements in the environment for the people living in the home, but this now needs expanding upon to ensure regular maintenance takes place and a programme set out for continued
Rivelin Residential Care Home DS0000002844.V354958.R01.S.doc Version 5.2 Page 7 refurbishment. This will make for more comfortable accommodation for people in the home. The laundry area needs particular attention to enable staff to work in a better environment to be able to produce clean clothes and linen for the home. More attention to detail is also required in the kitchen area to ensure that meals are always prepared in a clean and safe environment. The new Acting Manager ( who still needs to be vetted by CSCI) has started a quality assurance system along with other members of the management team. This needs to be further expanded in to the Company full quality assurance programme and views sought particularly of users of the service. This will ensure the home is being run for the benefit of the people living there and is safe and secure to live in with staff safe to look after them. 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. The summary of this inspection report can be made available in other formats on request. Rivelin Residential Care Home DS0000002844.V354958.R01.S.doc Version 5.2 Page 8 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 Rivelin Residential Care Home DS0000002844.V354958.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 1,3 and 6. Comprehensive information is available to ensure prospective service users can make informed decision about using the home. EVIDENCE: Since the last inspection new owners have taken over the running of the home and they have brought their expertise in running other local establishments into the home. The Statement of Purpose and Service Users guide has been completely revised and copies were given to us at the site visit. This includes all relevant information to enable prospective service users to make informed choice as to if the home is suitable to meet their needs. Rivelin Residential Care Home DS0000002844.V354958.R01.S.doc Version 5.2 Page 10 A daily register and admissions register is also now in place and commenced in June 2007. This ensures that staff are aware of who is resident and assists the billing arrangements to individuals. The Company decided that the Acting Manager, who has the advantage of being a professionally trained nurse, would complete all pre-assessments on prospective service users. This ensures that the mix of people living in the home meets the categories the home is registered for and the home can feel confident in meeting their needs. In the absence of the Acting Manager other managers with in the group or the Responsible Person appointed by the Company will assist. The home uses a very comprehensive tool to assess each person and looks at them in a holistic manner. This ensures all needs and tastes and expectations can be identified. These were in place in all care plans tracked and appeared to be accurate when discussed with people living in the home and staff. The home does not provide intermediate care so Standard 6 is not applicable. Rivelin Residential Care Home DS0000002844.V354958.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 7,8,9 and 10. The care plans kept on people using the service need further expansion to ensure all needs are being identified and regularly evaluated to meet current needs. Drug administration policies should be checked to ensure safe practises are in use. EVIDENCE: Since the new owners took over approximately 5 months prior to this inspection a lot of work has been undertaken to ensure the actual delivery of care has been correct to people using the service. New practises have been implemented for daily working process and tasks identified for each department, which fits the job descriptions of staff more accurately. For example care staff now attend to all care needs of individuals
Rivelin Residential Care Home DS0000002844.V354958.R01.S.doc Version 5.2 Page 12 and domestic staff no longer make beds but have a more thorough cleaning regime for each room. Staff who were interviewed and on surveys returned stated they found this very hard at first but can now see that this works well for people living in the home and better suits their needs. For example there used to be a strict toileting regime for the home, which suited the practises of the home not individuals and this has been changed to meet individual needs and demands due to peoples medical conditions. The care plans seen have not yet been changed to the Company format excepting that staff are being encouraged to write more clearly, accurately and give more information. Training is currently in place to ensure that all staff are aware of how and why care plans should be in place and what to include. This will ensure that all needs identified are current and they are evaluated regularly to ensure staff can met individuals needs and people are free from harm. At the site visit 4 care plans were looked at in depth. Various supplementary forms were in use such as weight charts, nutritional records and key worker check lists. There was a lack of consistence in some areas of this work and further expansion is needed. The daily report sheet also needed to be expanded and give a more accurate reflection on the actual care delivered, which for some people is extensive, on a daily basis. This has not appeared to have hindered the actual care delivered to people. Service users spoken stated for example “they are very good to me” and “I put my finger on the bell and they come” and “girls will come even at 3am like last night to help me”. An unused room has now been taken over to store all medication and other equipment. It was in the process of being refurbished during the inspection. This has made a more secure and quiet area for staff to administer and check medication. The Acting Manager was currently reassessing all staff giving medication to ensure they are safe, 3 had completed outside longer courses. The room was very untidy and some equipment had been placed on the floor, which could cause a hazard with dust particles getting into such as nebulisers used to assist peoples breathing. Care must be taken to ensure that all medication is sorted at the correct temperature both in the room and drugs fridge, but no records could be produced to show this was taking place. Failure to do so could result in harming people, as medication would then be unsafe for use. The drug administration sheets were checked and some changes had been made with out the correct information being present. The person assisting the inspector appeared to know the reasons why for example medication had been
