Inspection on 08/10/07 for Riverside Mews

This inspection was carried out on 8th October 2007.

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

The inspector 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 01/08/06

Riverside Mews 08/12/05

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 Stephen Robertshaw Key Unannounced Inspection 8th October 2007 09:30 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.V352690.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. Riverside Mews DS0000002906.V352690.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Riverside Mews Address Ancholme Court Market Place Brigg North Lincolnshire DN20 8LD 01652 653414 01652 655888 jan@nrthlincscare.co.uk 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.V352690.R01.S.doc Version 5.2 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 1st August 2006 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 wellestablished 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 service users, with problems of old age and other associated medical problems. Five of the bedrooms are registered for EMI care. 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. The current scale of charges are currently between £342 -£377 per week. Additional charges include hairdressing, chiropody, newspapers/magazines and holidays. A copy of the last report is openly available in the entrance of the home and can be accessed by the people that live there and their visitors. Riverside Mews DS0000002906.V352690.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit to the service was unannounced and took place on 08th October 2007. The visit was unannounced and the Commission were at the home for approximately six and a half hours. The evidence included in this report was gathered through a wide range of contacts including face to face with people that use the service and their visitors and interviews with management and staff. The Commission also sent out surveys before the site visit happened. Four were sent to individual service users and they all returned their forms to the Commission. Twenty surveys were sent to the home staff and only two were returned completed. The manager had returned the homes Annual Quality Assurance Assessment. This had been fully completed and gave a lot of information about the home and the people that are living and are working in it. The Commission case tracked four people living in the home and spoke with some of their families and social workers. What the service does well: The staff and the people that live at the home appear to have very good relationships with each other and the atmosphere between them is friendly and relaxed. This helps the service users to feel very settled and this means that they can rely on the staff for any support that they may need. Everyone is provided with meals that they choose and like, however they are encouraged to follow a healthy diet including. The home is very clean and pleasant this means that the environment is comfortable for them to live in. The health needs of the people living in the home are well met and staff are provided with a good amount of training to make sure that they understand the needs of the service users and that they can do their jobs well. The manager is well qualified and makes regular checks to ensure that the service is meeting the needs of the people living and working in the home. The people that live in the home say that they are ‘well looked after’ and they are happy to be living there. They are also given the opportunity to decorate their rooms to their own likes and comforts. Riverside Mews DS0000002906.V352690.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Riverside Mews DS0000002906.V352690.R01.S.doc Version 5.2 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.V352690.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This means that people living in the home are able to make an informed choice about the home and can be confident that the home can meet their needs due to a thorough assessment on admission. EVIDENCE: A copy of the homes statement of purpose and service seer guide were up to date and included all of the information that was required in these documents including details of the management structure, staffing levels, the proprietors and the services available to the people living there. Riverside Mews DS0000002906.V352690.R01.S.doc Version 5.2 Page 9 Copies of the statement of purpose and service user guide were available in the entrance of the home so that people living there and their relatives and visitors could have access to them. The last inspection identified some concerns about the owners’ dogs that are often located in the courtyard outside the home and are known to go in to the home on occasions. Some people found this to be intimidating. It was clarified that this is no longer the practice at the home and the dogs are securely kept at the proprietor’s residence. The inspector case tracked four of the people that were living in the home. All of their care files showed that they has their needs assessed before they had been admitted in to the home to make sure that the staff had the necessary skills and knowledge to be able to look after them. The inspector spoke with three of the service user that were case tracked and they supported the evidence that the home had assessed their needs. The manager had been asked to let people know of the existence of the dogs in the guides to the home so that they can make a more informed choice about where to live. The inspector was informed that the dogs are no longer brought in to the home and are restricted to the areas that they can access in the homes grounds. Service users confirmed to the inspector that the dogs no longer wander freely around the premises and grounds. The homes pre-admission assessments, and care management assessments where appropriate are linked to the homes care plans. Service users, their relatives and health professionals are consulted with and contribute to the overall assessment of need for individuals that live in the home. Some of the service users living in the home had dementia related problems. Their mental health assessments were very basic and simply included tick box recognition of needs. There was no indication of how these needs affected the people with dementia in their daily lives at the home. Due to this basic assessment it would be unlikely that an appropriate plan of care could be developed to support these needs. The assessment of mobility needs was also very similar to the mental health assessment format. The management of the home returned their Annual Quality Assurance Assessment form before the site visit took place. This document clearly identified that individuals are provided with an opportunity to experience the home and the services that it provides. One person that lives at the home said ‘I came her to have a look around and thought that it would be alright for me’. The home does not provide intermediate care. Riverside Mews DS0000002906.V352690.