Inspection on 06/12/06 for Rivendell [Chudleigh]

This inspection was carried out on 6th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 no outstanding requirements from the previous inspection report, but made 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Rivendell [Chudleigh] 04/10/07

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 Sam Sly Unannounced Inspection 6th December 2006 09:30 Rivendell DS0000003790.V314971.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.V314971.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.V314971.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 Margaret Lesley Wick Care Home 36 Category(ies) of Learning disability (36) registration, with number of places Rivendell DS0000003790.V314971.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th January 2006 Brief Description of the Service: Rivendell is one of a number of homes provided by HFT (formerly Home Farm Trust), 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. The site has recently had a Disability Discrimination Act 2005 audit and an action plan is in place to ensure longer-term compliance. The weekly fee levels for Rivendell range from: £272.29 - £1714.77. Additional charges are made for some leisure activities, hairdressing, holidays, personal toiletries, partial television licence, and papers/magazines. Some staff, residents and relatives said that they had not seen the Commission’s most recent report for Rivendell. The registered manager said she would make sure the report was available in the future. Rivendell DS0000003790.V314971.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit took place at Rivendell during two weekdays in November. The Inspector also stayed on into the evening on the first day. Residents, staff, the registered manager Lesley Wick and the responsible individual for HFT; Paul Rosam were spoken with during this time. Paul Rosam has been in post with Rivendell for six months. All types of written records were looked and a tour most of the premises were carried out. To write this report all the records of contact the Commission has had with Rivendell since the last inspection were looked at. The registered manager provided information too. Twenty of the residents, sixteen staff, sixteen relatives, and three care managers returned comment cards to the Commission. All the standards that the Commission thinks are most important were looked at during the inspection process. What the service does well: There are some areas of good practice where staff have been trained and are putting into place ‘person-centred’ plans for residents. Residents generally lead active, interesting lives at Rivendell and in the wider community. HFT is continually looking to improve the activities residents participate in, and involve residents in decision-making. HFT has taken proactive steps to ensure the buildings and services will be compliant with the Disability Discrimination Act 2005, and has put together an action plan. HFT also has good policies and procedures that reflect good practice for working with people with learning disabilities. Staff have the training and understanding to protect residents from abuse. The environment at Rivendell is generally clean, homely and residents are involved in choosing the décor. Staff are described by relatives, care managers and residents as caring and enthusiastic and undertake a range of training appropriate to their roles. Residents feel able to approach staff if they are unhappy. Rivendell DS0000003790.V314971.R01.S.doc Version 5.2 Page 6 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. Rivendell DS0000003790.V314971.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rivendell DS0000003790.V314971.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lack of information given to residents, means they are not clear about their rights and responsibilities. The lack of detailed assessments means resident’s needs are not always identified or met. EVIDENCE: No new residents have moved to Rivendell since the last Inspection. Care planning files for four residents were examined in detail and four more were examined in less detail during visits to different houses. The quality and detail of assessment was varied. All residents had assessments carried out by the Local placing Authority, however this was often many years ago and there was no standardised assessment format that detailed changing needs. The responsible individual said Rivendell was currently piloting a new assessment process for HFT. Some behavioural needs observed during the visit were not detailed in assessments or care plans and resident’s abilities to manage their own money and medication were not being routinely assessed to promote selfmanagement. Residents that returned comment cards to the Commission said that they had been provided with information before moving to Rivendell and made decisions Rivendell DS0000003790.V314971.R01.S.doc Version 5.2 Page 9 about moving. However, none of the residents spoken with during the visit had a copy of an up-to-date Service User Guide or contract. The Statement of Purpose for Rivendell is not up-to-date and does not reflect the current services. Rivendell DS0000003790.V314971.