Inspection on 21/06/05 for Riverside Mews

This inspection was carried out on 21st June 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Riverside Mews 02/10/09

Riverside Mews 08/10/07

Riverside Mews 01/08/06

Riverside Mews 08/12/05

Riverside Mews 07/02/05

Riverside Mews 09/08/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Riverside Mews Ancholme Court Market Place Brigg North Lincs DN20 8LD Lead Inspector Stephen Robertshaw Unannounced 23 August 2005 rd 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 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. Riverside Mews J54 s2906 Riverside UI v233883 230805 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Riverside Mews Address Ancholme Court Market Place Brigg North Lincs DN20 8LD 01652 653414 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) North Lincolnshire Care Ltd Mrs Jan Pursey Care Home 25 Category(ies) of DE(E) (5), OP (25) registration, with number of places Riverside Mews J54 s2906 Riverside UI v233883 230805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: There are no conditions to the registration of the home. Date of last inspection 31st March 2005 Brief Description of the Service: Riverside Mews is a care home providing personal care and accommodation for 25 older people. North Lincolnshire Care Limited owns and manages the home. The home is a converted Victorian property extending to three floors with a ground floor extension. All the homes bedrooms are single and there is a shaft lift connecting all three floors. Riverside Mews is a well-established care home in the market town of Brigg. It is set in the middle of the town overlooking the river Ancolme. There is easy access to all of the town facilities and events, including the weekly market. There are ample toilets and bathroom areas in the home. The dining room, and several bedrooms overlook the river, with very pleasant views. The home caters for predominately low to medium dependency service users, with problems of old age and other associated medical problems. Five of the bedrooms are registered for EMI care. Staff have received appropriate training in relation to Peg feeds for service users. The home has a relatively stable work force, that appears to be very committed to the home and promoting service users’ independence as much as they are able to, and for as long as is possible. Riverside Mews J54 s2906 Riverside UI v233883 230805 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of the home was an unannounced visit and was over seven hours. The inspector was able to speak to the service users, visitors to the home, staff and managers to gain the information for this report. The home provides a very comfortable setting and atmosphere for the service users. The service users appear to be very happy with their environment and the care that they receive at the home. What the service does well: What has improved since the last inspection? The Protection of Vulnerable Adults policy in the home has been updated. This makes sure that the service users in the home are protected from any abusive situations, and things are in place if any abusive situations arise. The damaged bathroom floor on the second floor had been replaced. Riverside Mews J54 s2906 Riverside UI v233883 230805 Stage 4.doc Version 1.30 Page 6 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. Riverside Mews J54 s2906 Riverside UI v233883 230805 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Riverside Mews J54 s2906 Riverside UI v233883 230805 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3,4 and 5 The home does not provide intermediate care. Service users have good opportunities to visit the home, and have a trial period there before they make a decision to stay on a more permanent basis. EVIDENCE: The inspector observed the case files of three service users, and the preadmission assessment of a prospective service user. All of the service users needs had been identified, and provision made to how they should be met at the home. Individuals placed at the home through care management all had care management assessments, and care plans included in their files. Service users and visitors spoken to by the inspector stated that service users were given the opportunity to visit the home before they made a decision to move there on a more permanent basis. They also confirmed that service users are encouraged to personalise their rooms to their own tastes and preferences. Riverside Mews J54 s2906 Riverside UI v233883 230805 Stage 4.doc Version 1.30 Page 9 Records of service user meetings evidenced that the service users are encouraged to give their views on how the home is run, and what activities are included. Care plans included written information of activities that the service users enjoyed, and the actual activities that they became involved in either in the community, or in the home itself. Riverside Mews J54 s2906 Riverside UI v233883 230805 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,9,10 and 11 The service users healthcare needs are generally met at the home, however some areas of healthcare need to be improved. EVIDENCE: The service users case files all included care plans completed by the home that met the assessed needs of the individual service users. Where appropriate the care plans were also supported by risk assessments. The care plans had not all been signed in agreement by the service users, or their representatives so therefore there was no written evidence that they agreed to the care they were receiving. Discussions with service users confirmed that they received the care that they require in their day-to-day lives at the home. Care plans in the home identified the last wishes of the service users in the event of their deaths. The inspector observed the case file of a recently deceased service user, and this confirmed the care that they received and the contact maintained with their family, friends, and healthcare professionals by the home. Riverside Mews J54 s2906 Riverside UI v233883 230805 Stage 4.doc Version 1.30 Page 11 The medication records in the home were observed to be recorded up to date. The recording of some of the controlled drugs in the home was not up to the correct standard and