CARE HOMES FOR OLDER PEOPLE
Riverslie 79 Crosby Road South Waterloo Liverpool Merseyside L21 1EW Lead Inspector
Miss Diane Sharrock Key Unannounced Inspection 15th March 2007 10:00 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 Riverslie DS0000059055.V336307.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. Riverslie DS0000059055.V336307.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Riverslie Address 79 Crosby Road South Waterloo Liverpool Merseyside L21 1EW 0151 928 3243 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) Innocare Limited Mrs Marie Elaine Williams Care Home 30 Category(ies) of Learning disability (1), Old age, not falling registration, with number within any other category (30) of places Riverslie DS0000059055.V336307.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Service users to include up to 30 OP and up to 1 LD. Maximum No. Registered - 30, of which a maximum of 18 N (nursing) and up to a maximum of 12 PC (personal Care). Date of last inspection 19/5/06 Brief Description of the Service: Riverslie is a Care Home with nursing and personal care only. In total the Home provides care for 30 service residents over retirement age. There are 22 single rooms, none with en-suite facilities, and 4 double rooms, none with en-suite. Bedrooms are situated on all floors. There is a single lounge located on the ground floor and a dining area that has two separate sittings for lunch and dinner also located on the ground floor. Riverslie is a converted building on 3 storeys and provides a passenger lift to all floors. There are gardens to the rear of the Home that are accessible from the ground floor. All areas of the Home are accessible to the residents and there are handrails and ramps provided throughout Riverslie for this purpose. Riverslie is situated in the Bootle area near to the local parks and the docks. The surrounding area is mainly residential. The Home is set back from a dual carriageway. Parking is available to the front of the building and there are main travel routes that provide easy access to the Home. Mr Vickers is the Responsible Person and currently the home have a Manager Michelle King who is yet to be Registered with CSCI. Riverslie DS0000059055.V336307.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over one day. The Manager was also in the process of her RDB audit so the inspection was planned around the Manager and the work she needed to carry out. During the inspection discussions took place with 7 Staff and 5 Residents. To date no comments cards have been were forwarded to the COMMISION with regard to the home. A selection of comment cards had been sent before the inspection and some were left during the inspection for anybody to use and send back to the Commission. The Inspector completed the inspection by looking at the homes records and undertaking a tour of the building. Feedback was given to the Manager at the end of the inspection. Information about fees has not been supplied, as the homes pre inspection questionnaire has still not been submitted to the Commission, despite several requests to the Manager. This must be supplied to the Commission. What the service does well:
There is a long-standing Staff team who were observed to have a genuinely caring attitude towards residents. The Staff observed during the inspection were attentive and polite to the residents at all times, and residents spoken with said, “Staff are lovely here”, Riverslie DS0000059055.V336307.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better:
During this key inspection numerous concerns were noted that needed attention. All concerns noted were discussed with the Manager. An action plan must be submitted to the Commission giving details of how the company will be meeting these regulations and how they intend to improve the home over the following months. On receipt of this report the Provider will be meeting with Representatives of the Commission to discuss the homes improvement plan. The repeated breaches of Regulations must not continue and the Provider must demonstrate his commitment and responsibilities in achieving compliance with the Care Home Regulations 2001. Staffing levels had been reduced on all shifts in the day and Staff felt it was difficult to provide good care in the morning and evenings. They felt the Staffing levels had been reduced by the Manager as they had some Resident vacancies. 2 Staff were new to the home and were included in the duty rota. The Provider must demonstrate that the home will always be staffed appropriately to meet the dependency levels of the residents. Appropriate staffing must be provided to supply and organise activities at the home.. (this was repeated and noted at the previous inspection) A complete review of how residents finances are managed must take place and be fully accessible to the Commission and residents at all times. Action must be taken to ensure that any procedures for managing finances are in line with the Care Home Regulations 2001 and National Minimum Standards and to show that residents have the protection of detailed and clear management policies. Some concerns around the management of finance records were also shared with the local Sefton contracting team under the COMMISION for SOCIAL CARE INSPECTION sharing of information policy.
