Inspection on 05/10/06 for Riverhead Hall Nursing Home

This inspection was carried out on 5th October 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Riverhead Hall Nursing Home 04/10/07

Riverhead Hall Nursing Home 09/01/06

Riverhead Hall Nursing Home 13/09/05

Riverhead Hall Nursing Home 01/03/05

Riverhead Hall Nursing Home 05/10/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Riverhead Hall Nursing Home Limited Riverhead Driffield East Yorkshire YO25 6NU Lead Inspector Anne Prankitt Key Unannounced Inspection 5th October 2006 09:10 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 Riverhead Hall Nursing Home Limited DS0000000948.V304249.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. Riverhead Hall Nursing Home Limited DS0000000948.V304249.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Riverhead Hall Nursing Home Limited Address Riverhead Driffield East Yorkshire YO25 6NU 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) 01377 253863 01377 257665 Wellburn Care Homes Limited Post Vacant Care Home 34 Category(ies) of Dementia - over 65 years of age (34), Old age, registration, with number not falling within any other category (34), of places Physical disability (4), Physical disability over 65 years of age (34), Terminally ill (6) Riverhead Hall Nursing Home Limited DS0000000948.V304249.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users admitted under the category of (PD) to be aged 50 years upwards and require nursing care. 9th January 2006 Date of last inspection Brief Description of the Service: Riverhead Hall is registered to provide nursing care and accommodation for up to 34 people. The registration allows the home to admit older people who require nursing care who have a disability, who are terminally ill, or who suffer from a dementia. The home is situated in beautiful grounds on the outskirts of the market town of Driffield. There are parking facilities within the grounds. The home provides two lounges, a dining room and a conservatory. There is also a patio area overlooking the garden. Since the last inspection, the home is now under the new ownership of Wellburn Care Homes Limited. The Commission was informed on 4 August 2006 that the current range of fees was £406 - £640 per week. Additional charges are made for chiropody, hairdressing and newspapers. Information about the home is given to service users within the Statement of Purpose, a copy of which is provided to them on admission. Riverhead Hall Nursing Home Limited DS0000000948.V304249.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the site visit, the previous manager provided certain information about the home within a ‘pre inspection questionnaire’. In addition, information about what has been happening at the home since the last inspection, has been collected by the inspector as part of an ‘Inspection Record’. Comment cards were sent to General Practitioners and Care Managers who visit the home. Four in total were returned. All of the information collected, including that which was gathered at the site visit, was used as part of the key inspection. The site visit lasted eight and a half hours. It was conducted by one inspector. Five hours preparation took place beforehand. The acting manager was available throughout, and feedback was provided to her at the end. The site visit consisted of an inspection of the communal areas, and a sample of private bedrooms. Kitchen and laundry services were also looked at. A selection of documentation was looked at, including a sample of care plans, health and safety records, staff records and residents’ monies. Quality assurance was discussed. Some staff, residents and relatives were spoken with, and time was spent watching the general activity at the home. What the service does well: Riverhead Hall provides a homely atmosphere for service users. There is a core of staff who have worked at the home for a number of years, and who know the residents well. Comments from service users included ‘Overall I am satisfied with the care’. A relative stated ‘I am happy that my relative’s needs are met’. Staff meet prospective residents before they are admitted, and look at their current needs and whether they can be met, before deciding whether the home would be appropriate for them. Residents also have the opportunity to look around the home before they decide whether it is suitable for them. Staff seek the advice of outside health professionals where it is identified that help is needed, so that residents needs can continue to be met. Comments from health professionals included ‘I feel Riverhead provides excellent care’. Riverhead Hall Nursing Home Limited DS0000000948.V304249.R01.S.doc Version 5.2 Page 6 Visitors are welcome at the home at any time. One visitor stated ‘I can come and go as I please and I can eat here if I want’. The acting manager of the home takes complaints seriously, and staff understand the importance of passing on any concerns to her in order to protect residents from risk. What has improved since the last inspection? What they could do better: Care plans could provide more up to date information to reflect the care that is being provided, and risk assessments need to be introduced, with priority being given to those residents where risk has been identified. Improvements could be made to the medication system, to ensure that the medication stored is in date. Staff must also remember that medicines prescribed for a resident are their property, and should not be shared with any other resident who may be prescribed the same medication. The way in which staff are vetted before they begin to work at the home must be made more rigorous, so that residents are protected from unsuitable workers. Some matters which relate to health and safety also need to be improved upon, and include fire safety arrangements, safe use of bed rails, safe storage Riverhead Hall Nursing Home Limited DS0000000948.V304249.R01.S.doc Version 5.2 Page 7 of denture cleansing tablets, and arrangement to have serviced some facilities at the home. 