Rivelin Residential Care Home DS0000002844.V354958.R01.S.doc Version 5.2 Page 13 stopped but there was inconsistencies in recording methods. This could give an inaccurate picture of what medication is required for each person and could result in them being put at risk if in correct dosages were administered. Rivelin Residential Care Home DS0000002844.V354958.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 12,13,14 and 15. A variety of activities are on offer to suit meet most people’s expectations, but needs expanding in the future. Care must be taken that the varied menu is prepared in a clean environment. EVIDENCE: There was ample evidence in the home that people’s individual needs and tastes were provided for in their rooms. Several positive comments were made by people using the service and relatives such as “the room is fine” and “I know I can bring things in for mum and they will be looked after”. The Company has recently employed an activities organiser who, with other staff, has begun to make very positive changes in what is on offer to meet people’s social, cultural and religious needs. Rivelin Residential Care Home DS0000002844.V354958.R01.S.doc Version 5.2 Page 15 Social needs assessments have been completed on each person and these were seen in the files. The planner looks at these being reviewed 3-monthly unless other changes occur. Some variety is in place such as one to one work with those not wishing to join in group activities or are too ill to do so. Group events such as word games, quizzes, reminiscence and parties were documented as taken place. On checking the care plans, speaking to people using the service and relatives and on the surveys returned this programme would need expansion to meet people’s diverse needs. This should include more for those with memory loss and for those with other communication difficulties. Some people expressed wishes to “play more whist” and to “possibly attend some sporting events”. The kitchen has begun to have a big overall of how it performs and what it provides. This has been challenging for staff, but those spoken to stated they could see the benefits to people using the service. The menus have been changed and copies seen by us which show a good nutritionally balanced diet is on offer. People stated to us, “It’s lovely to get 3 meals a day” and “I get more than enough to eat”. The local environmental health offer had visited in October 2007 and left some requirements for the home to complete, all of which had been completed by the time of our visit. All equipment in the kitchen area was in working order but there was a lack of attention to detail in the cleanliness of the environment at the time of our inspection. Individual items were fed back to the management team to address at the site visit. The new cleaning rota will need to be monitored more closely to ensure food is always prepared in a clean environment and people are free from harm. It would aid the practical work if the records kept by the kitchen could be more organised to show that safety requirements are being met. Rivelin Residential Care Home DS0000002844.V354958.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 16 and 18. Robust systems are in place to ensure people are protected from harm and are confident their concerns will be dealt with in confidence. EVIDENCE: Since the last inspection 2 concerns were raised to CSCI about care within the home. One was past to the safe guarding adults team and after investigation both were unsubstantiated. These were both before the present owners took over the home. A new complaints policy is in place, although a couple of relatives were unaware of this, so the Company may need to reiterate where this can be found in case any one wishes to raise concerns. One complaint had been dealt with by the home and evidence was seen on the complaints log that this had been dealt with appropriately and all events recorded. People using the service, other relatives and staff stated they had every confidence that the present management team would deal with any concerns
Rivelin Residential Care Home DS0000002844.V354958.R01.S.doc Version 5.2 Page 17 promptly and in confidence. This fosters a very open and transparent management style where people are not concerned about raising issues. A more robust system is in place to ensure staff are trained to recognise where people can be harmed and know how to refer issues should the need arise. The training of staff is now nearly complete and all policies were seen to have been reviewed. Rivelin Residential Care Home DS0000002844.V354958.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 19 and 26. Adequate standards of redecoration must be obtained to ensure that people are living in a safe and comfortable environment. EVIDENCE: The philosophy of the Company was stated as being that every one should live in a comfortable and safe environment suitable to their individual needs. Prior to the inspection when the new Company took over the home CSCI were contacted regarding the very poor decorative state of the home and assured us they would tackle as much as possible with as little disruption to people using the service. On speaking to staff, relatives and people resident in the home the Company has achieved a large amount of work since the take over.
