Inspection on 04/10/07 for Rivendell [Chudleigh]

This inspection was carried out on 4th October 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Rivendell [Chudleigh] 06/12/06

Rivendell [Chudleigh] 17/01/06

Rivendell [Chudleigh] 19/07/05

Rivendell [Chudleigh] 11/08/04

Rivendell [Chudleigh] 11/02/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Rivendell Woodway Street Chudleigh Newton Abbot Devon TQ13 0NE Lead Inspector Graham Thomas Unannounced Inspection 4th October 2007 09:30 Rivendell DS0000003790.V332642.R01.S.doc Version 5.2 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 Rivendell DS0000003790.V332642.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Rivendell DS0000003790.V332642.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rivendell Address Woodway Street Chudleigh Newton Abbot Devon TQ13 0NE 01626 853943 01626 854621 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) HFT Miss Margaret Lesley Wick Care Home 36 Category(ies) of Learning disability (36) registration, with number of places Rivendell DS0000003790.V332642.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th December 2006 Brief Description of the Service: Rivendell is one of a number of homes provided by HFT and is registered to accommodate up to 36 adults with a learning disability. The home is located just outside the small town of Chudleigh, and comprises of three residential units (each of two houses) around a core building. Most of these houses were built over twenty years ago and are domestic in style. In addition there are three more modern day services buildings and some offices. Three former residents also live on site as tenants of HFT (under the Supporting People arrangements). A wide range of day services is offered on site for the residents, and for the residents of a smaller satellite home in Kingsteignton also run by HFT. At the time of this inspection a programme of improvements was being implemented. This involves changes in nearly all aspects of the running of the home such as day services, staffing and care planning. The weekly current fee levels for Rivendell range from: £368 to £1,822. Additional charges are made for some leisure activities, hairdressing, holidays, personal toiletries, partial television licence, and papers/magazines. Rivendell DS0000003790.V332642.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Before the Inspection visit, information about the home was provided by the Registered Manager. We also met with the a Service Manager who is presently working with the Registered Manager on a range of issues to improve the service. Four relatives, three Care Managers and a staff member returned written comments before the visit. An inspection visit took place over one and a half days with a further feedback session to the Registered Manager and Service Manager. During the visit we toured the premises and spoke with people living at Rivendell, staff and the Registered Manager. We examined a sample of care plans, staff records and a number of other records. These included, for example, health and safety records. We examined how medicines were being managed and checked the arrangements for health care. What the service does well: What has improved since the last inspection? • Work is going on to make information about the home more user friendly. • The system for managing medicines has improved and is now safer for people living at the home. Rivendell DS0000003790.V332642.R01.S.doc Version 5.2 Page 6 • There is better guidance for staff about particular needs like moving and handling where this is needed. • Arrangements are in hand to ensure that staff are properly trained to manage behaviour which is challenging. • People are being given more independence in managing their money. • There are clear and thorough maintenance checks that are being acted upon. • There is better training and supervision of staff. • Staff are more aware of infection control procedures. • Staff have been made aware of good food hygiene practice. • Fire precautions have improved to make the home safer. • The Service Manager makes regular checks of the quality of the service provided. 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 Rivendell DS0000003790.V332642.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. Rivendell DS0000003790.V332642.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rivendell DS0000003790.V332642.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The assessment of people’s needs and goals is not yet good enough to make sure everyone’s needs are properly met. However, work is going on to apply consistent standards of assessment. EVIDENCE: Since the last key inspection, the home’s Service Users’ Guide and Statement of Purpose had been updated. The Registered Manager and Service Manager stated that the day services on the site were working with people living at Rivendell to make the guide more user-friendly. Individual files were discussed with senior support workers, the Registered Manager and Service Manager. A new computer based system of assessment and care planning is being piloted and an example of this was seen. This assessment provides the basis for a detailed plan to be made based on individual needs and goals. Seven paper based individual files were also examined. As the new system had yet to be fully implemented, the content of individual assessments, care planning and risk assessments was extremely variable. Some contained detailed information but others lacked updated assessments and care plans. Rivendell DS0000003790.V332642.R01.S.doc Version 5.2 Page 10 Rivendell DS0000003790.V332642.