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. Riverhead Hall Nursing Home Limited DS0000000948.V304249.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Riverhead Hall Nursing Home Limited DS0000000948.V304249.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. Service users can be assured that their needs will be assessed before they are admitted to the home. This will help to ensure that their admission to the home is appropriate to meet their needs. This judgement is made using available evidence including a site visit to the service. EVIDENCE: The staff carry out a pre admission assessment for prospective service users. They collect information from other agencies, such as the hospital or care manager, before deciding whether the needs of the service user can be met at the home. Service users are invited to visit the home to have a look round before deciding whether it is suitable for them. The acting manager explained that the home provides care and accommodation for service users who are referred to them by the intermediate care team if there are any vacancies available. The company employs a physiotherapist who will assist in the programme of rehabilitation if needed. Other rehabilitation activities are provided by the local hospital, and are Riverhead Hall Nursing Home Limited DS0000000948.V304249.R01.S.doc Version 5.2 Page 10 arranged by the intermediate care team. There were no service users admitted for intermediate care at the time of the site visit. Therefore it was not possible to seek any views about the service provided to them. Riverhead Hall Nursing Home Limited DS0000000948.V304249.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. Service users are cared for by staff who seek advice from other professionals where it is identified that it is needed. However, omissions in the care plans may result in risks associated with their care not being properly understood. This judgement is made using available evidence including a site visit to the service. EVIDENCE: The acting manager explained that new care plans are in the process of being introduced at the home, in line with Wellburn Care Homes Limited documentation. She recognises that there are some shortfalls in the current documentation, which did not always provide a true reflection of the care that was being provided to service users, or of current associated risks. Some of the care plan documentation, including risk assessments, was not completed, and there were some gaps in their review. This would cause problems should the home employ the services of agency staff, as they may find it difficult to gain a true picture of the care needed by the individual concerned. Discussion took place about those matters which should be addressed as priority within the care plans, so that important issues, especially pertaining to areas of risk associated with care are clearly recorded. For instance, one service user had Riverhead Hall Nursing Home Limited DS0000000948.V304249.R01.S.doc Version 5.2 Page 12 rails fitted to their bed. The pre inspection information stated that these were not used prior to being admitted to the home, and the accident book recorded an incident following admission where the service user had attempted to vacate the bed while the rails were in position. The acting manager was required to complete a risk assessment for the service user concerned to check whether the rails were necessary. She was also asked to review the care plan in place for the management of falls, as it was agreed that the recorded action to be taken by staff with regard to the restriction of mobility may not be to the satisfaction of the service user concerned. In practice however, staff were seen to assist the service user with dignity and patience. However, from observations made, discussion with service users and relatives, and from references seen within the daily records, it could be evidenced that the staff at the home are in regular contact with the General Practitioner, and that they seek advice from the dietician, tissue viability nurse and other key members of the community health team to ensure that service users receive the care and equipment that they require to meet their needs. The acting manager was reminded that staff should also inform the Commission for Social Care Inspection where service users are admitted with, or develop at the home, a pressure sore which is Grade 2 or above. Comments from health professionals included ‘I feel Riverhead provides excellent care’. Comments from service users included ‘Overall I am satisfied with the care’. A relative stated ‘I am happy that my relative’s needs are met’. Service users were observed being treated with respect by staff, and personal care was carried out in private. Screening was provided in shared rooms, and service users were able to see visitors in private, if this was their wish. Medication kept on behalf of the service users is received into and signed out of the home by the acting manager. The medication arrives in blister packs. There were good records kept of medication administered in the case of both general and controlled medication, which was stored appropriately. There is one service user who self medicates in part, and for whom a risk assessment was seen. The acting manager stated that one other service user who chooses to self medicate also has a risk assessment in place. She confirmed that their