Inspection on 02/07/09 for Rivelin Residential Care Home

This inspection was carried out on 2nd July 2009.

CQC found this care home to be providing an Adequate service.

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

Rivelin Residential Care Home 19/01/09

Rivelin Residential Care Home 12/08/08

Rivelin Residential Care Home 13/11/07

Rivelin Residential Care Home 17/11/06

Rivelin Residential Care Home 27/01/06

Rivelin Residential Care Home 14/09/05

Rivelin Residential Care Home 22/02/05

Rivelin Residential Care Home 10/11/04

Rivelin Residential Care Home 17/02/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Rivelin Residential Care Home 17/21 Albert Road Cleethorpes North East Lincs DN35 8LX Lead Inspector Theresa Bryson Key Unannounced Inspection 2nd July 2009 09:00 DS0000002844.V376239.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Rivelin Residential Care Home DS0000002844.V376239.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Rivelin Residential Care Home DS0000002844.V376239.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 Manager post 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.V376239.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. 19th January 2009 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. 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. Fees are renewed 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.V376239.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means that the people who use this service experience adequate quality outcomes. This inspection took place over one day in July 2009. Prior to this we sent out a number of surveys. Severn were returned by people using the service, six by staff and one from a health professional. We also looked at the service history since the last inspection. The home had sent us their Annual Quality Assurance Assessment (AQAA) previously which gave us a lot of information about the home and some statistical data. On the site visit day we looked at a number of records and other documents and spoke to some people living there, some relatives and staff. The Acting Manager was present throughout the visit and was accompanied by the Operations Director for the Company. What the service does well: Staff are always very welcoming and open about their knowledge base about the people they look after. They assist people with tasks in a calm and relaxed manner and are willing to find out more about how to look after the people in their care. The Company has introduced new auditing measures and now seeks to ensure that the views of people living in the home and other stakeholders are taken into consideration when planning the future of the home. The management team are open to new ideas and are happy to take the advice of other professionals to enhance the care of the people they look after. Rivelin Residential Care Home DS0000002844.V376239.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: No requirements have been made at this inspection but some recommendations have been made. These are considered to be good practise guidelines and are not enforceable. Rivelin Residential Care Home DS0000002844.V376239.R01.S.doc Version 5.2 Page 7 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Rivelin Residential Care Home DS0000002844.V376239.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.V376239.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards 3 and 6 were checked. Sufficient information is available about the home to ensure people can make informed choices about using their services. EVIDENCE: Since the last key inspection the home has been closed to admissions but the management team and staff have been preparing new documentation to ensure all current service users care needs are being met and their care plans are up to date. Rivelin Residential Care Home DS0000002844.V376239.R01.S.doc Version 5.2 Page 10 If incidents or accidents have occurred with people which are notifiable to CQC the management team have been very prompt in sending us these details so we can make a valued judgement as to whether they have taken sufficient action to safe guard individuals. The home does not provide care for people with intermediate care needs and there fore Standard 6 is not applicable. Rivelin Residential Care Home DS0000002844.V376239.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards 7, 8, 9 and 10 were checked. The standard of care plan recording has improved and staff are now able to see what the current needs of people are who live in the home and ensure they are free from risk and harm. EVIDENCE: Prior to the site visit for this key inspection a number of surveys were sent out by us and seven were returned from people using the service and one from a health professional who visits on a regular basis. All made positive comments about the home. Rivelin Residential Care Home DS0000002844.V376239.R01.S.doc Version 5.2 Page 12 During the visit a further five people living there were talked to and one relative. Again positive comments were made. People said “girls look after me very well” and “they do everything I want”. Another said “nothing is a problem to them”. People also talked about how well informed the staff were about their needs and felt they “anticipate what I want, so I don’t have to think too much, which means I can relax”. Three care plans were tracked in depth and showed a good improvement since the last visit. There was better consistence in the documentation found in each care plan. The management team had also ensured that where necessary incidents are reported to us and one such Regulation 37 notice was tracked on the visit. This showed that where an incident had occurred it