Inspection on 08/12/05 for Riverside Mews

This inspection was carried out on 8th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Riverside Mews 02/10/09

Riverside Mews 08/10/07

Riverside Mews 01/08/06

Riverside Mews 21/06/05

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 Lincolnshire DN20 8LD Lead Inspector Sarah Urding Unannounced Inspection 8th December 2005 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Riverside Mews DS0000002906.V272315.R01.S.doc Version 5.0 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. Riverside Mews DS0000002906.V272315.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Riverside Mews Address Ancholme Court Market Place Brigg North Lincolnshire DN20 8LD 01652 653414 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) North Lincolnshire Care Limited Mrs Jan Pursey Care Home 25 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (25) of places Riverside Mews DS0000002906.V272315.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Condition of Registration is that the home only uses designated beds for the DE (E) category of service user. To admit 1 Service User under the age of 65 years Date of last inspection 23rd August 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 18th century warehouse extending to three floors with a conservatory on the ground floor. 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 Ancholme. 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 residents, 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 residents. The home has a relatively stable work force, that appears to be very committed to the home and promoting residents independence as much as they are able to, and for as long as is possible. Riverside Mews DS0000002906.V272315.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over a period of five hours. The building was looked around and a number of records and policies were inspected. Twelve of the nineteen residents and four staff were spoken to including the manager. What the service does well: What has improved since the last inspection? A number of improvements have taken place since the last inspection. Care plans are now evaluated on a monthly basis, so that if the needs of residents change this can be reflected. 50 of the care staff are now trained to NVQ level 2 which will improve standards and knowledge in the home. The home is now safely recruiting prospective staff. References and POVA First checks are always in place prior to staff starting work. This means that the people looking after residents are safe to do so. Riverside Mews DS0000002906.V272315.R01.S.doc Version 5.0 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 DS0000002906.V272315.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Riverside Mews DS0000002906.V272315.R01.S.doc Version 5.0 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 the following standard(s): 3, 6 The home is able to meet the needs of residents owing to a thorough assessment on admission. EVIDENCE: Residents undergo a thorough assessment of needs prior to admission, which demonstrates that the home works in partnership with residents, their families and health professionals to glean full information about the lives of residents. The assessment covers all aspects of standard 3.3 and is completed in detail and well presented. The assessment links clearly to the care plan. The home does not provide intermediate care. Riverside Mews DS0000002906.V272315.R01.S.doc Version 5.0 Page 9 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, 11 Resident’s health and personal care needs are well met by staff and carried out in a manner that maintains their dignity but the lack of consistent weighing of some residents undermines what is otherwise a robust system. EVIDENCE: All residents have a detailed plan of care that provides staff with the information they need to ensure needs are met. The plan is clearly presented and in a format that is understood by staff. This links in to the home’s assessment on admission and is reviewed on a regular basis and when needs change. Generally, residents’ health care needs are being clearly identified and met by the home. Appointments with all health professionals are recorded on the residents’ files. Residents spoken to are satisfied that staff access them to health care services they need. There are however inconsistencies in practice when it comes to the weighing of residents. Three files looked at indicated that residents should be weighed on a monthly basis due to certain conditions. Although it was clear that the home monitored the weight of these residents, this did not take place as frequently as specified. In discussion with the manager, it became clear that some of the timescales had been set by the home rather than care management. The manager should review the plans Riverside Mews DS0000002906.V272315.R01.S.doc Version 5.0 Page 10 according to assessed need or keep to the timescales identified. In discussion with staff there was an inconsistent response to how hygiene was managed when administering a PEG feed for one resident. Although staff were clear about the procedure and had received appropriate training, some staff were adamant that gloves should be worn whilst others stated that clean hands were sufficient. The manager informed the inspector that administering PEG feeds was not a sterile procedure and required clean hands only. It is recommended that this aspect of care be revisited with staff and a copy of the hygiene procedure placed in the resident’s care plan. The home’s policy for medication is sound and protects residents from potential abuse. Staff are trained in the administration of medication prior to taking on this role. Medication is stored appropriately, which includes controlled drugs. Staff carry out their duties in a positive and caring manner. They are aware of the need for sensitivities when carrying out personal care tasks. Residents said that staff treat them with respect and maintain their dignity. Riverside Mews DS0000002906.V272315.R01.S.doc Version 5.0 Page 11 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, 