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lack of clear care plans and comprehensive risk assessments for all residents means needs are not always being met. Residents are supported to make decisions about their lives, but do not have sufficient control over their finances. EVIDENCE: Care planning files for four residents were examined in detail and these residents were observed or spoken with. Four more care plans were examined in less detail during visits to different houses and again these residents were spoken with or observed. Staff were also spoken with or observed whilst supporting residents. The care plans examined ranged greatly in quality and content. Some good practice ‘person-centred’ planning (PCP) had taken place with some residents, their representatives and professionals, and certain staff had received training on facilitating PCP. One plan had been photographed and formed the basis of the person’s day activity programme. There were also descriptive records of how a person liked to have personal support given. Other care planning files Rivendell DS0000003790.V314971.R01.S.doc Version 5.2 Page 11 did not have clear care plans, instead they recorded that care had been given, but the care detailed did not link to an assessment of need. Some residents had received reviews including professionals and family, however, these reviews were not linked to a care plan either. Some residents received extra staff support and it was not clear from care plans what this support was meant to achieve. Some residents required moving and handling techniques and care plans did not always detail clearly the support staff should give. Staff spoken with said they had received moving and handling training however, there was no record of this training on the training information given to the Commission. The quality and content of risk assessments varied, one of the team leaders was in the process of doing risk assessments for each resident that required moving and handling in two of the houses, this was not happening with all residents. One resident had a detailed behavioural plan developed with a professional. Other residents who required behavioural plans to give staff direction on how to support them did not have plans. Staff had not received training on supporting people who challenge, or on developing behavioural plans. The responsible individual Paul Rosam said that this had been identified as a training need and a trainer approached. Accident, incident, behaviour and epileptic seizure charts were being kept for different residents, however the information was not being systematically evaluated to inform the review of care plans. Residents who returned comment cards to the Commission or who were spoken with during the visit said they always or usually made decisions about what they did. One resident said he chooses to work locally at the weekends. Residents are given opportunities to meet together once a week, or to meet at house meetings to discuss issues. The responsible individual has asked two professionals to come and give residents support to make meetings really meaningful. Two residents said they attend a self-advocacy group locally. The registered individual Paul Rosam said that he was aware that Rivendell was not following the HFT policy on managing resident’s money and he had taken proactive steps to remedy this. Residents spoken with were able to access their pocket money easily, and records were kept in each house. However, residents did not have information available on what income they had and did not have copies of their bank accounts at hand. A representative of HFT is the Department of Work & Pensions appointee for most residents and steps are being made to ensure resident’s benefits are paid directly into their personal bank accounts. Rivendell DS0000003790.V314971.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents lead interesting active lives at Rivendell and within the wider community, however at weekends and during the evenings community presence can be restricted due to insufficient staff numbers. Residents enjoy a balanced, enjoyable diet. EVIDENCE: A resident that returned comments to the Commission said ‘I like living at Rivendell and I like living in my house’ Some staff that returned comments to the Commission said that changes to improve the service could include: ‘moving closer to the community’ and ‘expanding the service users network.’ ‘More 1:1 for service users who need it. More support in providing the less able with opportunities’. Rivendell has an inclusive 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, Rivendell DS0000003790.V314971.R01.S.doc Version 5.2 Page 13 pottery, drama, woodwork, cooking, gardening, photography, animal care, art and craft. Some of the art products made and photographs taken by residents were seen during the visit and were of a high quality and well presented. One resident’s artwork has gained national recognition. One resident said: ‘I do like to go to day care but sometimes the noise is terrible then I don’t want to be there.’ The registered manager said this comment would be looked into and action taken. 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. One resident said they would like to go out more often, and there was evidence from staff comments and observations that low staffing numbers in the evenings and at weekends curtailed community activities at these times. Relatives that returned comment cards to the Commission all said they were made welcome, could see their resident in private and were kept informed and consulted about decisions in relation to their resident. Relatives said: ‘X has lived at Rivendell for many years. I have never had to make a complaint. The conditions are really good and the staff are excellent and very caring’ ‘we are grateful that X has a place with HFT the care received is excellent and the atmosphere is always happy and friendly’. HFT had recently carried out an audit to ensure the buildings and services provided at Rivendell complied with the Disability Discrimination Act 2005. The responsible individual, to meet shortfalls, had drawn up an action plan. HFT had some equality and diversity policies and provide some training. The main meal is eaten at lunchtime during the week in a communal dining hall. This meal was shared with residents on both days during the Inspection; there was a choice of two or three different meals. It is a lively, noisy time, which those residents spoken with said they enjoyed. Staff and resident sit 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, or those residents in their own flats prepare snacks and breakfast for themselves. Residents spoken with said the meals were good. Residents were regularly weighed and special dietary needs catered for. The menu is discussed and agreed at resident meetings. Discussion with residents found that the written menu and staffing rotas were inaccessible to those who could not read. Residents felt photos, symbols and pictures would help this information be accessible to everyone. Rivendell DS0000003790.V314971.