could put service users health at risk. Staff administering medication in the home receive accredited medication training before they are given this responsibility. Direct and indirect observations confirmed that the service users are treated with dignity and respect at all times in the home. The service users confirmed to the inspector that if they have any visits from family, friends, or healthcare professionals then these can always take place in private. Service users stated to the inspector that if they have any healthcare needs then these are always met by the correct healthcare professional. Individual service users case records identified any contact they had with professionals including GP’s, district nurses and dentists. Riverside Mews J54 s2906 Riverside UI v233883 230805 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13 and 15 The service users at the home can have visitors at any reasonable time, and they receive three meals a day, and these include choice and a varied and appealing diet. EVIDENCE: Visitors to the home, and service users confirmed to the inspector that the homes links to the community were very good. Visitors stated that they often see service users in the town with support from the homes staff. The service users and the visitors seen by the inspector said that visitors are encouraged to visit the home, and when they arrive they are always made to feel welcome. The inspector ate lunch with the service users. Appropriate support was observed to be offered to individual service users to eat their meals, a choice of meal was available and the presentation of the food was very good. The homes kitchen was very clean, and there were plentiful stocks of food in the fridge, freezers and dry stores. Riverside Mews J54 s2906 Riverside UI v233883 230805 Stage 4.doc Version 1.30 Page 13 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 standard(s) 16 and 18 The homes policies and procedures for complaints and the Protection of Vulnerable Adults ensure the safety of vulnerable people at the home. EVIDENCE: There had been no complaints recorded at the home since the last inspection, however interviews with staff, and discussions with service users identified that they were aware of how to raise complaints if they had one, and were confident that they would be dealt with appropriately by the management of the home. The homes policy and procedure for the Protection of Vulnerable Adults has been updated, and the home staff receive training in this area. Any concerns of abuse are immediately reported to the appropriate authorities by the home, and all staff interviewed were aware of the reporting procedures of suspected abuse. Riverside Mews J54 s2906 Riverside UI v233883 230805 Stage 4.doc Version 1.30 Page 14 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 standard(s) 19,20,21,23,24,25 and 26 The home meets most of the health and safety requirements that is required of it in relation to the environment. All of the moving and handling equipment in the home is well maintained and serviced. Service users individual rooms include furniture and fittings that are appropriate to their needs. The home is very accessible, and is kept clean, tidy and free from any bad smells. Any previous requirements in relation to the environment were generally met. EVIDENCE: A tour of the premises by the inspector confirmed that there are appropriate communal spaces for the service users to use, and these are well maintained and decorated. Riverside Mews J54 s2906 Riverside UI v233883 230805 Stage 4.doc Version 1.30 Page 15 Several service users showed the inspector their individual rooms and these were all personalised to their own tastes and preferences. This included pictures, ornaments, and some items of furniture. Service users stated that this helped them to settle in to the home having things around them that they cherished. The bathrooms and toilets are well spaced around the home, and are close to communal areas that the service users share. Some rooms did not include all of the furniture and fittings that are required by the National Minimum Standards, however where this was identified, the service users involved had a risk assessment included in their care files stating why certain items were not available. All service users spoken to by the inspector were very content with the furniture and fittings supplied in their rooms. New thermostatic valves have been fitted to hot water outlets in the home. The temperatures must be maintained close to forty-three degrees celcious to ensure the safety of the service users. The temperatures of the water through the hot water outlets measured between twenty-nine and thirty-one degree celcious. There was also exposed hot water pipes in the home this could cause injury to the service users if their skin came in to contact with them. The home is maintained very clean and tidy. The service users confirmed that the home is always clean, and that they have no concerns in the hygiene in the home. Riverside Mews J54 s2906 Riverside UI v233883 230805 Stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30 The home with its current commitment should achieve a minimum of 50 of the care staff to have achieved NVQ 2 or equivalent by 31st December 2005. The home does not follow appropriate employment policies and procedures that ensures the safety of the service users. EVIDENCE: The training records in the home confirmed that approximately 47 of the care staff in the home have already achieved NVQ 2 or equivalent. Six staff have completed NVQ 2 in care, and another member of staff is registered on the award. One member of staff has achieved NVQ 3 in care, and a further two staff are registered on the award. One member of staff has completed a City and Guilds certificate in care skills. New staff to the home are interviewed in accordance with equal opportunities, however the management of the home were employing staff to work at the home before they had received clearance through POVA First, or full CRB clearances. This could place vulnerable service users at risk of abuse from staff without appropriate safety checks. Riverside Mews J54 s2906 Riverside UI v233883 230805 Stage 4.doc Version 1.30 Page 17 An immediate