15 Social activities are well organised, creative and provide stimulation and interest for people living in the home. Meals are nutritious and balanced and offer a healthy and varied diet for residents. EVIDENCE: Residents’ lifestyle in the home satisfies their social, cultural religious and recreational needs. This was evidenced in care plans and in talking to residents. A range of weekly activities is offered in the home including bingo, arts and crafts, memory board, dominoes and board games, which residents were really positive about. The residents go out with staff to the local market and enjoy regular shopping trips. There was evidence that this took place during the inspection. Residents are able to attend church services in the community if they wish. Several residents receive regular communion. Other residents spoken to said that although they are religious they did not wish to practice at the present time. They were confident that if they wished to the home would facilitate this. Residents are involved directly in making decisions through residents meetings. Riverside Mews DS0000002906.V272315.R01.S.doc Version 5.0 Page 12 Contact with family and friends is promoted well by the home. Residents were positive about being able to see their friends and family when they wish. They said that staff welcome their family when they visit. Residents are encouraged to maintain choice and control over their lives on a daily basis. Staff spoken to described how they ensure that residents are consulted with and empowered to make their own decisions. This ensures that residents maintain their independence for as long as possible and that staff are aware of treating people in a positive and inclusive manner. On admission a copy of “Care Aware” is given to residents and their families, which contains details of a range of advocacy service available to them. This is good practice. A number of people in the home commented about the food and how good it was. One resident said, “The food is good. They try to please us as much as they can”. Menus were found to be well balanced and varied. Choice is offered at every meal and care plans evidence the likes and dislikes of all residents. Riverside Mews DS0000002906.V272315.R01.S.doc Version 5.0 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 the following standard(s): 16, 18 Arrangements for complaints and the protection of vulnerable adults are handled well and ensure that residents’ feel listened to and protected. EVIDENCE: The home has a clear complaints procedure in place. Residents spoken to said that they had no complaints about the home but felt confident to raise issues of concern if they arose. Complaints are recorded and addressed by the manager. There had been several complaints since the last inspection, which evidenced how the complaint was dealt with and the outcome. Not all complaints however demonstrated the residents’ level of satisfaction with the outcome. This should be recorded consistently. One record of complaint had not been completed so did not demonstrate that the home had addressed this. The manager assured the inspector that this was a recording oversight and that it had been addressed. This is accepted as all other complaints indicated a swift response and detailed a conclusion. The home has an appropriate policy in place for the protection of vulnerable adults. Staff spoken to were clear about reporting procedures should a resident make an allegation and around the indicators of abuse. Residents spoken to said that they felt safe when being looked after by staff. A copy of the Area Adult Protection Guidelines was present in the home. Riverside Mews DS0000002906.V272315.R01.S.doc Version 5.0 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 the following standard(s): 19, 25, 26 The home is well maintained and very clean providing residents with a pleasant, homely and comfortable environment in which to live. EVIDENCE: Residents live in clean and comfortable surroundings that are well maintained. Residents commented on how lovely and clean the home was kept. The environment was kept to a high standard in terms of cleanliness and décor. A plan is in place outlining the work that has been undertaken in the home over the past year. This included the re-decoration of one residents room; the fitting of radiator covers; the purchase of new bedspreads; the re-decoration of the lounge, stairs and downstairs toilet and the fitting of a non-slip flooring in the bathroom. The manager discussed future plans that she has for the redecoration of the home. A plan was not available for inspection however it was clear that the home’s upkeep was of priority and an ongoing process. It is recommended that a projected plan of routine maintenance be produced so that the home can demonstrate its intent in maintaining standards. Riverside Mews DS0000002906.V272315.R01.S.doc Version 5.0 Page 15 A requirement made at the last inspection regarding the temperature of hot water could not be reassessed due to work to the hot water system in the home on the day of inspection. It was evident however from the homes records that there are on going fluctuations in the temperature of the hot water. At times the temperature of the hot water exceeds 43oC. Systems are in place to ensure that when residents bathe the temperature of the water is monitored by staff and maintained at a safe level. However the temperature at residents’ hand basins cannot be so closely supervised. There are some hand basins that are fitted with pre-set valves but others do not have this facility. It is recommended that the manager risk assess those residents who are not provided with pre-set valves to maintain temperature at their hand basins and provide this facility where the risk from scalding is evident. Good practices were observed in the areas of infection control and the homes policies on this were comprehensive. Appropriate facilities were in place for the laundering of clothes and residents commented upon how clean their clothes were on return form the laundry. Riverside Mews DS0000002906.V272315.R01.S.doc