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Better plans are being made to show what people need and want. However, these are not yet consistent enough to make sure everyone’s needs are being well met. EVIDENCE: We looked at seven people’s plans and saw an example of a new planning system that is being piloted at Rivendell. This was discussed with senior support workers, the Registered Manager and the Service Manager. The new system had yet to be fully implemented so the content of individual files was extremely variable. As stated above, all the files examined contained details provided by the placing authority. Detailed assessments, plans and risk assessments were seen in some but were absent in others. It was therefore clear that these were not yet being used as working documents. Rivendell DS0000003790.V332642.R01.S.doc Version 5.2 Page 12 For some people, person-centred planning was being put into action. For example, one person did not like to speak with others at his planning meeting but wanted to make his ideas known. With the help of staff he had used his interest in computers to make a PowerPoint presentation to the meeting about his life. This had been saved for future reference. One care manager commented: “As someone who was visiting Rivendell for the first time I was impressed with the way in which X’s Annual Contract Review document was put together. It became clear that X is someone who is keen to keep busy, undertake lots of activities and be in control of what he wants to do. This became evident as the review progressed” One person, who was approaching the end of life, was receiving substantial physical support. There were detailed guidelines in place for staff concerning moving and handling. Charts concerning personal care, continence and night checks were being maintained. A plan had also been produced concerning the wishes of the person and their family in the event of the person’s death. At the last inspection, some issues were raised concerning support for people whose behaviour challenged the service. Discussions with the Registered Manager and Service Manager confirmed that behaviour management plans and staff training were being developed through links with the local Learning Disabilities Team. People living at Rivendell said that they decided what they do each day. One person talked about her work outside the home and trips to a nearby town. Others were seen following their own routines and being offered choices such as going swimming. Discussion with the Registered Manager and Service Manager confirmed that changes in staffing arrangements were being negotiated so that daily routines could be made more person-centred. Since the last inspection, people living at Rivendell have been helped to open their own accounts and given more control over their money which is paid into the accounts. Some small amounts of cash are held for people in each house. New secure storage is being put in place for this. We checked a sample of these cash amounts in one house. Detailed records and receipts were kept and these agreed with the amounts of cash held for each person. Rivendell DS0000003790.V332642.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People lead active, interesting lives at Rivendell and within the wider community. Ongoing reorganisation will improve the range of opportunities available to people. EVIDENCE: All the people living at Rivendell with whom we spoke were happy with their life there and felt that they could do what they wanted. Rivendell has its own day service that is also attended by residents from another HFT home in nearby Kingsteignton. The day service is provided in a purpose built building and a variety of activities are offered: computers, pottery, drama, woodwork, cooking, gardening, photography, animal care, art and craft. Rivendell DS0000003790.V332642.R01.S.doc Version 5.2 Page 14 In the community some residents have work or College placements and participate in activities such as bowls, horse riding, swimming, theatre, cinema, going to the pub and meals out. Recently, people had become involved in running local coffee mornings. Some staff commented that low staffing numbers in the evenings and at weekends curtailed community activities at these times. At the time of this inspection visit, a rearrangement in staffing and in the day services was being negotiated. This was discussed with the Registered Manager and Service Manager. The purpose of this reorganisation was to increase the range of opportunities available to people and increase individual choice. There is also a growing emphasis on gaining access to opportunities in the wider community. A care manager commented: “X has a varied range of activities that he accesses through the on-site day service, many of them connected to the outdoors, e.g. gardening and animal husbandry. However, he is also able to have a community presence in Chudleigh, and is also undertaking bus training to go further afield (with support