was recorded in that person’s care plan, it was also part of a management review of that person’s care and a new behaviour chart was in place to record incidents, which protects the person and others living in the home. In another care plan there was a notification of the need for a person to have a special diet for example fortified drinks. The records also showed how the home was liaising with other health professionals and the care plan had been revised, amended and further evaluated. Along side of this was a nutritional risk assessment, a daily meal record and a record where regular weights were taken. This ensures the person is helped to maintain a good nutritional input to ensure their health and well-being. Another plan showed where the health support services were liaising with the home for someone who had a wound management problem. The person’s care plan had been reviewed and evaluated and regular recordings were made on a pressure area care chart and in the Waterlow risk assessment tool. This ensures that care has been taken to assess this person’s risk and ensure careful monitoring is in place to check this wound. The care plans generally showed more accurate recording and individual planning of people’s needs and expectations. There was written evidence that people living in the home or their advocate had contributed to the care plans. Health professionals told us that the staff now liaise more with them and they are happy to give their advice where necessary. The management team have introduced an auditing system to ensure that a more senior member of staff is ensuring the current needs of people living in the home are recorded and staff are delivering the care described. Written documentation was seen to show this was taking place and staff spoken to also stated they felt they had more senior staff to approach if they are unsure of the correct procedures to follow. People living in the home made positive comments about how well staff fulfil their needs and expectations. At the next inspection we hope to see these improvements to have continued and there being constant consistence. A senior member of staff escorted the inspector when we were checking the drug administration records. Rivelin Residential Care Home DS0000002844.V376239.R01.S.doc Version 5.2 Page 13 There now appeared to be safe practises in place and staff appeared to be more confident in their knowledge base about how incorrect practises could harm individuals. To help them an up to date reference book was seen to be in place. The drug auditing system was new but it was proving invaluable to staff to ensure correct processes were in place and where necessary more senior management could be come involved to liaise with other health professionals to ensure the correct medication was prescribed and reviewed, where necessary. This should be maintained to assist staff. During the course of the site visit staff were observed delivering personal care tasks to people, assisting with daily choices (such as whether to go out shopping) and with social activities. Tasks were performed showing dignity and respect to people living there and each staff member had a calm and relaxed manner. Since the last inspection staff have been given training in dignity and respect and written evidence was produced that this had taken place. Rivelin Residential Care Home DS0000002844.V376239.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards 12, 13, 14 and 15 were checked. A more varied programme of social activities are now in place to meet people’s social, cultural and religious needs and expectations. More work still needs to take place to ensure people are more integrated into the local community. EVIDENCE: Since the last key inspection improvements have been made in the way social activities are recorded in each person’s care notes. Of the three care plans tracked, all had social family history forms in place, a brief life history and an outline of their current needs and expectations. This ensures staff are aware of what every one requires. There was also documented evidence that other professionals such as Occupational Therapists Rivelin Residential Care Home DS0000002844.V376239.R01.S.doc Version 5.2 Page 15 had been involved with some peoples needs assessments, particularly where equipment such as walking frames were required. The service keeps separate activities records, where staff can record specific events. The records which were seen showed one record where an activity such as reading a newspaper or taking part in exercises had taken place. An individual person’s involvement such as “participated well” or “just observed” were recorded. This enables staff to see which events people favour and where some people may need encouragement. Also in these records are long and short term goals and when these have been reviewed. Such as: - a person becoming more integrated in the home and making friends or where a better choice of reading material may be required for those confined to their rooms. An activity planner for the year appeared to have been followed on the site visit day and staff were able to describe how they were planning other events such as viewing the local carnival and shopping trips or clothes parties in the home. Some more time needs to be given to ensure that events outside the home are explored for people living in the home and encouragement given to other organisations such as to help those with specific needs such as dementia can be brought into the home. There was ample evidence in people’s bed room areas that they had been able to personalise their rooms. People told us that this had helped them settle into the home and relatives informed