Riverslie DS0000059055.V336307.R01.S.doc Version 5.2 Page 7 New Staff must be supported and given full induction, training and supervision. Appropriate assessment and support must be given to new Staff who are new to care work. They must be supported in being able to provide appropriate care to all Residents. In reviewing records and discussion with Staff, some Staff have received their mandatory training, however some Staff are still awaiting training for abuse awareness, moving and handling, this lack of training has the potential to place Staff and Residents at risk of harm. Training records must be updated and evidence of 3 days paid training given for all Staff. Pre-admission assessments must be done by a person qualified to assess the persons needs including their nursing needs, so that Staff can determine if the home can meet their needs regarding the homes current registration status of older people over 65 with dementia. Further work, development and management must take place to ensure all Residents needs are taken into account. The home does not have a person employed to organise activities. Care staff tried their best to implement some form of activities when they could. Activities must be developed and Residents consulted about what they would like at their home. Care plans did not give much detail about how Resident’s social needs would be met. Many Residents were noted to have good abilities to be involved however some said they were “bored” and didn’t have much to do. The Provider must evidence how communication and participation will be improved including their thoughts and needs around activities, and their home. The environment had been improved to an adequate standard however there were many areas still in need of repair maintenance and decoration. Maintenance and decorating programme must be developed and shared with Residents/ Representatives and staff to show how the home will be developed. Risk assessments must be updated, and in place for all noted hazards, including, doors wedged open, flooring that’s uneven and a ripped, broken recliner chair. Updated maintenance records must be in place for all facilities including in house fire checks and the Electrical installation certificate, to ensure safety of Residents and Staff. Riverslie DS0000059055.V336307.R01.S.doc Version 5.2 Page 8 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. Riverslie DS0000059055.V336307.R01.S.doc Version 5.2 Page 9 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 Riverslie DS0000059055.V336307.R01.S.doc Version 5.2 Page 10 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): Quality in this outcome area is (poor). 3 standard 6 is not applicable This judgement has been made using available evidence including a visit to this service. The home does not always gather or provide sufficient information to prospective Resident’s, therefore they cannot ensure they are able to meet their needs and choices prior to them moving in. EVIDENCE: In case tracking care plans it was noted that one Resident had been admitted as am emergency however, no assessment was carried out before admission into into the home. The Manager explained the difficulty in obtaining records in emergency situations, however discussions recognised that some information had to be supplied before admission, so that they can assess if they can provide the right care and support, to enable Residents in their personal choices of what they would like. One Residents requested to go to bed and lie down as they were sat in an armchair, which did not have a presurre relieveing cushion, and consequently
Riverslie DS0000059055.V336307.R01.S.doc Version 5.2 Page 11 found this uncomfortable due to their skin condition. The recliner this person was using, was noted to be broken and could no longer recline. Staff need the right training and support to assist the Residents needs, as the care was not detailed in the care plan or pre assessment. Any Residents admitted to the home must be supplied with the right equipment and support to meet their needs. Pre-admission assessments must be done by a person qualified to assess the persons needs including their nursing needs, so that Staff can determine if the home can meet their needs and whether they have the right equipment in place to make residents comfortable. Information about fees has not been supplied, as the homes pre inspection questionnaire has still not been submitted to the Commission despite several requests to the Manager. This information must be submitted to the Commission any prospective Residents so they can make their own choices and decisions about the home. Following the previous inspection the Manager explained that she had assessed all of the Residents at the home and felt that every Resident is within the homes registration category. Riverslie DS0000059055.V336307.R01.S.doc Version 5.2 Page 12 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): Quality in this outcome area is (adequate). 7/8/9/10 This judgement has been made using available evidence including a visit to this service. Progress has been made with careplans and the Health and Personal care needs are mainly being met. Residents are treated with respect by the Staff, who understand how to maintain individual dignity and privacy. EVIDENCE: Three care plans were reviewed for case tracking. They each had had records in place to eventually meet the standards and show how the Resident will be supported and cared for. Care plans generally showed basic limited details of social care needs being met. This must be developed so that Residents social needs and choices can be supported and explained how Staff will do this within the care plan. Riverslie DS0000059055.V336307.R01.S.doc Version 5.2 Page 13 The Staff observed during the inspection were attentive and polite to the Residents at all times. Some Residents said, “Staff are very good” and “they are lovely girls they work very hard.” A review of medications showed various improvements with the storage and recording of medications. The drug fridge was broken and Staff were unsure when it was being replaced however the Manager stated it was being replaced the following week so that any medications could be stored safely. Most medication records seen looked detailed and recorded correctly. Just one record had a blank space and should be reviewed by the Manager. The Manager carry’s out regular reviews to make sure that medications are stored and managed safely and administered in the best interest of the Residents. Riverslie DS0000059055.V336307.