from HFT initially)” Relatives who returned written comments were positive about the way in which they were able to keep in touch. Comments included: “We have our son home up to three times a year. We meet the staff and talk to them each time we visit”, and “Try to keep family ties. Endeavour to adapt to individual needs. High proportion of very caring staff. Good quality of care” Observation during the visit and discussion with staff showed that people’s friendships and relationships were respected. People living at Rivendell could take friends to their rooms and take time alone if they wished. The main meal is eaten at lunchtime during the week in a communal dining hall. We joined residents for a meal on the first day of the visit; there was a choice of two different meals. The meal was taken in a lively and friendly atmosphere which people said they enjoyed. Staff and residents sat together and staff were observed to be assisting residents sensitively. Several residents who did not wish to eat in the dining hall could eat in one of the houses. Staff prepare breakfast and tea with resident support in the separate houses. People in their own flats prepare snacks and breakfast for themselves. People with whom we spoke said they usually enjoyed the meals. Records showed regular weight checks and special dietary needs catered for. Menus and information for residents were not yet provided in a user-friendly format. Rivendell DS0000003790.V332642.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19, 20 and 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Rivendell can feel confident that they will receive the personal and health care they need. There have been improvements in the use of medicines which has reduced potential risks. EVIDENCE: All the care managers who returned surveys felt that people’s healthcare needs were being met. Comments were made such as: “It was evident from the review that X’s health care needs are met as necessary by Home Farm Trust support staff. His key worker is the main person who monitors his health and any medication needs” and “I noted a good rapport between X and care staff. With support X is now accessing health care services. X had lacked confidence in this in the past” Records and discussion with staff and the managers showed there were appropriate links with healthcare professionals. All the people living at Rivendell DS0000003790.V332642.R01.S.doc Version 5.2 Page 16 Rivendell have a local Doctor. Individual files contained records of both routine and specialist treatments. One person was approaching the end of life and required substantial personal care. Aids and adaptations such as a pressure relieving mattress and a bed with sides and protective cushions were in place. Healthcare notes were seen as well as detailed guidance for staff in matters of personal care. Information had been prepared on the person’s and family’s wishes in the event of death. Discussion with the Manager and staff demonstrated their awareness, understanding and sensitivity to this person’s needs. In other files charts were seen concerning epileptic seizures and weight. However, as stated above, the content of individual files was extremely variable and did not always appear to reflect the needs of the person. The staff training programme showed that there was ongoing staff training in topics relevant to individuals’ personal care needs. This included forthcoming training for staff in invasive medical procedures. Staff were observed during the Inspection providing personal care to residents. Staff were sensitive, and respectful of resident’s privacy and dignity and when spoken with were knowledgeable about how residents liked to be supported. We examined how medicines were administered in the home. Risk assessments had been conducted to check whether residents were able to administer their own medication. The system examined in two houses and we observed medication being administered in one. Medicines were securely stored with additional security for controlled drugs. Records were up to date, accurate and in good order. In one instance the supplying pharmacy had made an error in the pre-printed record. This had been noticed by staff the correct action taken. A sound process was seen during the administration of medicine involving two staff who both signed the record sheet. There were clear records of medicines returned to the pharmacy. In one house a very clear stock control sheet was seen which aided the process of auditing the medicines held in the home. Rivendell DS0000003790.V332642.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 22 and 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living at Rivendell can feel confident that staff will listen to their concerns and act upon them. Staff are also sufficiently well trained in safeguarding people from abuse. EVIDENCE: People living at Rivendell who spoke with us said that they felt that staff listened to them and would act on what they said. Rivendell has a complaints procedure which was seen on display. Since the last inspection the Commission’s address has been added to this. Of three surveys returned to us by relatives, two stated that they knew how to make a complaint. Comments included: “If we need to complain the staff will listen to us”, and “Have had no need to complain in the years our son has been at Rivendell” Further reminders concerning the complaints procedure had yet to be sent to relatives as recommended at the last inspection. There were clear records of all complaints and the action taken. The staff with whom we spoke were clear about issues of abuse and could identify appropriate ways of reporting it. The staff training records showed that there was ongoing training in safeguarding vulnerable adults from abuse. Rivendell DS0000003790.V332642.R01.S.doc Version 5.2 Page 18 Copies of the local procedures were available in the home together with the local “No Secrets” training video. Rivendell DS0000003790.V332642.