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people that live in the home have their personal and healthcare needs supported through a staff group that understands their individual needs. EVIDENCE: The inspector observed the care plans for four of the people that were living in the home. Most of the individuals personal and healthcare needs had been identified in their care plans. There was evidence that the standard of the care plans in the home have improved, however there were still some areas that would benefit the services being provided if they were improved further. The care plans were quite basis and although they identified the peoples needs they did not identify how the individuals preferred their needs to be met. For example a care plan may state Riverside Mews DS0000002906.V352690.R01.S.doc Version 5.2 Page 11 that a person has mobility needs, however they do not go in to any detail to describe how those needs effect the person and the support they require to support them. Some of the care plans were supported with very detailed instructions for example how people liked to be washed and dressed. The other care plans in individuals care files would benefit from this type of development. The care plans for people that live at the home and who experience dementia related problems were limited due to the basic nature of the assessment of their mental health care needs. Another person whose assessment stated that they had challenging behaviours did not have a clear care plan that detailed how these behaviours should be managed in the home to safeguard the person and others around them. One person spoken to by the inspector stated ‘you couldn’t ask for anything else, the staff are wonderful and know how to look after you properly’. Interviews with care staff and observation of their training records showed that they have the necessary skills and knowledge to care for the people that are living in the home. Information included in peoples care files supported that they can see a GP of their choice when they request. Records also supported the evidence that dentists, opticians and chiropodists visit the home to support the needs of the people that live there. The prescribed medication in the home is safely stored. Direct observation of the administration of medication support that the staff follow safe administration practices. The records for the administration of medication were up to date and had been accurately recorded. People that live in the home are provided with the opportunity to self-administer their medication if this is assessed as safe for them to do for themselves. Direct observation and discussions with people that live in the home that were spoken to said that staff treat them with dignity and respect at all times and commented that they are always polite. Staff were also observed knocking on peoples doors before entering their personal rooms. Direct observations supported that positive relationships have been developed between the staff and individuals that live at the home. One person said to the inspector ‘the staff are friendly and know how the brighten you up tour day when your down’. All of the care files observed by the inspector included the last wishes of the service users ion the event of their deaths. This included the type of religious service that they would prefer. Staff training records and interviews with staff supported that they understand how to care for people with terminal care needs and at the same time they can also support the families and friends of those involved. Riverside Mews DS0000002906.V352690.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means for the people who live at the home good and varied activities are made available to them in their daily lives. EVIDENCE: The home has a wide range of activities that are made available to the service users. These include activities both in the home and in the community. The management of the home have recently employed a new activity coordinator and they are currently meeting with the service users on an individual and in group settings to determine what their interests and hobbies are. The activity coordinator is also beginning to develop the residents personal profiles in their care files. This will help to develop an understanding of the hobbies and interests that they had before they were admitted in to the home and if they still wanted to maintain them. Riverside Mews DS0000002906.V352690.R01.S.doc Version 5.2 Page 13 One of the people spoken to by the inspector stated that ‘I go out in to the town whenever I want and at the home I play dominoes and games in the house’. Most service users stated to the inspector that they were happy with the range and frequency of activities that were offered to them. Direct observations showed that service users are approached and asked by the staff if they wanted to become involved in the ongoing activities at the home. A weekly activity plan is clearly distributed on the notice board in the entrance to the home. A three monthly newsletter is also produced by the service to inform the people that live in the home the activities that had been undertaken and to inform them of future events. Visitors are made to feel welcome to visit the home at any reasonable time. One visitor spoken to by the inspector stated that ‘the staff work very hard and are very friendly. They have a hard job but they are always smiling’. Documentation in the home and discussions with the management supported that when people that lived in the home were very unwell then provision s were made for their families and friends to stay close to them. Direct observation supported the evidence that the people that live at the home are provided with choices throughout their daily lives at the home. They confirmed that they could choose what time to rise from and retire to bed and what to eat and where to have their meals. The inspector ate lunch with several of the homes residents. The mealtime was very relaxed and the meals were well presented. The people spoken to by the inspector said that generally their meals at the home were always good. The homes menus are over a seven-week period and this allows for a greater variety in the meals being offered. The inspector looked around the homes kitchen and although it is quite small it was very well organised and was very clean. Riverside Mews DS0000002906.V352690.