medication is kept in the locked facilities provided to them. The following issues were raised: • Medication, such as Lactulose and Paracetamol, was being dispensed to a number of service users from one bottle or package, rather than from the medication dispensed solely for their use. This is not good practice. Temazepam is stored appropriately, but is not recorded in the Controlled Drugs register. It would be good practice for this to be introduced. There were two medications to be used in the case of an emergency, which were out of date in 2000. Whilst there were duplicates available which were in date, staff must ensure that the stock is checked on a • • Riverhead Hall Nursing Home Limited DS0000000948.V304249.R01.S.doc Version 5.2 Page 13 regular basis. This will reduce the risk of service users receiving medication which is no longer effective, or which may cause them harm. • One eye drops did not record the date that it had been opened, or when it needed to be disposed of. This means that the service user could have been receiving medication which was out of date or no longer effective. Riverhead Hall Nursing Home Limited DS0000000948.V304249.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. Service users can maintain important contact with family and friends. However, their quality of life may be further improved with the introduction of additional activities. This judgement is made using available evidence including a site visit to the service. EVIDENCE: In the absence of an activities co-ordinator, the activities programme is coordinated by a member of nursing staff. The acting manager explained that it consists of mainly group activities, but that there is also a library, which provides ‘talking books’, and staff attempt to spend one to one time with service users. A communion service is held monthly at the home by the local vicar, and the Roman Catholic priest visits individual service users. This assists in meeting the spiritual needs of those service users who currently live at the home. Occasional trips out are organised. The acting manager stated that the service users at the home have in the past been reluctant to become involved in activities that have been provided. There were no activities organised during the day of the site visit. One service user and their visitor stated that there was ‘not a lot going on’. Service users watched television, or chatted amongst themselves or with visitors. A number of newspapers had been delivered, and were waiting to be distributed to the individuals for whom they had been ordered. It is planned that an activities programme will be Riverhead Hall Nursing Home Limited DS0000000948.V304249.R01.S.doc Version 5.2 Page 15 formalised, and all service users will be provided with a copy, so that they can decide what they would like to attend. The arrangements for visiting are very flexible, and relatives are welcomed into the home at any time. They may visit service users in communal areas, or in their own rooms if this is their choice. One visitor stated ‘I can come and go as I please and I can eat here if I want’. Generally, service users spoken with thought that there was some flexibility in the routine. One service user explained how they were able to maintain their independence as much as possible, with help from staff. Bedrooms were individualised, and contained personal belongings. The dining room was nicely set out. Although there was insufficient seating should all service users wish to eat together, the acting manager explained that additional chairs and tables were available. The lunchtime meal looked appetising and wholesome. There were sufficient staff available to assist where required in a dignified way. The cook explained that the menus have recently been amended by the company, to provide advertised choice at each mealtime, although service users are currently offered alternatives if they do not like the meal on offer. Service users are asked in advance their choice of meal, and the cook is able to make amendments to the menu should this be necessary. Dietary needs are catered for. These currently include diabetic and soft diets. Enriched diets are also provided for service users who have experienced weight loss. The home has recently achieved the ‘Heartbeat Award’, in recognition of the healthy food that is provided. There was a good supply of fresh vegetables and fruit, and meat is delivered fresh on a regular basis. Cold drinks were available in the communal areas for service users to enjoy between meals, and food and fluids are available over a twenty four hour period. Riverhead Hall Nursing Home Limited DS0000000948.V304249.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. Service users can be assured that the manager will take their complaints seriously. This judgement is made using available evidence including a site visit to the service. EVIDENCE: There was no record of any complaints having been made to the home during the period since the last inspection, and there have been none made directly to the Commission for Social Care Inspection. Service users and relatives consulted were satisfied, should they have any complaints, that these would be dealt with by the home. Comments from service users included ‘I could complain to the manager’, ‘I would think that I could complain to the manager if necessary’. Comments from relatives included ‘I have no complaints. Any complaints I did have the manager would sort out’, ‘I can go to the office if I have any issues’. One issue that had not been brought to the attention of the manager was discussed with her at the site visit. She took the matter seriously, and stated that she would look into the matter through staff supervision. The complaints procedure is included in the Statement of Purpose. It would be good practice for this to be posted in a public area of the home. Staff have received training in abuse awareness, and all spoken with were clear about their responsibilities in reporting matters of suspected abuse to the manager, who in turn, knew their responsibilities in referring such matters to the local authority for investigation. Staff understood that they were not in a position to keep secrets, in order to protect the service users who live at the home. Riverhead Hall Nursing Home Limited DS0000000948.V304249.