Inspection on 10/05/07 for Rivendale Lodge EMI Care Home

This inspection was carried out on 10th May 2007.

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

Rivendale Lodge EMI Care Home 30/01/07

Rivendale Lodge EMI Care Home 11/05/06

Rivendale Lodge EMI Care Home 12/10/05

Rivendale Lodge EMI Care Home 17/05/05

Rivendale Lodge EMI Care Home 19/01/05

Rivendale Lodge EMI Care Home 03/06/04

Similar services:

Springfield House

The Old Downs Care Home

Ridgemount

Lawrence House

Anchorstone Services Limited

Lulworth Residential Home

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

CARE HOMES FOR OLDER PEOPLE Rivendale Lodge EMI Care Home 14 Prideaux Road Eastbourne East Sussex BN21 2NB Lead Inspector Judy Gossedge Key Unannounced Inspection 10th May 2007 1:00 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 Rivendale Lodge EMI Care Home DS0000046374.V338193.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. Rivendale Lodge EMI Care Home DS0000046374.V338193.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rivendale Lodge EMI Care Home Address 14 Prideaux Road Eastbourne East Sussex BN21 2NB 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) 01323 731575 01323 738970 Rivendalecare@aol.com Mr Sunjay Kumar Rai Mr Ashish Sharma Tony Gaitskell Care Home 26 Category(ies) of Dementia - over 65 years of age (0) registration, with number of places Rivendale Lodge EMI Care Home DS0000046374.V338193.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the folloiwng gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - (OP) 2. Dementia (DE)(E) The maximum number of service users to be accommodated is twenty-six (26). 30th January 2007 Date of last inspection Brief Description of the Service: Rivendale Lodge is a residential care home for older people with dementia. It is situated in a residential area of Eastbourne. The home is a detached older-style building, on three floors standing in its own grounds. There are sixteen single and five double bedrooms sited on all floors, with a lounge/dining room on the ground floor. It is not purpose built and there is no passenger lift, but equipment is provided in the home to help service users up and down the stairs to the first floor if required. All the bedrooms have a wash-hand-basin. The majority of bedrooms do not have ensuite facilities, but three bedrooms have a toilet and wash-hand-basin and of these three, one also has a shower facility. Assisted bathing facilities are available in the home. There is a garden laid to lawn with a decking area at the rear of the home. The Statement of Purpose, Service Users Guide and a copy of the last inspection report are available to reference in the entrance to the home. At the time of the inspection fees were documented to be between £366.00 and £500.00 per week. Additional charges are made for hairdressing, chiropody, newspapers and dry cleaning. Rivendale Lodge EMI Care Home DS0000046374.V338193.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five hours on 10 April 2007. Prior to the Inspection the Registered Manager completed an Annual Quality Assurance Assessment (AQAA) and information detailed is quoted in this report. A tour of the premises took place to look at communal areas and a selection of service user’s bedrooms and care records were inspected. Twentyfour service users were resident, but due to communication difficulties it was not possible to speak to all service users individually, though a number were spoken with as part of the inspection process. The care that four of the service users received was reviewed. The opportunity was also taken to observe the interaction between staff and service users in the communal area. No service user surveys were sent out on this occasion. One new care worker; a cook, two kitchen assistants, a laundry assistant, the deputy manager and the Registered Manager were all spoken with. Further care workers were spoken with as part of the inspection process. Three relatives, two visitors and an NVQ assessor were spoken with during the inspection. An ESCC care manager was subsequently spoken with over the telephone. There is now a Registered Manager for the home and from 3 February 2007 the name of the home changed from Brook Hill to Rivendale Lodge. What the service does well: The staff team were observed during the inspection to ensure that the privacy and dignity of service users is respected at all times. The care and support provided was observed and detailed in service users individual care plans to enable service users where possible to exercise choice whilst at Rivendale Lodge. The feedback from all the relatives and visitors was that they were happy with the overall care provided in the home. Relatives/visitors comments included ‘ on the whole I am happy with everything,’ ‘ I am very happy with the care provided,’ ‘nothing is too much bother,’ ‘my relative is happier here than anywhere else,’ ‘staff are very friendly, caring and welcoming,’ ‘my relative is always clean and tidy,’ ‘I have never seen any animosity between the staff, they work as a team and help each other,’ ‘staff are really great,’’ I have been very happy that my relative is here in the home and my relative is very happy,’ ‘all the staff are extremely caring,’ and ‘I feel the staff are caring all the time when they speak to the service users.’ Regular activities are being organised for service users during the week with opportunities for service users to socialise with their relatives/representatives at events arranged in the home. A periodic newsletter is sent out to inform every one of the forthcoming events in the home. Rivendale Lodge EMI Care Home DS0000046374.V338193.R01.S.doc Version 5.2 Page 6 The home provides service users with a homely, relaxed and caring environment. Service users are enabled where possible to exercise choice and control over their lives whilst resident in the home. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Rivendale Lodge EMI Care Home DS0000046374.V338193.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rivendale Lodge EMI Care Home DS0000046374.V338193.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 5 and 6. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Potential new service users are individually assessed prior to any admission to ensure that their care needs can be met in the home and they and their representatives are provided with detailed information about the home. EVIDENCE: The Statement of Purpose, Service User’s Guide and a copy of the last inspection report are available to read in the entrance to the home. The Registered Manager stated that these documents had been recently reviewed and updated. Two relatives spoken with who had been party to the admission the process of their relative, both stated they had received enough information about the home before moving in. One was able to confirm receipt of these documents and one could not remember. Both had visited the home prior to their relative’s admission. Rivendale Lodge EMI Care Home DS0000046374.V338193.R01.S.doc Version 5.2 Page 9 The Registered Manager stated that service users are visited prior to any admission. This is to ensure individual service user’s care needs can be met in the home and to provide staff with information on the care to be provided. For the one new service user admitted to the home since the last inspection there was detailed pre-admission information viewed, which had been completed. New care workers receive an induction and attend mandatory training. See Standard 30 in relation to the induction of new care workers. There are policies and procedures in place for staff to reference. There is a programme for National Vocational Training (NVQ). All care workers have received guidance/training for providing care to service users with dementia. Intermediate care is not provided in the home. Rivendale Lodge EMI Care Home DS0000046374.V338193.R01.S.doc Version 5.2 Page 10 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): 7, 8, 9 and 10. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users have individual plans of care in place and personal care and support is provided in a way that maintains and respects the privacy, dignity and lifestyle of the service user. Detailed policies and procedures in place to manage medicine ensure the protection of service users. EVIDENCE: The AQAA detailed that there are policies in place to ensure that equality and diversity issues for individual service users are both identified and incorporated into service users individual plans of care. A selection of four of the service user’s individual care plans was viewed. The information detailed on three of the care plans demonstrated that the detail being recorded continues to be developed. This gives clear guidance to staff of the care to be provided, service user’s personal and health care requirements, dietary needs, social and leisure interests, how any identified risks are to be managed. The care plans viewed had been reviewed to ensure that this information is up-to-date and current care needs are being met. Service users religion is recorded to ensure Rivendale Lodge EMI Care Home DS0000046374.V338193.R01.S.doc Version 5.2 Page 11 where a death occurs appropriate actions are taken in line with service user or relative’s wishes. For the last admission to the home the information received as part of the inspection process had not been collated into a plan of care. This was discussed with the Registered Manager who stated a care plan was being drafted, that he would address this and has subsequently confirmed a care plan is now in place, so a requirement has not been made on this occasion. The staff team were observed during the inspection to ensure that the privacy and dignity of service users is respected at all times. Feedback received of the care and support provided, observations and information detailed in service users individual care plans was that service users are enabled where possible to exercise choice whilst at Rivendale Lodge. The feedback from all the relatives and visitors was that they were happy with the overall care provided in the home. Relatives/visitors comments included ‘ on the whole I am happy with everything,’ ‘ I am very happy with the care provided,’ ‘nothing is too much bother,’ ‘my relative is happier here than anywhere else,’ ‘staff are very friendly, caring and welcoming,’ ‘my relative is always clean and tidy,’ ‘I have never seen any animosity between the staff, they work as a team and help each other,’ ‘staff are really great,’’ I have been very happy that my relative is here in the home and my relative is very happy,’ ‘all the staff are extremely caring,’ and ‘I feel the staff are caring all the time when they speak to the service users.’ Medication policies and procedures are in place and staff-administering medication has received medication training. The Registered Manager stated an update of medication training is due to be facilitated shortly and also confirmed that a pharmacist regularly visits the home, but the records of these visits were not viewed during the inspection. The storage and a sample of the recording of the administration of medication were also viewed and were adequate. Where PRN medication is administered the deputy manager stated that verbal guidance had been given to staff as to when this should be administered. It was recommended that this guidance be also clearly recorded. All the relatives stated that they felt that their relatives medical care needs were met in the home. Rivendale Lodge EMI Care Home DS0000046374.V338193.R01.S.doc Version 5.2 Page 12 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): 12, 13, 14 and 15. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Where possible service users are enabled to exercise choice in their lives whilst resident in the home, there are opportunities to participate in social and recreational activities provided. Service users are encouraged to maintain contact with family and friends as they wish and a varied diet is provided. EVIDENCE: Service users social interests are recorded on their individual care plans and the AQAA detailed that a regular programme of activities is arranged. An activities’ co-ordinator works in the home twenty hours a week over five days, who organises the activities’ and additionally care staff may facilitate an activity after the co-ordinator had finished for the day. The AQAA detailed that many of the staff have also attended dementia activities training and that activities are facilitated in the home by staff or by external entertainment/activities groups including an exercise group and musical entertainment. On the day of the inspection a group of service users were playing ‘catch’ with a large ball and there was a pleasant atmosphere and good interaction between staff and service users was observed. The lounge is Rivendale Lodge EMI Care Home DS0000046374.V338193.R01.S.doc Version 5.2 Page 13 decorated and personalised with some of the themed artwork service users have completed. A periodic newsletter is sent out to inform service users and relatives of the forthcoming events in the home and several of the relative’s spoke of receiving the newsletter and attending events run in the home including a Christmas party and coffee afternoons. Additionally a vegetable garden has been planted in the back garden as a further activity for service users to become involved in. Three relatives/visitors had observed activities taking place and comments received were, ‘it is amazing who the staff manage to encourage to join in the activity,’ and ‘staff encourage the service users to join in the activities.’ One service user went out with their visitors for a walk along the seafront during the inspection and relatives also commented that they also took their relatives out of the home to participate in local activities. All the relatives/visitors confirmed there was flexible visiting, that staff are very welcoming and they could see their relative/friend in private if they wished. When asked what the home does well one relative answered that the staff welcome when they arrived was appreciated, as was the opportunity to sit with their relative with the offer of a cup of tea. A rotating menu is place, which the deputy manager stated has been seasonally varied, takes into account service users likes and dislikes and was seen to identify the choices available at all meals. Lunch on the day was recorded to be two beef options. Staff spoken with confirmed that they are still looking at the options provided to ensure more variety. Special diets are catered for. Records viewed following the last inspection evidenced that all the service users have recently been placed on a reducing diet and service users individual weight charts recorded significant weight losses for some service users. It was not possible to evidence on the day, but subsequently the Registered Manager confirmed that where there are three service users currently on a reducing diet, medical guidance and dietetic guidance has been sought and recorded to ensure an appropriate diet to take into account each individual service users dietary needs are met. Tea on the day was spaghetti on toast or a selection of various sandwiches and a whip. Staff stated that there is a regular order of fresh fruit delivered to the home for the service users. Some service users observed were being assisted with their tea in the dining room and lounge area and it was a relaxed environment taking into account the different length of time that individual service users would need to finish their meal. Records are kept of food consumed individually by each service user, but were not viewed on this occasion. Two relatives/visitors who had observed meals provided in the home stated that the food was good and felt that their relative enjoyed their meals. Rivendale Lodge EMI Care Home DS0000046374.V338193.R01.S.doc Version 5.2 Page 14 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): 16 and 18. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Policies and procedures are in place to enable service users or their representatives to raise any concerns about the care being provided and to ensure that service users are protected from abuse. EVIDENCE: There is a detailed complaints policy and procedure in place. The AQAA detailed that no complaints had been received at the home during the last year. The CSCI have not received any concerns in relation to the care provided at Rivendale Lodge. The relatives/visitors stated that they had not raised any complaints and where one relative had raised a concern they had been happy with the outcome. All felt it was an environment where they would feel comfortable to raise any issues and that they would be listened to. The AQAA detailed that there are policies and procedures in place in relation to the protection of vulnerable adults and training records evidenced staff had attended related training. One new care worker spoken with confirmed they had attended this training and demonstrated an awareness of the policies and procedures. Rivendale Lodge EMI Care Home DS0000046374.V338193.R01.S.doc Version 5.2 Page 15 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): 19 and 26. 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. The home is decorated and furnished in a homely style, but the standard is variable. The maintenance plan and ongoing work to refurbish and improve the facilities in the home ensures that the standard of the environment continues to be maintained and improved. EVIDENCE: The external décor of the home has been improved with the installation of new windows and external doors. There are still some windows to be replaced and the Registered Manager stated that this work is ongoing, that it had been planned to finish this work by April 2007, but that there has been a delay in completing this work. A tour of the building was made. The home is decorated and furnished in a homely style, but the standard of the décor and furnishings varies. The Rivendale Lodge EMI Care Home DS0000046374.V338193.R01.S.doc Version 5.2 Page 16 Registered Manager confirmed an awareness of this and stated there is an ongoing maintenance programme-taking place in the home and improvements planned to ensure the continual improvement of the environment. The AQAA detailed proposed further developments of the rear garden, further refurbishment of the lounge/dining room and plans to increase in the communal space for service user to use. There is not a passenger lift in the home, but the Registered Manager stated that the proprietors are still currently reviewing options for a passenger lift to be installed to access all floors in the home. The Registered Manager has also written to the CSCI with proposals to make all the existing double bedrooms in to single bedrooms and is currently seeking guidance as to the best way to achieve this. There is a garden to the rear of the home, which has a decking area and work is due to commence to provide a raised flowerbed. Access to the garden is via a doorway off the lounge where there is a steep ramp in place. This has been previously discussed with the Registered Manager who stated that the staff team follows the risk assessment in place when assisting service users outside using the ramp. A stair lift is available to service users unable to use the stairs to the first floor. Access to the second floor is by way of a steep stairway with no alternative means of escape in case of a fire. Stair gates have been fitted on this stairway. The Registered Manager has stated that a risk assessment has been completed and the fitting of these discussed with representatives from the external fire company who recently completed a fire risk assessment for the home and were satisfactory. Service users accommodated on this floor should be fully ambulant. The care needs of the service user at present living on that floor should continue to be reviewed on a regular basis to ensure their safety and care needs continue to be met whilst resident on the second floor. There are sixteen single bedrooms and five double bedrooms on all floors in the home. The décor and furnishing of the bedrooms is variable and the Registered Manager stated work continues to improve each of the bedrooms. A number of bedrooms were viewed and displayed service users individual styles and interests. Night-lights have been purchased instead of a bedside light. Though some bedside lights have been provided if this is identified to meet individual service users care needs. An emergency call system was fitted in the home during 2005 so all bedrooms now have an emergency call bell system. A number also have an alarmed floor mat to alert care workers particularly at night where a service user may need assistance. Service users are unable to control the temperature in their own bedrooms. The homes recording of the testing of the hot water temperatures was viewed and detailed that water at the majority of outlets accessed by service users is being maintained at close to 43 º C. Where lower temperatures were recorded Rivendale Lodge EMI Care Home DS0000046374.V338193.R01.S.doc Version 5.2 Page 17 for two outlets the Registered Manager stated that work has already been completed to address this. Bathroom facilities are provided throughout the home. However most service users use the assisted bathroom on the ground floor. The home does not provide sufficient toilets throughout the building, particularly on the ground floor where most of the service users were observed to spend a significant part of their day. The proprietors have previously stated that they have reviewed this and currently there are