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (adequate). 12/13/14/15 This judgement has been made using available evidence including a visit to this service. The home did not provide adequate support to Residents to meet their social needs. EVIDENCE: The home does not have an activities organiser and Staff are expected to manage and organise activities. An activities board was seen in the main lounge advertising various events however no activities were seen during this visit. Staff interviews explained that they were trying their best to provide some activities when they had a chance during their shift. Staff felt they would benefit from training in activities. Staff felt it was difficult to organise activities as they had recently had their care hours reduced with less care Staff on duty during the days. Some Residents said “there’s nothing much to do” and one person said they were” bored.” One Resident said they couldn’t see the television. This was noted as all the chairs were positioned around the edges of the room with the TV in one corner. Staff stated that generally there are no residents meetings, which indicates no formal way for residents to be consulted and give their opinions on how the
Riverslie DS0000059055.V336307.R01.S.doc Version 5.2 Page 15 home operates. These are all areas and comments noted at the previous inspection. The minutes of a relatives meeting for November 2006 were seen. This seemed to be the last minuted meeting. Relatives had made queries about wanting access to free chiropody and access to a dentist for their Relatives. Feedback should be given to these queries as the Manager explained what she had done. Regular minuted meetings will help to improve communication and gain peoples opinions and requests to what they want at the home. Activities must be developed and Residents consulted about what they would like at their home so their social needs and support can be provided and met. Residents stated that they were happy with the food provided and commented that it was “ok”, It was noted some areas in the kitchen were in need of deep cleaning. However during discussion and in looking at Staff rotas it was noted that the kitchen had also had a reduction to staffing levels. The Cook no longer has a kitchen assistant and now manages the kitchen on her own. This should be reviewed by the Manager with appropriate action taken to ensure good standards of hygiene are maintained at all times and that appropriate Staffing levels are provided to safely manage the kitchen area. The dining room was in need of redecoration and repair of the flooring. The Manager explained that they did have plans to refurbish this area but no dates were given. A small area outside the dining room had been provided with a dining table for residents to use. It was acknowledged during lunchtime that just 16 residents were accommodated in the dining room and that the current dining area could not easily provide space for all residents at the home. The development of good dining facilities for all the residents must be provided and discussed with the residents so their views can be taken in to account when refurbishing this facility. Riverslie DS0000059055.V336307.R01.S.doc Version 5.2 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (adequate). 18/19/20 This judgement has been made using available evidence including a visit to this service. The home have some Staff with updated abuse awareness training however some Staff still needed training to help them safequard Residents. EVIDENCE: In discussions with Residents and Staff everyone described whom they would speak to if they had any concerns or complaints and they all felt they would be listened to. Most Staff had received training in abuse awareness and staff felt they had benefited from this training. Some staff had still not received this mandatory training although it is acknowledged that this training had been implemented following the previous inspection. This is a repeated concern. All staff must received this mandatory training to make sure they are able to protect and support residents appropriately at all times. Riverslie DS0000059055.V336307.R01.S.doc Version 5.2 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (adequate). 19/26 This judgement has been made using available evidence including a visit to this service. The home did provide an adequate environment for Residents to live in. Risk assessments must be updated to ensure the safety of the home and Residents. EVIDENCE: A sample of areas seen during this site visit showed a clean and tidy area with no unpleasant smells. There was one domestic Staff member on duty and general discussion found that domestic hours had been reduced from 2 Staff daily to just 1 Staff member. Staff found it difficult at times to clean the home and explained that anything they didn’t get to finish then the laundry assistant would do later in the afternoon. There has been some redecoration following the previous inspections and a selection of bedrooms had been updated and redecorated.