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff provide resident’s personal care and health care support in ways residents prefer and require. Shortfalls in the staff medication administration procedures could put residents at risk. EVIDENCE: The responsible individual said that all staff that administered medication had received training, staff confirmed this, however certificates were not available, and the training records sent to the Commission did not include medication training. Medication records and procedures were examined and observed in several of the houses. In one house there were gaps in the records of medication administered by staff. A notice was issued to the responsible individual to ensure medication was administered safely immediately. Some resident’s medication records contained their photo’s to make the administration process safer, some did not. Written records of medication received was not being checked and signed by two staff for safety. Risk assessments were not being routinely carried out to promote the selfadministration of medication by residents. Records of medication returned to the Pharmacy were not being kept. Rivendell DS0000003790.V314971.R01.S.doc Version 5.2 Page 15 Records and discussion with staff and the managers showed that appropriate referrals are made to specialist health and social care professionals. All residents had local Doctors and saw dentists and had other regular health checks. Some staff had received training on early-onset dementia so they could be vigilant for any signs of deteriorating health in those residents with Down’s syndrome. 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. This support was not always backed up with detailed care planning. Three care managers returned comments to the Commission. They all said that staff understood the needs of residents, they were informed of events affecting the welfare of residents and they were satisfied with the overall care provided. Comments included ‘I am made to feel very welcome when visiting. A holistic approach to care benefiting clients.’ ‘I was impressed with the home, the staff and the way service users felt they could easily communicate their needs, wishes and concerns.’ Rivendell DS0000003790.V314971.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and their relatives do not have the necessary information to complain, and a robust procedure is not in use. Staff have awareness about how to protect residents for abuse, however behavioural incidents that are affecting the welfare of residents are not being dealt with. EVIDENCE: Residents who returned comment cards to the Commission said they knew who to go to if they were unhappy; several gave staff names. However, half of them did not know how to make a complaint and seven of the sixteen relatives were not aware of Rivendell’s complaints procedure. There was no complaints procedure displayed in any of the houses visited. There was a HFT complaints policy and procedure, however there was some information missing; the local Commission contact details, local Authority contact details and investigation timescale details. The registered manager had recorded that two complaints had been received from residents, and she talked about the action that had been taken to investigate this. However, residents had not been told that their complaint would be dealt within in a set timescale and the complaints book did not contain records of the investigation. When the complainants were spoken with they gave different views from the registered manager on what they thought the outcome of their complaint was. The majority of staff had received adult protection training, and several senior staff had undertaken training for trainers. There were sufficient adult Rivendell DS0000003790.V314971.R01.S.doc Version 5.2 Page 17 protection procedures in place. The local Authority Alerter’s Guidance was not available to all staff. The registered manager is reporting incidents that affect the welfare of residents to the appropriate Agencies including the Commission. Staff spoken with were able to demonstrate an awareness of abuse and the procedure to follow. However, several incidents of resident’s physical aggression directed towards staff and other residents, unwanted physical contact and self-harm recorded on incident sheets, observed during the visit, and reported to the Commission by a resident and relatives were not being managed in a planned way by staff. One resident commented to the Commission that they were getting hit by another resident and would like this to get sorted. The responsible individual was aware of this and was dealing with it through the complaints procedures. Rivendell DS0000003790.V314971.