no plans to increase the number of toilet facilities. But the main toilet used off the lounge area has been extended so that it is more easily accessible. This does mean that as well as the door at the entrance to the toilet there is also an external fire door and exit leading out to the back of the home. This has discussed with the Registered Manager who stated that advice and guidance again had been sought from a representative from an external fire company as part of the fire risk assessment for the home and that this was acceptable. There is one lounge/dining area on the ground floor and is where the majority of the service users congregate during the day. This area has been redecorated following the loss of two walls from an adjacent staff room, which has been incorporated into and extended the communal space available. The Registered Manager acknowledges that new flooring and new dining room furniture would further improve this environment and is part of the plans being looked for the ongoing upgrading of the homes environment. The AQAA details that there is a policy in place for managing infection control and that Department of Health Guidance has been used to assess current infection control management. The floor finish in the laundry is readily cleanable. Feedback received confirmed that that system is in place to sort clothes in the laundry area and ensure all items of clothing are named. It was not clear how it was ensured that female service users only wear their own stockings and the Registered Manager stated he would look into this issue and ensure that this was the case. The home was clean and odour free in the majority of the home although there were a couple of bedrooms where there was a slight odour. Feedback from relatives and visitors to the home was that the home was always fresh and clean. The laundry assistant spoken with had not received training/guidance in infection control or the control of substances hazardous to health regulations (COSHH). This was discussed with the Registered Manager who stated this training has been arranged during May for staff to attend. Recording was viewed of routine fire checks that had been carried out in the home. Rivendale Lodge EMI Care Home DS0000046374.V338193.R01.S.doc Version 5.2 Page 18 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): 27, 28, 29 and 30. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are detailed recruitment policies and procedures in place to protect service users and staff are provided with opportunities for training to develop their skills and ensure the individual care needs of service users can be met. New staff would benefit from receiving the induction training at the start of their employment. EVIDENCE: Staffing on the day was adequate to meet the number and care needs of the service users resident. Staff spoken with confirmed that five members of care staff are deployed to work in the home during the day with the senior staff on duty and two members of care staff undertake ‘waking night’ duties. They also confirmed that there is now only limited use of agency care workers to work in the home, but where it is required staff who have already worked in the home are requested to attend. The Registered Manager stated that staffing levels have been reviewed following the increase in occupancy in the home. There are also ancillary staff that work in the home and who cover catering, domestic and laundry tasks. Relatives stated that they felt there were adequate numbers of staff on duty during their visits and that felt that their relative received the care and support that they needed. When relatives were asked what the home does well one answered that considering the varying care needs of the service users the staff managed these very well. Rivendale Lodge EMI Care Home DS0000046374.V338193.R01.S.doc Version 5.2 Page 19 Standard 28 has not been met as fifty percent of the staff have not achieved NVQ level 2 or equivalent in care by April 2005. But the AQAA detailed that one care worker holds an NVQ Level 2 in care and seventeen care staff are currently working towards either NVQ level 2 in care or towards NVQ level 3. The Registered Manager stated that the home had recently been awarded the YMCA training award, ‘Super Employer Award’ for 2006 in recognition of its training achievements. The NVQ Assessor spoken with confirmed this and stated this was to acknowledge the support of care workers receive to complete an NVQ award. The recruitment process followed was viewed for the two new members of care staff and a volunteer working in the home, all of whom had been recruited since the last inspection. A satisfactory recruitment practice iwas evidenced to be in place, with the completion of an application form, two references and a completed a Criminal Records Bureau check (CRB)/and a Pova check had been received prior to staff commencing work in the home. The Registered Manager had stated that induction training to meet the requirements of the General Skills for Care induction standards had been received and would be introduced for the new staff working in the home to complete. The two new members of care staff who had been recruited since the last inspection, one of whom was spoken with who confirmed and they had received an initial induction in to the home, but neither had started induction training to meet requirements and had been working in the home for several weeks. This was discussed with the Registered Manager who stated it was the intention for both members of start to complete the required induction. It was recommended that the guidance as to the timescale to complete an induction be followed to ensure that staff has been provided with the required information at the start of their employment. An annual appraisal to be undertaken with each care worker is due to be introduced within the next two months. Rivendale Lodge EMI Care Home DS0000046374.V338193.R01.S.doc Version 5.2 Page 20 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): 31, 32, 33, 35, 36 and 38. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management team have strived to create an atmosphere within the home, which is open, relaxed, homely and caring. Quality assurance systems have been developed to enable ongoing feedback about the care provided in the home and systems are in place to ensure a safe environment for staff and service users. EVIDENCE: There is now a Registered Manager for the home, who has completed the Registered Managers Award and stated is currently working towards NVQ Level 4 in Care. There have also been further training opportunities which the Registered Manager has attended. There is a deputy manager to support the Registered Manager and feedback received was that the running of the home Rivendale Lodge EMI Care Home DS0000046374.V338193.R01.S.doc Version 5.2 Page 21 was open and transparent and there were opportunities for staff, service users and their representatives to affect the way in which the service is delivered. A quality assurance system has been developed. It was evidenced that feedback about the service provided has been sought from service users, relatives/representatives and other professionals who attend the home in August 2006, all of which has been collated and the Registered Manager stated that all service users representatives had received a copy. The overview detailed that there had been a seventy-five percent response to the questionnaires distributed during the survey period. When asked about the general satisfaction of the care provided the majority of responses stated very good and good. The Registered Manager stated a survey for 2007 is due to be sent out shortly. The AQAA detailed that policies and procedures had been reviewed. A regular recorded visit by a proprietor of the home to meet Regulation 26 has been made. Service users’ money is not held at the home, but where service users wish to purchase items the home pays for these and accounts are sent to service users’ representatives quarterly. There were adequate records to support this activity. Supervision for all care staff has been introduced and maintained to meet the requirements of Standard 36. Training records were viewed so it was possible to evidence if all staff had received training in moving and handling, basic food hygiene, first aid and infection control within the required timescales. The Registered Manager stated that he and the deputy manager have attended a moving and handling risk assessors course so that they can complete any moving and handling risk assessments where identified in the home. The AQAA detailed that the maintenance of equipment and services has been carried out. The proprietor has commissioned an external agency to complete a fire risk assessment for the home and the Registered Manager has stated that the recommendations made following this have been addressed. Records evidenced that staff attended fire training and there are also fire drills facilitated in the home and the staff spoken with confirmed attendance at this training. An external provider was commissioned last year by the proprietors to undertake an environmental risk assessment of the building. The Registered Manager stated that a programme to review this has been introduced. At the last Inspection the Registered Manager stated that there was a regular a regular environmental check of the building, which includes a fire check, but that there was no record of this and this would be addressed. A record of checks undertaken is still not in place and a requirement has been made. Rivendale Lodge EMI Care Home DS0000046374.V338193.R01.S.doc Version 5.2 Page 22 Recording was viewed of incidents and accidents, which had occurred in the home and which have now been collated, which helps to facilitate easy access and to identify any patterns in incidents and accidents, which have occurred in the home. Rivendale Lodge EMI Care Home DS0000046374.V338193.R01.S.doc Version 5.2 Page 23 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 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 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 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 3 X 2 Rivendale Lodge EMI Care Home DS0000046374.V338193.R01.S.doc Version 5.2 Page 24 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. 1. Standard OP38 Regulation 13 (4) (a) (c) Requirement That there are regular environmental checks of the building to ensure that a safe environment is maintained. Timescale for action 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Rivendale Lodge EMI Care Home DS0000046374.V338193.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Rivendale Lodge EMI Care Home DS0000046374.V338193.R01.S.doc Version 5.2 Page 26 - 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. 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