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that people that are living in the home are protected from abuse and there is an easy to follow complaints procedure that ensures that the individual’s views are heard. EVIDENCE: There are clear policies and procedures in the home that support the people that live in the home to raise any concerns that they may have in relation to the environment that they live in, or the care that they receive in the home. The home also has a quality assurance system that also gives the people that use the service an opportunity to air their views. There had been no recorded complaints made at the home since the last inspection of the service. People spoken to by the inspector stated that they have no complaints about the home and feel confident enough to raise any issues of concern if they arise. The relationships between the staff and people that use the service were observed to be open, friendly and inclusive. Riverside Mews DS0000002906.V352690.R01.S.doc Version 5.2 Page 15 The inspector case tracked four of the people that were living at the home and all of their files showed if they had responsibility of their own finances or if someone else had been identified as their representative for their financial affairs. The files also indicated that the service users were appropriate had been included in postal ballots in the election process of local and national government. Staff training records and interviews with management and staff confirmed that the staff receive safeguarding adults training. The staff that were interviewed were aware of how to raise any concerns that may arise to the appropriate authorities. The home has clear safeguarding adults policies and procedures in place. There had been no safeguarding issues raised since the last inspection. Riverside Mews DS0000002906.V352690.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,24,25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the environment is suitable to meet the needs of the people that live in the home. EVIDENCE: Since the last inspection the management of the home have received a grant of approximately £8,000 to support the development of the environment for the residents. The grant has been used to purchase a new large screen television that is also equipped with a loop system to help people in the home that have hearing problems and use hearing aids. Riverside Mews DS0000002906.V352690.R01.S.doc Version 5.2 Page 17 A large amount of the grant is to be used to develop the outside garden area for the people that live in the home to make the area safe and comfortable for them. The inspector made a tour of the premises. The home was well decorated, was very clean and tidy and was free of any offensive odours. The home employs domestic staff that are responsible for keeping the home clean and tidy, and maintenance staff are employed to carry out any repairs and to carry out the serving and maintenance of the equipment used in the home. These records were observed by the inspector and were seen to have been acted upon and were up to date. People that live in the home were very positive in relation to the environment that is provided for them. One person said ‘my room is always clean, nothing is too much trouble for the staff’’, a visitor to the service stated ‘The home always smells very fresh and pleasant’. There is a choice of three communal areas for the people that live in the home, which they can choose to use to see their friends or family. Each of the residents have their own individual bedrooms. Three people that live in the home invited the inspector to look at their rooms. These had all be decorated and furnished to their own tastes and preferences. The people had individualised their rooms with their own small items of furniture, ornaments and pictures. The toilets and bathrooms are well spaced around the home and are close to the communal areas and the peoples individual rooms. Since the last inspection thermostatic valves have been fitted to all of the hot water outlets in the bathrooms and toilets to minimise any risks to the people using the taps. The grant identified earlier is also going to be used to develop one of the homes bathrooms in to a walk in shower room. This will allow the people that live in the home to have a greater choice of whether to have a bath or o shower. The heating and lighting in the home was domestic in character and the homes water systems are regularly monitored for their temperatures and to protect individuals against Legionella. The washing machines were programmable to disinfection and sluicing standards. The laundry appeared to be well organised. A service user stated to the inspector ‘I always get my own clothes back clean and ready to wear’. This was also confirmed in the inspector’s conversations with several other people that live in the home. A large exercise bed was on one of the landing spaces in the home. This could cause an accident to people in the event of a fire and poor visibility and must Riverside Mews DS0000002906.V352690.R01.S.doc Version 5.2 Page 18 be moved to a safer place otherwise this could result in serious injuries to anyone that tripped over it. Riverside Mews DS0000002906.V352690.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the staff have the knowledge and skills to be able to safely care for the people that are living in the home. EVIDENCE: The staff rotas support that there are adequate staff on duty at all times. Interviews with management and staff also supported this evidence. One person that lives in the home commented ‘the staff are very busy, you sometimes have to wait for them, but we understand that at times other people might need the staff more that us and I can accept this’. Staff spoken by the inspector said that they feel supported by colleagues and the senior members of staff and management. One member of staff commented that they ‘enjoy coming to work’ and added ‘it’s a pleasure working here, the staff and residents all get on well’. Staff training records showed that the staff receive all of the mandatory training that is required and they also receive specialist training including dementia related care and safeguarding vulnerable adults. The staff and Riverside Mews DS0000002906.V352690.R01.S.doc Version 5.2 Page 20 management interviewed by the inspector had a good and clear understanding of the needs of the people that live in the home. Before the site visit took place the inspector sent out surveys to all of the staff that work at the home. Only two of the questionnaires were returned to the Commission. The questionnaires and interviews from staff only identified one area of concern for the staff group. The care staff completed the laundry duties and would prefer that a person is employed separately to complete the laundry to allow the care staff to have more time available to the people that they support. Nineteen care staff are employed at the home. Three of these have completed National Vocational Qualification 2 in care (NVQ2). This means that approximately 16 of the staff group have attained their NVQ award. The manager stated that the service have recently transferred to another training provider for the staff NVQ training. This should be more effective in the future as the training provider is going to provide their training in-house and not at any alternative place in the community. It is important that the service attains a minimum of 50 of the care staff have achieved NVQ2 or equivalent to show that they have the right skills to care for the people that they are responsible for. The inspector observed four of the personnel and training records for the staff that are employed at the home. This supported that equal opportunities were followed in their employment processes and appropriate safety vetting had been completed before they had been employed to have any contact with the people that live in the home. Interviews with staff and management supported the evidence that individuals made an application, were interviewed and references were sought before they began work at the home. Riverside Mews DS0000002906.V352690.