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. Service users live in an environment which is clean and pleasant, and the company recognises where further improvements could be made for the benefit of those who live there, and are acting upon this. This judgement is made using available evidence including a site visit to the service. EVIDENCE: The environment is homely, and service users appeared comfortable. It was spotlessly clean, free from offensive odours, and a credit to the cleaning staff. It is surrounded by beautiful grounds, which service users enjoy. One stated ‘I have the best seat here. I can look out onto the gardens’. The home is subject to a programme of redecoration. The front door and the conservatory door are fitted with a mortice type lock. The key was kept in the door of the conservatory, and the key for the front door was hung in the entrance hall. The locking device, and the way in which the keys are stored, has not previously been raised as an issue when the fire Riverhead Hall Nursing Home Limited DS0000000948.V304249.R01.S.doc Version 5.2 Page 18 officer has inspected the home. However, in light of the recent changes in fire legislation, the registered person must consult with the fire safety officer to check that this system remains acceptable to them, and the fire safety risk assessment updated following their advice. The bathroom to the top floor of the home is currently used for storage of equipment. The acting manager explained that the facilities are not suitable for use. However, she explained that the company is currently looking at a plan of refurbishment of the room. This is good practice, and would allow service users to have a bath on the floor on which they live. The laundry contained a range of suitable equipment. Washing machines have a sluicing facility, and there are sluice disinfector facilities in the main part of the home. Service users wear only their own clothes. The laundress was satisfied that she is provided with sufficient information from staff when they deliver soiled linen, so that she can take extra precautions, and the company will soon be providing ‘dissolvobags’ to further improve infection control measures. There was a supply of gloves and aprons available. Staff have recently undergone training in infection control. Riverhead Hall Nursing Home Limited DS0000000948.V304249.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. Whilst staff are appropriately trained, shortfalls in the current recruitment practices have the potential to place service users at unnecessary risk from unsuitable workers. This judgement is made using available evidence including a site visit to the service. EVIDENCE: On the day of the site visit, staff did not appear to be rushed. They were observed to explain to service users what assistance they were about to provide before they carried out the task. There were variable comments made about staffing availability. One service user commented ‘I feel that staff are rushed, but this may be due to my high expectations’. Another stated ‘The home is short of staff, but gaps are filled where possible’. A visitor stated that the atmosphere is relaxed, and that staff have the time to indulge in some light banter with their relative, which was appreciated. A service user stated ‘the staff are nice – there are plenty of them’. The acting manager stated that the staffing provision has been reviewed, and that it is the intention of the company that an extra member of care staff will be available each morning in the near future in order to further improve the staff availability. This is good practice. Within the three recruitment files seen, one staff member had been deployed upon receipt of a POVAFirst check, but no written references had been received. In the case of another, only one written reference had been Riverhead Hall Nursing Home Limited DS0000000948.V304249.R01.S.doc Version 5.2 Page 20 obtained. The acting manager stated that all staff who are deployed prior to the return of the Criminal Record Bureau Check are supervised and supernumerary. However, the recruitment procedures need to be improved upon to ensure that service users are properly protected from unsuitable workers. The home has an ongoing training programme in place. The majority of staff have recently undertaken a three day health and safety training course, which covered Moving and Handling, Fire Training, Food Hygiene, First Aid, and Infection Control. Training for the remainder of staff is planned in the near future. The staff member appointed as training co-ordinator carries out in house training, such as the use of hoisting equipment, and role play, to supplement the training sourced from outside the home. In addition to statutory training, a number of staff have also received training in dementia care, challenging behaviour and wound care. There is also an NVQ programme in place. Six staff have qualified at, and six are studying towards, NVQ 2 or above in care. Riverhead Hall Nursing Home Limited DS0000000948.V304249.