Rivelin Residential Care Home DS0000002844.V354958.R01.S.doc Version 5.2 Page 19 We toured the home on our own and also with the Acting Manager and Director of Operations. There is still an extensive amount of work to do, especially in service users rooms, where in some cases they have not been decorated for a number of years and bathroom and toilet areas, which would not be conducive to having a relaxing time. The Company recognises that a lot of work still needs to be done and are formulating a new maintenance plan to ensure all areas are looked at on a rolling programme. Rooms which were in a particularly poor state of repair have been taken out of commission until problems can be solved in those areas. In the last 5 months, since the Company took over work which ahs been completed has included; - all corridors and stairs, lounges and dining room being repainted. The hall, stairs and corridors have had new carpets and some lounge areas. New arm chairs have been purchased for the lounges and windows measured for curtains. Some rooms have been redecorated and refurbished, which those spoken to have very much appreciated. The home has very awkward systems of stairs and lifts to get around the whole of the building. The Acting Manager has produced a list of everyone’s disabilities and identified their nearest exit points when they are in their rooms in case the home needed to be evacuated. There is limited parking at the home, but it is close to public car parks and street parking. Part of the maintenance plan the management team stated will be to look at sitting areas outside the home for people to access fresh air. There was only one small courtyard area, which needed a bit of tidying at the time of the site visit. The Company has now appointed a housekeeper to assist them in maintaining the home to a better standard. Routines of the domestic and laundry staff have been changed but those spoken to could see how well this was benefiting the people living there. Staff need to be encouraged to keep areas tidy, but it appeared clean. This will help people to feel more relaxed and for them to be able to live in a comfortable environment better suited to their needs and tastes. The laundry room was in a poor state of repair and not a good working environment in which staff have to work. Staff stated it has been this way for a number of years. The sink unit area needs particular attention and the room was cold due to part of the window openings not being able to be closed. It was very small and with the volume of people living in the home very little space in which to place baskets of clean service users clothing. This could result in people’s clothing not being adequately maintained due to poor working conditions. Rivelin Residential Care Home DS0000002844.V354958.R01.S.doc Version 5.2 Page 20 At the time of the site visit no concerns had been raised about the standard of cleanliness and repair of clothing, linen and towels and all equipment was in working order and a safe system in place to prevent cross infection of soiled linen. New towels and face towels had been purchased and a full audit was going on to assess other linen in use. This will ensure that supplies and systems prevent people from being unkempt and free from infection. Rivelin Residential Care Home DS0000002844.V354958.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 27,28,29 and 30. Robust systems are in place to ensure staff are safe to work with people who live in the home and are then trained to do their jobs. EVIDENCE: Since the new Company took over the home it has revised the way staff work, in their different disciplines and also how staff numbers are calculated to ensure sufficient are on duty at all times to meet the needs of the people who live there. Staff surveys did indicate that they felt at times, particularly at night there were insufficient staff on duty, service users stated all their needs were being met. We saw the matrix in use and the dependency of service users and there appeared to be adequate staff hours allocated. The local management team were currently looking at extra provision at night in case they needed to respond to an emergency situation. 4 staff files were tracked in depth and appeared to have sufficient information to test they were safe to work with the people in the home. The Company has checked each staff members Criminal Investigation Bureau disclosure since taking over and all were in place and had been paid for. A full audit of all files