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment at Rivendell is homely, well decorated and in good repair, however without regular checks it will not remain this way or be safe and hygienic. EVIDENCE: Eighteen residents that returned comments to the Commission said the environment at Rivendell is always or usually clean and fresh. Residents spoken with were proud of the bedrooms and their houses, and were happy to show them off. Bedrooms reflected the personalities of the residents, and they chose décor. Bedroom doors were lockable and residents offered a key. The environment was generally clean, homely and bright with day-to-day and longer-term maintenance and renewal taking place. A maintenance team was employed at Rivendell. Two houses had just had new kitchens installed. Regular environmental risk assessments and maintenance checks were not taking place, which meant maintenance issues were not always quickly picked up and acted on. A programme was shown that indicated that checks on fire Rivendell DS0000003790.V314971.R01.S.doc Version 5.2 Page 19 systems, security, and on the structure of the building should be taking place. The cupboard doors and fridge handle in one flat were broken and the registered manager had not been informed. The sofa in one house was hard to get out of once sat in, and this could potentially restrict the movements of residents. Some food handling procedures being adhered to in the central kitchen that prepared lunches each day were not being adhered to in the houses where breakfast and tea was prepared and served and food was stored. Flies were observed landing on food preparation surfaces in two houses, there were no insect killing devices being used. Fridge and freezer temperatures were not being monitored and recorded and food was not routinely wrapped and dated when stored in fridges in the houses. A meat temperature probe was not used to check that meat was properly cooked before serving in the houses. Each house was domestic is style and included a washing machine and dryer in the kitchen area, as well as a separate laundry room for heavily soiled laundry. There was no written procedure for staff to follow to ensure soiled laundry is only washed in the commercial laundry, and to prevent to spread of infection through the misuse of the washing machines in the kitchen area. The environmental health department or the Fire service has not visited Rivendell since 2003. Rivendell DS0000003790.V314971.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are protected by the staff recruitment practices at Rivendell and are supported by enthusiastic, caring staff. However, the insufficient numbers of staff, lack of supervision and lack of certain training means staff cannot always meet resident’s needs. EVIDENCE: All the residents that returned comments to the Commission said staff always or usually treated them well and listened and acted on what they said. Some residents named particular staff as listening to them. Half those relatives that returned comment cards to the Commission did not think there was sufficient numbers of staff at Rivendell. Comments were: ‘day activities are fairly well covered but a shortage of staff means that evening activities are curtailed and have been for some time.’ ‘I cannot wish for more except someone to take X out of the campus.’ Staff that were spoken with or that returned comment cards to the Commission also often felt that more staff were required. It was observed during the evening of the visit that in several houses staff were extremely busy with meal preparation and household tasks and not able to spend time with residents. In one house one staff member was responsible for nine residents. Rivendell DS0000003790.V314971.R01.S.doc Version 5.2 Page 21 Staff said that it was very difficult to take residents out in the evenings and at weekends due to these staffing levels. It was reported that sometimes the staffing levels funded by the Local Authority to provide extra support for particular residents was not provided consistently due to sickness or staff shortages. The staffing in one house ceases on a Saturday and Sunday at 3pm. One resident explained this was because they were independent in this house. These residents could phone another house if they require assistance, however records indicated that during the un-staffed times behavioural incidents that affect the welfare of other residents occur. Also these residents are unlikely to go out in the community at these times due to the lack of staff support. Some staff felt that the residents who required more support did not get the same opportunities as those requiring less support: ‘More 1:1 is needed with service users who need it. More support in providing the less able with opportunities.’ Half the staff that returned comments to the Commission said they had enough support from Rivendell to do their job well. Staff felt Rivendell ‘offered support to service users to extend themselves, and respected their views’ ‘provides a happy home for all our service users with plenty of leisure and activities for a social life’ ‘the standard of care is very good’. Staff singled out the new day care manager and training co-ordinator for praise. The responsible individual for all new, and some of the longer-term staff are introducing an induction programme in January 2007. Some staff spoken with did not have the required food handling training and were preparing meals. Others did have this training, however basic food hygiene practices were observed to not being adhered to, putting residents at risk of food poisoning. A high proportion of staff have achieved NVQ at levels 2 and above. Other training staff have received in 2005/06 has been: epilepsy, communication, protection of vulnerable adults, basic first aid, recording skills, diversity awareness, basic food hygiene, dementia, fire awareness, and person centred planning. Staff did not have training files with copies of the Certificates received for training. It had been recognised by the responsible individual that staff required behavioural management training and this was being arranged. There was also no overall staff training plan, linked to the training needs of staff identified in supervision or residents care plans with timescales for completion. Certain training that the responsible individual and staff said had happened; medication administration and moving and handling were not recorded on the training records sent to the Commission. Four staff files were examined in detail and records showed that appropriate recruitment procedures including criminal record bureau checks (CRB), references, forms of identification, application forms and interviews had taken place before employment. Rivendell DS0000003790.V314971.R01.S.doc Version 5.2 Page 22 The responsible individual and registered manager had identified that supervision for staff is presently inadequate. Staff that returned comments to the Commission said ‘meetings are arranged and cancelled.’ The supervision arrangements for relief and bank staff are also are not sufficient. A staff member commented to the Commission: ‘as a relief worker, apparently I am only entitled to one supervision a year, this has never been offered to me’. Staff meetings and management meetings were being held and records kept, these records did not always show time was given for staff to air their views and one staff member had commented to the Commission that ‘more communication is needed, there is a lack of time for discussion as there are no staff breaks/staff room.’ Rivendell DS0000003790.V314971.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Rivendell is currently not a well run home, however the Owners have acknowledged this and are working hard towards making the necessary improvements. Shortfalls in the fire precautions at Rivendell put residents at risk. EVIDENCE: Comments received by the Commission from relatives and staff and acknowledged by the responsible individual Paul Rosam and registered manager Lesley Wick indicate that Rivendell has gone through a lot of changes in the time since the last Inspection, due to significant shortfalls being identified in the service. This was described as ‘over the last few years standards have really been allowed to slip and it is a big job to bring it back up to level.’ The responsible individual has put together a thirty-four point action plan to improve the service provided to residents. The HFT area manager is Rivendell DS0000003790.V314971.R01.S.doc Version 5.2 Page 24 supporting the responsible individual regularly and the registered manager is receiving regular supervision from the responsible individual. It shows promise that the responsible individual has identified, in the six months he has been in post, and has put together an action plan to resolve many of the requirements identified during this inspection. Comments from staff received by the Commission indicated that staff felt the new responsible individual Paul Rosam is ‘sorting out issues that should have been looked at by the previous management’ and staff members described Paul Rosam as ‘a new manager who is bringing new ideas that seem to be working.’ ‘Paul seems to be a great force for good’. The registered manager has sufficient qualifications and experience to manage Rivendell with NVQ 4 and the Registered Manager Award plus an NVQ Assessors qualification. The comments received by staff indicated that at times some staff did not feel they receive the support, guidance, and leadership that they required from their team leaders. Some staff felt there was little cohesion between houses and day care, and that communication could be better all around. The responsible individual said that HFT had carried out a staff questionnaire recently and received similar comments, which they were addressing. A tour of the houses found that wedges were being routinely used to keep fire doors open, some fire doors did not close tightly and the required fire checks had ceased when a maintenance person had left several weeks before. The responsible individual bought and started a new fire check book during the inspection. A notice was issued to the responsible individual during the inspection to ensure wedges were removed and checks were started again immediately. Other Central heating and gas checks had been carried out this year, as had electrical checks and hoist/adaptations checks. COSHH (harmful substances assessments) were in place. HFT had issued staff and managers at Rivendell with a comprehensive, good quality set of policies and procedures. The responsible individual Paul Rosam said that he had already identified that staff at Rivendell were not implementing these policies and procedures, and this was on his action plan. HFT has a Quality Assurance system policy and has undertaken themed quality monitoring exercises, the most recent being on the day service. Residents have been involved in giving their views. Surveys are being sent out to family, staff and Commissioners every two years and audited by an independent company. The staff survey was recently sent out. The responsible individual was did not know if the Quality Assurance system included an annual development plan, although he felt the action plan he had recently written was Rivendell DS0000003790.V314971.R01.S.doc Version 5.2 Page 25 based on a systematic appraisal of the service. The policy stated that regular visits were to be carried out by Regional Directors and Service Managers according to a format complying with the Commission’s requirements, however this was not happening. Rivendell DS0000003790.V314971.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 2 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 2 X 2 2 X 1 X Rivendell DS0000003790.V314971.R01.S.doc Version 5.2 Page 27 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. Where necessary, residents must have plans to identify, and as far as possible eliminate risks arising from behaviours that challenge. 