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Rivendell is a sufficiently clean, safe, homely and comfortable place for people to live. EVIDENCE: During this visit we toured the premises and spoke with the home’s maintenance staff. All parts of the home were furnished and decorated in a comfortable and homely style. People’s rooms were individualised with personal possessions, ornaments and pictures and they took evident pride in these. The individual rooms were lockable and their occupants had been offered a key. In general, the houses and communal areas were sufficiently clean and well decorated. Evidence was seen of ongoing maintenance and redecoration. One person’s room had recently been fitted with an electrically controlled door. A Rivendell DS0000003790.V332642.R01.S.doc Version 5.2 Page 20 person living in this house told us that a walk-in shower was due to be fitted on the ground floor. This was confirmed by the home’s maintenance staff. One bedroom in the “farmhouse” smelt damp and musty and there was mould growth in the bathroom. Records were seen confirming recent safety checks such as legionella testing and the testing of electrical circuits. Tests of personal appliances expired in June 2007 and were therefore overdue. Managers and maintenance personell were aware of this and were planning to address the issue. Maintenance logs are currently held centrally. However, at the time of this inspection, there were plans to hold a separate log in each house. Some windows on the upper floors were restricted. Risk assessments were not available for all the windows that were not restricted indicating that this was safe for people living in the home. Each house had its own domestic scale laundry facilities. Staff were clear about procedures for handling heavily soiled and potentially infected laundry. Rivendell DS0000003790.V332642.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 33, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Rivendell are supported by a committed and caring staff team. Issues concerning staff training and supervision are being effectively addressed to improve the service. EVIDENCE: We examined four staff files and spoke with staff, residents and managers about staffing issues. The service users with whom we spoke felt that staff would listen to them and act upon what they said. During the visit, staff were seen to be respectful, helpful and supportive towards people living at the home. In surveys returned to us a care manager commented “I was impressed with the length of time that X’s key worker has worked with him and the support that is offered (to X and his mother). The review also highlighted the various skills of the other staff who support X with his various day time activities” Rivendell DS0000003790.V332642.R01.S.doc Version 5.2 Page 22 and a relative stated “High proportion of very caring staff. Good quality of care” Some staff expressed the view that there were not enough staff available during the day as it was not now automatic for people to use the on-site day service. One relative commented: “There are always staff shortages and changes and if the situation could be improved the resident could perhaps feel more secure” At the time of this inspection visit consultations were taking place with staff in preparation for a reorganisation of working times. This was part of a wider strategy to give more independence and responsibility to individual houses, reorganise day services and ensure appropriate numbers of staff were available at particular times. Further clarification was needed to demonstrate how the additional funding for people requiring extra support was being deployed. Staff described a sound recruitment process involving a formal application, references, criminal records checks and an interview. This was confirmed in the records we examined which included statements of terms and conditions. Training issues identified at the last inspection had been addressed or were in the process of being addressed . A clear training strategy had been developed which identified individual training needs. For example, training was being undertaken in food hygiene for those staff handling food. Training concerning people whose behaviour challenges the service was being developed in consultation between the Principal Social Worker of HFT and the local specialist team. In the last 6 months a “professional passport” has been introduced for staff, an example of which was seen. This breaks down each staff member’s role and identifies the competencies they need to carry out their work. It therefore provides a means both of appraisal and identifying individual areas for further development. Staff with whom we spoke confirmed that progress had been made in reintroducing regular supervision. Two staff confirmed that they had supervision appointments during the inspection visits. Regular team meetings were being held, the minutes of which were held in individual houses. A meeting for the whole site was being planned at the time of this visit. Rivendell DS0000003790.V332642.R01.S.doc Version 5.2 Page 23 Rivendell DS0000003790.V332642.