requirement was issued in relation to the employment of new workers at the home and the importance of the new staff receiving the appropriate safety clearances before they begin work at the home. Until a full CRB clearance is received new staff can commence work following the receipt of a POVA First, but must not work unsupervised until a full enhanced Criminal Record Bureau clearance has been received by the home. New staff also receive induction training that meets the requirements of the National Training Organisation workforce training targets. The staff training records in the home evidenced that the mandatory training requirements for the staff are met, and are on a rolling programme of renewal in the home. Discussions with service users identified that they believe that the staff in the home have the necessary skills and abilities to care for and meet all of their needs. Riverside Mews J54 s2906 Riverside UI v233883 230805 Stage 4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,35,36 and 38 The management of the home meet most of the service users health and safety requirements. However there were serious concerns in relation to the safety of the gas supply to the home. EVIDENCE: The home had recently had the gas system serviced and the engineer had condemned the system as not having an adequate air supply. The proprietor stated to the inspector the engineer had failed to identify an additional air supply to the system and this was the problem with the certificate. An immediate requirement was issued in relation to obtaining a completed gas systems safety certificate. A new linen store had been created on one of the upstairs corridors. A curtain was placed across it. As this is accessible to anyone passing through it could Riverside Mews J54 s2906 Riverside UI v233883 230805 Stage 4.doc Version 1.30 Page 19 cause problems with the control and spread of infection. This could also provide a fire hazard. The manager of the home is working towards the Registered Managers Award and with her current progress should complete it before the end of 2005. The service users, visitors to the home, and the staff confirmed that the management approach to the home is open, positive, and inclusive. This standard was exceeded. Verbal references for staff are not always followed up by the home, this practice could place service users at risk of abuse. The quality assurance and monitoring system in the home has improved from previous inspections, however the system is not yet complete. The home sends out questionnaires to service users, family, friends, and outside professionals. The information received back to the home is analysed, and graphs, and pie charts representing the results of the surveys are created. New questionnaires have been introduced by the home. These include more room for quality responses as opposed to tick box answers. This should give clearer detail of how service could be improved at the home that would benefit the service users. The quality assurance results and plan are not yet published. The home has a newsletter that these results could be published in. The results of the surveys were identified as being discussed in service user, and staff meetings. The homes newsletters also include activities and events that are taking place in the local community. Service users pocket money accounts were all well managed. However good practice should include two signatures for any transactions made. Riverside Mews J54 s2906 Riverside UI v233883 230805 Stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 x 3 3 2 4 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 4 2 x 2 2 x 1 Riverside Mews J54 s2906 Riverside UI v233883 230805 Stage 4.doc Version 1.30 Page 21 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 7 Regulation 15 Requirement The registered person must ensure that all of the individual care plans in the home are evaluated on a minimum of a monthly basis. The registered person must ensure that all of the medication records in the home are appropriatly recorded, and the medication involved is accounted for. The registered person must ensure that the temperature of the hot water at the outlets is close to forty three degrees celcious to ensure the safety of the service users. The registered person must ensure that a minimum of 50 0f the care staff have achieved NVQ . The registered person must ensure that prospective new employees to the home have the appropriate POVA First, and CRB clearances befroe they commence work at the home The registered person must ensure that the homes manager has achieved a minimum of the reistered Managers award or J54 s2906 Riverside UI v233883 230805 Stage 4.doc Timescale for action 31 October 2005 2. 9 12 immediate 3. 25 12 31 September 2005 4. 28 18 31 december 2005 immediate 5. 29 18 6. 31 8 31 December 2005 Page 22 Riverside Mews Version 1.30 equivalent. 7. 33 24 The registered person must ensure that the home has an appropriate quality assurance and monitoring system in place to ensure the safety and well being of the service users. The registered person must ensure that all service users pocket money accounts are counter signed for each transaction. The registered person must ensure that all verbal references for new staff are followed uo by a written reference. The registered manager must ensure that the gas supply to the home is certified as being safe to protect the service users living there. The registered person must ensure that the new linen store is secored to ensure the control of infection and disease in the home. The registered person must ensure that all hot water pipework and radiators in the home are protected with low temperature surfaces. 31 November 2005 8. 34 20 31 August 2005 9. 36 18 31 August 2005 immediate 10. 38 12 11. 38 12 immediate. 12. 25 16 01 October 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Riverside Mews J54 s2906 Riverside UI v233883 230805 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Unit 3, Hesslewood Country Office Park Ferriby Road Hessle East Yorkshire HU13 0QF 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 Riverside Mews J54 s2906 Riverside UI v233883 230805 Stage 4.doc Version 1.30 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!