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. Whilst the company is making positive steps towards improvements, protection of service users from unnecessary risk will be improved upon further once outstanding health and safety matters are fully addressed. This judgement is made using available evidence including a site visit to the service. EVIDENCE: The previous registered manager has retired from her position since the last inspection. The deputy manager has been promoted to the position of acting manager. She has worked at the home for a number of years, is a registered nurse, and has completed her Registered Managers Award. Staff and service users were complimentary about her input since taking over the manager position. She appreciates the support provided by the area manager for Wellburn Care Limited, who carries out regular visits to the home, following which they provide a detailed report to the Commission for Social Care Riverhead Hall Nursing Home Limited DS0000000948.V304249.R01.S.doc Version 5.2 Page 22 Inspection, and an action plan to the acting manager. She is aware of the challenges that the position as manager will pose, but was conscientious, and eager to progress. Representatives for Wellburn Care Homes Limited organised a meeting with service users and their families after acquiring the home, in order to introduce themselves, and to discuss some of their future plans. It appeared that a small minority of service users are still adapting to the changes, which include future plans to extend the home. One service user thought that the service had ‘gone down’, because they missed the ‘personal touch’ that the previous provider offered. However, on discussion, the acting manager explained that the area manager makes an effort to visit service users in their rooms during their visits. One comment made by a relative was that there were ‘no great changes’ to the service, except that it was ‘much more relaxed’, and that this was a positive outcome for the home. The acting manager explained that the quality assurance programme is in the early stages of development, but that progress is being made in seeking the views of service users, relatives and others who have an interest in the home. She explained that all service users have recently been provided with satisfaction surveys, and the results are now being collected. She explained that the residents’ meeting is overdue. It would be good practice for this to be reintroduced, as it would provide another method by which feedback from service users could be sought. As there were varying views collected during the site visit about the staffing provision and activities at the home, a good practice recommendation would be that, as part of the quality assurance programme, the acting manager carries out a survey in order to seek service users’ views formally, to identify what, if any, improvements could be made in each of the areas concerned. There are no service users for whom the home acts as appointee. Monies are handled by family members, and a small float kept for each service user. Families are approached where the service user requires more money, out of which hairdressing and chiropody is paid for on their behalf. Service users have lockable facilities where they are able to store valuables should they choose to do so. A member of the care staff has recently been appointed as health and safety person. They are responsible for the weekly fire alarm checks, and also for staff fire training that is supplementary to the annual training provided by a qualified trainer. Whilst staff have recently undertaken fire training as part of their health and safety training, the acting manager stated that this was the first to have been received for one year. However, from discussion with the health and safety person, and from the documents seen, it is evident that it is the intention of the company that this will be provided six monthly to day staff and three monthly to night staff. This is good practice. The fire training records were difficult to follow however. It is recommended that they are reviewed, so that they clearly identify who requires training, and when. In Riverhead Hall Nursing Home Limited DS0000000948.V304249.R01.S.doc Version 5.2 Page 23 addition to this, it is important that the fire alarm system is checked on a weekly basis. The records evidenced that this was not currently the case. The fire exit from the kitchen area was blocked, and therefore could not be easily accessed in the case of fire. The acting manager arranged for the area to be cleared immediately. One set of bed rails checked was loose and required attention. The acting manager was required to check all bed rails before next being used to ensure that they were safe and properly fitted, and to introduce a means of recording on a regular basis that this has been done. Denture cleansing tablets were kept in service users’ rooms, but were not locked in the facilities provided to them. The acting manager was required to check on the day of the site visit that those service users who keep their own denture cleansing tablets were safe to do so, to take appropriate steps where they were not, and to ensure that service users keep them locked away when not in use, so that the more vulnerable service users who may gain access to them are protected. The acting manager could recall a previous incident which had occurred as a result of denture cleansing tablets not being locked away, and identified immediately at least one service user that could be at risk under the current storage arrangements. She agreed that this assessment would be carried out forthwith. The health and safety person checks the hot water temperatures that are accessible to service users on a monthly basis. It was evident from the records that some temperatures had been too hot, and