Version 5.0 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 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, 30 Residents’ needs are met by the good level of staffing and training provided in the home. Residents are protected by the home’s recruitment procedures. EVIDENCE: The home is well staffed at all times. Four staff are on duty throughout the morning and three members of staff are on duty in the afternoon, supported by the manager. The home employs one domestic and two cooks. Two staff are on duty at night. A senior member of staff is on duty at all times. The home meets the standard on training staff to NVQ level 2. Currently 50 of staff are trained to this level additional staff are currently undertaking this training. This is good practice. Recruitment practice in the home is adequate to ensure that residents are protected. Application forms are fully completed and gaps in employment explored. Written references and POVA First checks are in place prior to staff starting work. This ensures that residents will be looked after by safe people. Staff are trained appropriately and receive a thorough induction. Staff spoken to feel supported well by colleagues and senior members of staff. Riverside Mews DS0000002906.V272315.R01.S.doc Version 5.0 Page 17 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, 32, 33, 35, 36, 37, 38 The good management and administration of the home ensures that residents live in an environment that is safe and protects their interests but more attention to detail is required in some of the records kept by the home. EVIDENCE: The registered manager has fifteen years experience in running the home. She has recently completed the Registered Manager’s Award and is awaiting confirmation of certification. Staff spoken to said they felt supported by the manager and they were clear about their roles and responsibilities. The staff team is experienced and supportive of each other. Staff were particularly positive about the strengths of the manager and the way in which they were supported. They feel able to raise issues readily and that they are listened to. The manager is clear in her direction of staff. The home does not have a high turnover of staff and this stability ensures that the home is consistently managed. Riverside Mews DS0000002906.V272315.R01.S.doc Version 5.0 Page 18 High levels of consultation and regular reviews by the manager ensure that residents are looked after in an environment that is both safe and inclusive. The home operates an effective quality assurance system that seeks the views of residents and staff on a regular basis. It would be good practice if the views of health professionals were sought in this process. There is a monthly audit system in place that looks at key areas aimed at improving standards. Staff are supervised frequently and records are kept. Supervision levels meet the standard. Residents are protected by the financial procedures of the home. The home does not act as appointee for any residents and looks after the money for residents appropriately. Written records of all transactions are accurately maintained. The home has detailed policies and procedures in place. Appropriate records are kept but there is a current shortfall in the detail of some residents’ accidents. It was not clear in all accounts how accidents occurred as the descriptions were poorly worded and lacked clarity. This must be addressed so that residents’ safety can be monitored. The home operates in the best interests of the health and safety of residents and staff. All safety checks are carried out within the specified time frame and policies are in place for safe working practice. There is one matter that requires attention form the manager regarding the home’s gas safety certificate. Whilst the system is reported as safe, the remedial work identified is yet to be completed. The manager said that there is a disagreement around the identified work and is confident that the existing system is adequately ventilated. This situation must not be ignored and the responsible person must seek a second opinion if the disagreement cannot be resolved. This matter must be given priority. All staff receive health and safety training. Riverside Mews DS0000002906.V272315.R01.S.doc Version 5.0 Page 19 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 X 3 3 2 2 Riverside Mews DS0000002906.V272315.R01.S.doc Version 5.0 Page 20 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 OP8 Regulation 12, 13 Requirement Timescale for action 31/12/05 2. OP25 12, 23 3. OP37 17 4. OP38 12, 23 Needs identified in care plans must be followed. Weighing of residents must take place within the timescales specified. The registered person must 31/01/06 ensure that the temperature of the hot water at hand basins is close to forty-three degrees Celsius to ensure the safety of the residents. Risk assessments must be carried out to identify those residents who are at risk from scalding. Records must be appropriately 31/12/05 kept. Records of complaints must be fully completed and evidence the complainants level of satisfaction with the outcome. Records of accidents must be clear and concise. The registered manager must 31/12/05 ensure that the remedial work to the gas supply to the home is carried out or a second opinion sought evidencing that this is not necessary. Riverside Mews DS0000002906.V272315.R01.S.doc Version 5.0 Page 21 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 OP8 OP19 OP33 Good Practice Recommendations A copy of the hygiene procedure for PEG feeds should be placed in the care plan of residents. A maintenance plan should be drawn up illustrating the ongoing re-decoration of the home. The views of health professionals should be sought when reviewing the quality of care in the home. Riverside Mews DS0000002906.V272315.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle 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 DS0000002906.V272315.R01.S.doc Version 5.0 Page 23 - 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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