Rivelin Residential Care Home DS0000002844.V354958.R01.S.doc Version 5.2 Page 22 had taken place and there was documented evidence of this event. The Company has strict policies in place to ensure suffiecnt safety checks are completed prior to commencement of employment of any staff member and they are safe to work with the people in the home. The home has also been asking staff to undergo a large amount of training in the last 5 months, which staff surveyed and spoken to appeared to appreciate. All had taken part in a skills matrix exercise to ascertain where mandatory training updates were required and what individual specific training was required. We were able to see the induction books staff were completing. The company decided that all staff should complete this exercise so they had a base line on which to work with individual staff members. Mandatory training was still taking place for some staff and booking forms were seen for topics such as first aid, infection control, diabetes and care planning. Each staff member now has an individual training plan and is encouraged to keep it up to date. This will ensure that staff are safe to do their jobs and have the latest knowledge base to work to, to enable them to look after the people in the home. Rivelin Residential Care Home DS0000002844.V354958.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 31,33,35,36 and 38. There are adequate standards of monitoring in the home to ensure it is safe and secure to live in and people’s views are sought. EVIDENCE: The Company has recruited a new Acting Manager for the home. This only came into being because the previous one was a partner in the out going Company. This person is still to be vetted by CSCI. The quality assurance systems were not in place when the new Company took over. The management team were beginning to tackle this large task. People
Rivelin Residential Care Home DS0000002844.V354958.R01.S.doc Version 5.2 Page 24 using the home, relatives and staff were all able to state instances of meetings having taken place and surveys already sent out to ascertain their views on the running of the home. The Company recognised that there is still a lot of work to do, but they are suing a system which has provided useful in other sister homes in the Group. To enable the Company to ascertain how staff work more diligent records are now kept on staff supervision times. The old records seen were very basic and staff completed mainly self-assessment forms. The new process staff stated had been challenging to them but they were able to put their views across and plan training to suit their needs. A new log of supervisions was seen and at the moment the Acting Manager is completing them all to get a good picture of each staff member. This will ensure they are all-capable of doing the job they are employed to do and are safe to work with the people in the home. Records were also seen to ensure that the Company is ensuring the building is safe and all financial records are kept in accurate order. It is working closely with the Local Authority finance department to maintain accurate records for the new Company. Other documentation was seen for example fire checking books, lifting equipment certificates, gas certificates to ensure the building and equipment is safe.- for people resident in the home to use. Rivelin Residential Care Home DS0000002844.V354958.R01.S.doc Version 5.2 Page 25 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 3 X 3 Rivelin Residential Care Home DS0000002844.V354958.R01.S.doc Version 5.2 Page 26 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. 2. Standard OP7 OP9 Regulation 15.1 and 2.b. 13.1.2. Requirement Care plans on each individual person must be up to date to ensure it meets current needs. Drug administration records must accurately reflect medication required to ensure people are free from harm. Storage of all medication and associated equipment must be in a clean and tidy environment to ensure it is always safe to use. Activities must be arranged to meet the diverse needs of the client group and be accurately recorded. All meals must be prepared in a clean environment and accurate records to prove safety standards have been met to ensure people are free from harm. A maintenance plan must be in place and work detailed to ensure people live in a comfortable environment. The laundry must be refurbished to allow staff to work in a safe and clean environment to enable them to provide a good service
DS0000002844.V354958.R01.S.doc Timescale for action 28/03/08 28/03/08 3. OP9 13.1.2. 28/03/08 4. OP12 16.2.m.n. 30/03/08 5. OP15 16.2.j. 28/03/08 6. OP19 23.2.b. 30/05/08 7. OP26 23.2.b. 30/03/08 Rivelin Residential Care Home Version 5.2 Page 27 8. OP31 8.1.a. 9. OP33 24.1. to people living in the home. The Company must ensure that the Acting Manager apply for the Registered Manager’s post as soon as they are confident the person can do the job. A quality assurance programme must be in place to ensure the home is being run for the people living their, it is safe and their views have been taken into consideration. 28/03/08 30/05/08 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. Refer to Standard OP13 OP36 Good Practice Recommendations More links should be made with the local community to ensure the diverse needs of the people can be met. The programme of supervision should continue and also reflect the observational supervision, which currently takes place. Rivelin Residential Care Home DS0000002844.V354958.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Rivelin Residential Care Home DS0000002844.V354958.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. 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!