us it helped as a talking point to remind their loved ones about photographs in place in bedroom areas. The management team are now able to evidence to us with copies of letters sent and minutes of meetings held how they are communicating with people living there and their loved ones. Particularly around their individual care plans and also changes to the building and redecoration programme. This has shown how people’s views are sought and acted upon. A brief tour of the kitchen took place. At the last site visit, six months ago, the staff were able to demonstrate how they had achieved a 4-star rating with the local Environmental Health Officer for standards in the kitchen. The management team had also decided to take on board the recommendation to ensure when food is taken to the upper floors of the home that the temperature is taken to ensure it is safe to eat. The floor in the kitchen area is very worn and although not a trip or safety hazard could be assessed for replacement, at some stage, on the refurbishment plan. Initially this does require a deep clean, which we understand is in process of being set up. Food appeared to be prepared in a clean and safe environment and there were adequately trained staff on duty to prepare meals. There were choices on the menu and people told us how much they enjoyed the food. They told us “I get drinks when I like and staff respect that I like to let my hot drinks go cold” and Rivelin Residential Care Home DS0000002844.V376239.R01.S.doc Version 5.2 Page 16 “I have enough to eat and the choice is good”. Also “staff cope with my loved ones diabetic diet”. There are also nutritional assessments in each person’ care plan to ensure they maintain a good balanced diet to help their health and well-being. Rivelin Residential Care Home DS0000002844.V376239.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards 16 and 18 were checked. Staff are more competent in referring concerns to the management team and the documented evidence is more legibly written. EVIDENCE: Since the last inspection there have been no new concerns raised about the care people are receiving in the home. All polices concerning complaints, concerns and allegations which could result in a safe guarding adult’s referral being made were seen to have been reviewed. Staff records showed that all staff have now received training in these topics and they were able to inform us, when questioned, of how the different procedures take place. People spoken to also had been made aware of how they can make concerns heard and all people contacted either through surveys or spoken to say they had every confidence the management team would deal with concerns promptly and in confidence. Rivelin Residential Care Home DS0000002844.V376239.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards 19 and 26 were checked. More planning has now taken place to ensure the building is safe to be in whilst the rebuilding work takes place and people are consulted about their environment. EVIDENCE: Over the last six months the new management team have ensured they have kept people living in the home informed about the current extensive refurbishment work in progress. And also CQC. A new action and contingency plan is now in place and this encompasses other work such as refurbishment of Rivelin Residential Care Home DS0000002844.V376239.R01.S.doc Version 5.2 Page 19 some other rooms. A file was seen to be in place which detailed, for example, daily information and reports from the builders, letters sent to people living there and where necessary relatives or advocates, all risk assessments and maintenance records. A tour of the home took place and all areas of the home appeared safe for people to move about in, despite the extensive rebuilding work. A new staff room, manager’s office and laundry was now in place, as well as a smoke room which could be accessed from the garden area and inside the building. A selection of bed room areas were seen and some of these had been refurbished. As part of the auditing process to ensure the building was safe there was written evidence to show that all commodes had been looked at and where necessary new purchased. Part of the outside area was still in the hands of the builders, but one area had been tidied and was very colourful with hanging baskets and seating. The building was clean and tidy and sufficient staff were now employed to ensure areas remained safe to use and live in. When necessary we have been informed when extra staff have been put on duty when extra work may be required due to the building work. For example when part of the fire and water services were disrupted due to the old system joining the new build. This ensures people are safe at all times. Rivelin Residential Care Home DS0000002844.V376239.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards 27, 28, 29 and 30 were checked. There is a more robust system of staff recruitment and training in place to ensure staff working in the home are safe to work with the people living there. EVIDENCE: A lot of work has been undertaken since the last key inspection concerning sufficient staff being on duty to ensure the needs of people living there are being met. There was written evidence to support that all dependency levels were up to date and that the Residential Forum Staffing Matrix has been used to determine the correct levels of staff needed each day. We have also been informed when extra staff have been put on duty due to disruption in the home because of extensive building work in progress and also when the Personal Emergency Evacuation Plans have been completed for the fire brigade to determine risk in the event of a fire. People living there