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the home is well managed to support the needs of the people that live in the home and to support the staff in carrying out their work. EVIDENCE: The manager of the home has extensive experience in running home and has completed the Registered Manager’s Award. The manager is also one of the registered providers. The style of management is inclusive and supportive. Staff interviewed by the inspector and people that live in the service that were Riverside Mews DS0000002906.V352690.R01.S.doc Version 5.2 Page 22 spoken to stated that the manager is approachable and they feel able to offer their views in relation to how the home should be run. The managers daughter is currently in an unpaid position in the home assisting the manager as their ‘deputy. She has already begun to complete her Registered Managers Award and is a qualified Probation Officer. It was explained to the inspector that this is to train the deputy to take over the service as the registered manager when the current registered manager retires from the management home. Direct observation showed that the manager is very approachable. People that live in the home were seen to constantly approach the manager for some ‘friendly banter’. The manager stated that she enjoys ‘the contact with the residents, more that the paperwork involved in running the home’. The home has previously had a clear quality assurance and monitoring system, however this has not been fully put in to practice since the last inspection. However some recent questionnaires that had been sent out by the management were shown to the inspector. The management also ensures that people who live in their service can offer their views and opinions through service user and family meetings. The home also produces a quarterly newsletter and this was seen to include planned improvements for the service that had been identified by people that live in the home or by their visitors. Personal finances for people that are living at the home are controlled by either themselves or their representatives that have been identified in their care plans. This included family members and solicitors that held Power of Attorney responsibilities. Supervision records and interviews with management and care staff showed that they are not all receiving the required minimum of supervision to make sure that they are carrying out their roles properly and effectively and to identify their training needs. The senior care staff only receive supervision 2-3 times a year. All care staff working in the home and the manager must receive the recommended minimum of six formal recorded supervision periods per year (pro-rata). This should record all aspects of practice, the philosophy of care in the home and career development needs. The manager has increased the staff hours during the busy times of the day and has employed an activity coordinator for 12 hours per week. The records in the home were all up to date. However as sated earlier some of the records are brief and need to be improved. This includes the daily diary records that are held on the homes computers. An example of this is when it has been identified that blood tests have been requested and taken for a person that lives in the home, any results or follow up are accurately recorded. Riverside Mews DS0000002906.V352690.R01.S.doc Version 5.2 Page 23 Some development is also required for the homes initial assessments and care plans. All of the required safety certificates were seen to be in position and were up to date. The service and maintenance records for the equipment used in the home were open to inspection and as far as is reasonably practicable the health and safety and welfare of the people that live or work at the home is maintained and upheld. Riverside Mews DS0000002906.V352690.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 3 X 2 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 18 3 2 3 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 2 3 2 Riverside Mews DS0000002906.V352690.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP19 OP38 Regulation 12.1a 23.4ciiii Requirement The registered person must remove the exercise machine from the corridor to support the health and safety of the people that are living in the home. The registered person must make sure that a minimum of 50 of the care staff have completed NVQ2 or equivalent. This means that the staff will more clearly understand their roles and how to care for the people that they are responsible for. The registered person must reestablish the homes Quality assurance and monitoring system to allow other people to offer their views and opinions on the service and how it could develop. The registered person must make sure that all care staff receive the recommended minimum of six formal recorded supervision periods per year (pro-rata). This will make sure that all of the staff have all of the necessary knowledge and DS0000002906.V352690.R01.S.doc Timescale for action 14/11/07 2. OP28 18.1a,c 30/01/08 3. OP33 24.1 30/01/08 4. OP36 18.2 28/02/08 Riverside Mews Version 5.2 Page 26 skills to care for the people that are living in the home. 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 OP3 OP7 Good Practice Recommendations The registered person should develop the homes preadmission assessment and care plan material to include more detail of how individual’s problems affect their daily lives. This includes the mental health and mobility needs of the people that live in the home. The registered person should make sure that all documents that are completed in the home are fully signed by the people responsible for completing them. Initials should not be used as this could this could cause some confusion as to who has actually completed them. The registered person should continue to develop the personal profiles on the people that are living in the home, this will help to identify their personal interests and hobbies before they were admitted in to care. 2. OP36 3. OP36 Riverside Mews DS0000002906.V352690.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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