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home is introducing many improvements to benefit people living at Rivendell. These changes are being well-managed. EVIDENCE: The registered manager has sufficient qualifications and experience to manage Rivendell. She holds a National Vocational Qualification (NVQ) at level 4 in Management and a Certificate in Social Service. Additionally, she holds an NVQ assessors qualification. Before the inspection visit we met with a Service Manager employed by HFT to support the management of the home to introduce a programme of improvements. There were further discussions with the Registered Manager and the Service Manager during the inspection visit and feedback session. Rivendell DS0000003790.V332642.R01.S.doc Version 5.2 Page 25 It was clear from these discussions, talks with staff and residents and examination of records that Rivendell is in a period of substantial change. These changes include most aspects of the service including, for example, care planning, lifestyles, policies and procedures, staffing arrangements and the reorganisation of day services on the site. The changes so far have been introduced in a planned manner in consultation with HFT’s central organisation. Copies of action plans were seen during this inspection. The changes have addressed or seek to address a number of issues highlighted at the last key inspection. This work has resulted in evident improvements in areas such as the management of residents’ monies, medication issues and staff training. Whilst there has been some delay in meeting the timescales set in the some of the requirements made at the last inspection, it was evident that there was a clear strategy in place and a commitment to meeting targets set for improvement. During a tour of the premises we examined health and safety issues. Records concerning health and safety were also examined during a discussion with the home’s maintenance personnel. The staff training plan showed training regarding issues such as food hygiene, moving and handling and fire safety. Records were seen which included certificates of inspection for hoists used on the site, contracts for electrical repairs, gas safety and legionella checks. Each house held its own fire log and all except one of these was up to date. Each house had been provided with a copy of the Food Standards Agency’s manual “Safer Food Better Business”. Accidents and incidents were being monitored centrally and feedback on trends provided to the home. Regular reports were being made following visits to the home required by regulation. These form part of the home’s quality assurance system. It was evident from the multiple changes occurring at the time of this visit that concerted action was taking place as part of a quality assurance exercise. People living at the home were involved in elements of this such as the development of user friendly literature. Rivendell DS0000003790.V332642.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 x 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 X X 3 X Rivendell DS0000003790.V332642.R01.S.doc Version 5.2 Page 27 Yes 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 YA2 Regulation 14 (1)(2) Requirement Each resident must have a detailed assessment of his or her needs, which is kept under review and revised when necessary. Each resident must have a detailed plan that records how his or her needs, identified in the assessment and risk assessment will be met. This plan must be kept under review and be accessible to the resident. Each resident must have a detailed risk assessment to identify and as far as possible eliminate risks that might affect his or her health and safety. Risk assessments must be completed for all environmental hazards (In particular risk assessments must be completed for all unrestricted upper floor windows) There must be clear records as to the additional staffing DS0000003790.V332642.R01.S.doc Timescale for action 01/02/08 2. YA6 15 (1)(2) 01/02/08 3. YA9 13(4) 01/02/08 4 YA24 13(4)(c) 01/02/08 5 YA33 18(1)(a) 01/02/08 Rivendell Version 5.2 Page 28 arrangements for individuals where this is being specifically funded. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA17 YA22 YA24 Good Practice Recommendations Menus and information for residents should include the use of photos or pictures to make them accessible. Residents’ relatives should be reminded of Rivendell’s complaints procedure. The musty odour in one bedroom and mould growth in the bathroom of the “farmhouse” should be eliminated. Rivendell DS0000003790.V332642.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Rivendell DS0000003790.V332642.R01.S.doc Version 5.2 Page 30 - 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. 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