told us that they were happy with the care being given to them and made such comments as “nothing is too much trouble” and “I spend a lot of time in my room but when I want them they are there”. Rivelin Residential Care Home DS0000002844.V376239.R01.S.doc Version 5.2 Page 21 Seven staff were also spoken to during the site visit and we looked at the six surveys returned to us by staff and they were able to tell us what training had been put in place since our last visit and how they feel this has “enhanced the care we give”. Some describe how they had received “loads of training” and how some topics had been rearranged to suit staff’s personal home commitments. We saw the training matrix which is just being developed and will include not only mandatory training but topics specific to an individual staff member’s needs and more specific topics to suit the types of client using this home. This will need to be worked upon to ensure staff have all the information to hand when dealing with specific illnesses of those residents. A lot of training had taken place since the last visit, which has enabled staff to catch up on mandatory training and start thinking about more topics specific to their needs and those of the people they look after. We tracked two members of staff’s personal files in depth and there was sufficient evidence to support that adequate safety checks had been made to ensure they were safe to work with people prior to their commencement of employment. A checklist was seen where senior staff had completed audits on all staff personal files to ensure that they are still suitable to be working with this client group and not putting people at risk. Rivelin Residential Care Home DS0000002844.V376239.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards 31, 33, 35, 36 and 38 were checked. There are now more robust systems in place to ensure the views of people living there are being sought and more auditing systems in place to ensure the home is a safe place to live and work. EVIDENCE: Since the last inspection the company has taken on board the recommendation to monitor more closely the personal allowance and “Comfort” fund of the Rivelin Residential Care Home DS0000002844.V376239.R01.S.doc Version 5.2 Page 23 people living there. The written evidence showed that recent checks had been made. This ensures that there is no fraudulent use of people’s funds. The senior management team have made some good progress with the supervision of staff and the written records seen showed a balance of discussion and observational practise having taken place. Staff were also able to tell us about some recent topics of their own supervision sessions and how their practise, in some cases, they felt had improved because of the suggestions made. This important topic must continue and the Company’s policy adhered to, to ensure all staff members are safely monitored to look after people in the home. People living in the home, visitors and staff all commented in surveys and when spoken to that they had every confidence now in the current management team and Company structure that any issues and concerns raised would be dealt with quickly and efficiently. The quality assurance programme was being developed to ensure the views of people living there and other stakeholders were taken into consideration when planning the progress of the home. The management team and staff are developing twelve topics to look at and will include in the process reviews of documentation such as care plans, accidents records, meal provision, staff training, policy reviews and surveys through out the year. The overall picture will be put together in an annual development plan. All safety certificates were also seen to ensure that the building and equipment in use is suitable and safe to use for people living at the home. The home is still operating with only an acting manager, but they are supported by other registered managers in the group and the Operations Manager who visits on a frequent basis. Rivelin Residential Care Home DS0000002844.V376239.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 10 11 3 X X X X X X 3 STAFFING Standard No Score 27 28 29 30 2 3 X 3 3 3 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 Rivelin Residential Care Home DS0000002844.V376239.R01.S.doc Version 5.2 Page 25 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. 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 Refer to Standard OP9 Good Practice Recommendations The auditing programme which is in place should be maintained to ensure safe practises are being used in the administration of medicines and staff as safe practioners. The replacement of the kitchen flooring material should be considered in the refurbishment plan to ensure all areas are free from hazards but a deep cleaning programme be put in place initially. The continuing programme of staff training should continue and service specific topics to cover the current needs of people living in the home included on the training matrix. The new quality assurance programme should be maintained to ensure people’s views are sought and the home is being run for their benefit. The new programme of staff supervision should continue to ensure staff are monitored and can look after people DS0000002844.V376239.R01.S.doc Version 5.2 Page 26 2 OP15 3 OP30 4 5 OP33 OP36 Rivelin Residential Care Home safely and not put them at risk. Rivelin Residential Care Home DS0000002844.V376239.R01.S.doc Version 5.2 Page 27 Care Quality Commission North Eastern Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.northeastern@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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