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. The registered person must make arrangements for the safe recording of medication. The registered person must make arrangements for the safe disposal of medication. (This refers to having a suitable returns procedure). DS0000003790.V314971.R01.S.doc Timescale for action 12/03/07 2. YA6 15 (1)(2) 12/03/07 3. YA6 13(4)(c) 12/03/07 4. YA9 13(4) 12/03/07 5. 6. YA20 YA20 13(2) 13(2) 07/12/06 12/01/07 Rivendell Version 5.2 Page 28 7. YA22 22 The complaints procedure must be accessible to residents, and must contain the appropriate information. Records must be kept that detail that appropriate complaint investigations have been carried out by the registered person. Risks to the health and safety of residents must as far as possible be eliminated. (This refers to the behavioural incidents identified during the Inspection where residents are experiencing self-harm, or are being affected by the behaviours of others). All parts of the service must be kept in a good state of repair. (This refers to a regular environmental risk assessment and maintenance checks being carried out and acted on). Suitable arrangement must be in place to prevent the spread of infection. (This refers to having a policy and procedures in place for taking dirty laundry to the washing machines that are situated in kitchens). At all times there must be appropriate numbers of staff to meet the needs of residents. (This refers to the particular residents who are funded for additional support, as well as for other residents). Staff must have training appropriate to their work and implement this training. (This refers to all staff that prepare food receiving training and implementing safe food handling techniques). Staff must have regular suitable supervision. DS0000003790.V314971.R01.S.doc 12/01/07 8. YA23 13(4)(c) 12/03/07 9. YA24 23(2) 12/03/07 10. YA30 13(3) 12/03/07 11. YA33 YA7YA13 18(1)(a) 12/02/07 12. YA35 18(1)(c) 12/02/07 13. YA36 18(2) 12/03/07 Rivendell Version 5.2 Page 29 14. YA42 23(4) The registered person must take adequate fire precautions. (No wedges must be used on fire doors, all fire doors must close tightly and regular checks of fire precautions must take place and be recorded). 07/12/06 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 YA1 YA1 YA6 Good Practice Recommendations Each resident should have a copy of an up-to-date Service User Guide with a copy of his or her contract in it. The Statement of Purpose should be up-to-date and reflect the current service provided at Rivendell. Where necessary, residents should have detailed written moving and handling plans. Care plans should detail any 1:1 or additional staff support that is being funded. The HFT policy on resident’s finances should be implemented fully. Each resident should have access to their bank statements, and should have information on how much money they have and what benefits they receive. Incident and accident reports, seizure charts and behavioural charts should be regularly analysed and results should be reflected in care plans. Menus and information for residents should include the use of photos or pictures to make them accessible. Clear records should be kept of staff who have been trained to give invasive medical interventions. All resident’s medication records should include a photo of the resident. There should be a system in place to monitor the medication procedures until they are safe. Written medication records should be checked and signed by two staff. 4. YA7 5. 6. 7. 8. YA9 YA17 YA19 YA20 Rivendell DS0000003790.V314971.R01.S.doc Version 5.2 Page 30 A medication risk assessment should be in place to promote self-medication. 9. 10. 11. 12. 13. YA22 YA23 YA24 YA30 YA30 The medication policy should be easily accessible to staff. Resident’s relatives should be reminded of Rivendell’s complaints procedure. There should be a copy of the Local Authority Alerter’s Guidance accessible to all staff. The sofas identified as restricting the movement of residents should be changed and the broken cupboard doors and fridge handle identified should be mended. There should be devices to prevent flies contaminating food preparation areas. Fridge and freezer temperatures should be recorded in all the houses, food should be appropriately wrapped, and dated in fridges and freezers. Meat temperature probes should be used with records kept. The Food Standards Agency Safer food better business guidance should be introduced. Staff should have appropriate behavioural management training to meet the needs of the residents they are supporting Staff team meetings should have an agenda, space for staff to air their views and discuss issues, and an action plan. The registered manager should be aware of issues that come out of staff meetings. There should be an overall staff training plan that not only records training delivered but also details training that is identified through supervisions and appraisals with timescales. Each staff member should have a training file, which includes copies of their training certificates. An employee of HFT who is not directly concerned with the conduct of the home should visit the home at least monthly, and a report should be sent to the Commission. The Quality Assurance system should include an annual development plan that is made available to the Commission and other interested parties. The HFT policies and procedures in place should be implemented. 14. 15. YA32 YA33 16. YA35 17. YA39 18. YA40 Rivendell DS0000003790.V314971.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Rivendell DS0000003790.V314971.R01.S.doc Version 5.2 Page 32 - 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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