there was no remedial action recorded. However, the acting manager gave assurance that they had in fact been adjusted by the maintenance man. The temperature at which hot water was emitted from immersion baths was checked at the site visit, and was found to be satisfactory. There were good records kept within the kitchen area of cleaning schedules, fridge and freezer temperatures, and the temperature at which hot food is served. Stored food was dated and labelled. The home does not currently record the temperature at which food is delivered. The administrator is in the process of updating the health and safety maintenance records for the home. The service for the following systems is overdue: • • • The fixed wiring certificate expired on 26/09/06 The last gas landlords certificate was dated 21/04/05 The last legionella certificate is dated 16/09/04 There are some systems which have recently been serviced, but for which certificates are not yet available. Riverhead Hall Nursing Home Limited DS0000000948.V304249.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 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 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 1 Riverhead Hall Nursing Home Limited DS0000000948.V304249.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES 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 OP7 Regulation 13, 15 Requirement With regard to the care plan discussed during the site visit, the following action must be taken: A risk assessment must be completed for the use of bed rails, to ascertain whether or not they should be used • The care plan in place in relation to the recorded action to be taken by staff with regard to the restriction of mobility must be reviewed During the planned introduction of new care planning material, priority must be given to those service users’ care plans and associated risk assessments which are incomplete, missing, or not regularly reviewed. This includes risk assessments for bed rails, tissue viability and nutritional screening. • Medicines must only be administered to the person for whom they have been prescribed, labelled and DS0000000948.V304249.R01.S.doc Timescale for action 05/10/06 • 2 OP7 13, 15 30/11/06 3 OP9 13 05/10/06 Riverhead Hall Nursing Home Limited Version 5.2 Page 26 4 OP19 13, 23 5 OP29 19 supplied. The medication stock must be checked on a regular basis, and out of date stock removed. • The date at which eye drops must no longer be administered must be clearly recorded, and the medication disposed of. In light of recent changes in fire 31/10/06 legislation, the registered person must consult with the fire officer to check that the systems for maintaining the security of the building at the main entrance and conservatory remain acceptable to the fire authority. Following consultation, the registered person must update their fire safety risk assessment, and take any remedial action necessary following any recommendations and timescales made by the fire officer. The registered person must 05/10/06 ensure that, prior to deployment of staff, they have obtained two satisfactory written references relating to the applicant. • (Previous timescale of 09/01/06 not met) The registered manager must ensure that the weekly checks of fire alarms and emergency lighting are carried out. (Timescale of 30/01/06 not met) The kitchen final fire exit must be kept clear at all times. All bed rails must be checked before next being used to ensure that they are safe and properly fitted. Record must be kept to evidence that the equipment is 6 OP38 23 (4(v)) 05/10/06 Riverhead Hall Nursing Home Limited DS0000000948.V304249.R01.S.doc Version 5.2 Page 27 checked on a regular basis. The acting manager must carry out an assessment of risk based on the vulnerability of service users to ascertain: • Those service users who are able to manage their own denture cleansing tablets safely To take appropriate action where the assessment concludes that the service user is not able To ensure that denture cleansing tablets are kept in suitable locked facilities • • 7 OP38 13 The risk assessment must be formalised. A system must be devised in order that the delivery temperatures of meat can be obtained, and subsequently recorded. Action must be taken in order that the following systems are serviced, and/or a satisfactory certificate obtained: • • • Electrical fixed wiring Gas landlords certificate Legionella certificate 31/10/06 Riverhead Hall Nursing Home Limited DS0000000948.V304249.R01.S.doc Version 5.2 Page 28 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 4 Refer to Standard OP9 OP12 OP16 OP33 Good Practice Recommendations It would be good practice for the receipt, administration and disposal of Temazepam to be recorded in the controlled drugs register. The registered person should consider the provision of an activities co-ordinator. The complaints procedure should be posted in a public area of the home. The home should continue to develop the quality assurance systems at the home, seeking the views of service users, relatives and others with an interest in the home, such as visiting professionals. Consideration should be given to carrying out a survey which seeks the views of service users about staff availability and the provision of activities. It is recommended that the fire safety training records are reviewed, so that they identify clearly who has had training, when it has been received, and when an update is required. 5 OP38 Riverhead Hall Nursing Home Limited DS0000000948.V304249.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Riverhead Hall Nursing Home Limited DS0000000948.V304249.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. 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