Riverslie DS0000059055.V336307.R01.S.doc Version 5.2 Page 18 However some areas still needed attention with repairs and maintenance and the home did not have a maintenance and development plan that could be shared with Residents and Staff to gain their opinions about their home. A sample of areas seen were discussed with the Manager e.g. doors wedged open, flooring that’s uneven and ripped, broken recliner chair, broken toilet seat, dining room floor and dining facilities, broken drug fridge, replacement of the main cooker. Risk assessments are in place at the home but they need updating and all areas seen should be included in these assessments. The Manager agreed to carry out all necessary actions to ensure the safety of the home Regular audits of the home by the Provider will identify areas for repair and development prior to any further inspections and will show what actions are being planned to make the home safe and of a good standard to live in. Riverslie DS0000059055.V336307.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): Quality in this outcome area is (poor). 27/28/29/30 This judgement has been made using available evidence including a visit to this service. The home did not provide sufficient, experienced and trained Staff to meet Residents needs. EVIDENCE: There is a long-standing Staff team who were observed to have a genuinely caring attitude towards Residents. Staffing rota’s indicated that Staffing levels had been reduced on all shifts in the day. This was further evidenced in discussions with Staff The Provider must review these opinions, to maintain staff moral, and ensure that good care is delivered safely. Staff considered the Manager had reduced staffing levels as they had some Residents vacancies. Two Staff were new to the home and were included in the duty rota. It was clarified that one nurse works on every shift, with 3 care Staff in the morning, 2 in the afternoon and 2 at night. This is a significant reduction to the Staffing levels provided during the previous inspection, which stated 5 care Staff in the morning, 4 in the afternoon and 2 at night. The Manager did explain that the Provider had carried out a calculation of the hours but this assessment was not at the home and not shared with Residents
Riverslie DS0000059055.V336307.R01.S.doc Version 5.2 Page 20 or Staff. This document has still not been shared with the Commission despite requests during this site visit. The companies’ commitment to the basic number of Staff on each shift must be displayed in the homes statement of purpose. Any changes to the basic levels must show evidence of a clear reason to link the levels with the Residents needs and in consultation with all Residents, Relatives and Staff. The Provider must demonstrate that the home will always be staffed appropriately to meet the dependency levels of the Residents so their needs can always be met. In assessing the procedures for the recruitment and selection of Staff , three Staff files were sampled, including two new members of Staff. These files have improved and have been developed with good evidence of interviews and recruiting Staff following the interview. These files showed that checks are in place prior to recruitment, however supervision was not evident and training records were often not up to date. Two new members of Staff had not had any assessment or support to show whether they were competent to provide care work and there was no evidence of induction of whether their training needs were being fully met. There was no evidence of supervision for these members of Staff. The rota showed they had been included in the Staff rota. Good detailed induction must be provided for all new Staff so that they are trained and supported in being able to provide the right care for Residents. Two Staff had basic “PoVA” first checks and there was no evidence that they were being supervised during their employment until full police checks had been obtained. Another Staff member had a police check which named another establishment as their employer. This must be reviewed by the Company and action taken to ensure the recruitment and selection of all Staff are in line with the Care Home Regulations and are appropriately carried out to ensure the safety of Residents at the home. This is a repeated concern from the previous inspection. There was no structured plan to evidence what actions the company was taking to ensure NATIONAL CARE QUALIFICATION training would eventually meet the National Minimum Standards target Records showed that Staff had received some mandatory training, however some were out of date and some were blank. The Manager did start to develop and update the homes training matrix during this visit. During discussions Staff felt that they enjoyed the training on offer and always tried to attend the training when it was arranged. Some Staff still need mandatory training in “abuse awareness and moving and handling.”
Riverslie DS0000059055.V336307.R01.S.doc Version 5.2 Page 21 The Provider must audit the records to show what training individuals need and must be able to evidence how the trained nurses are receiving continual professional development. Riverslie DS0000059055.V336307.R01.S.doc Version 5.2 Page 22 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): Quality in this outcome area is (poor). 31/33/35/38 This judgement has been made using available evidence including a visit to this service. The home was not always well managed and run in the best interests of Residents. EVIDENCE: The Manager has recently submitted her application to register with the Commission. Regulation 26 reports were not available at the home. This is legal requirement of the provider and monthly reports must be carried out to show that the Provider is appropriately reviewing the care, the safety and management of the home.
Riverslie DS0000059055.V336307.R01.S.doc Version 5.2 Page 23 The Manager has recently purchased updated policies and procedures which once implemented will help to manage the home safely and in the best interests of the Residents. Samples of finances managed by the Manager and the homes administer were reviewed during this inspection. A pre inspection questionnaire has still not been sent to the Commission, however the Manager was able to verbally confirm that the Provider acts as appointee for at least 6 Residents. Areas of concern and poor recording and storage were discussed with the Manager. These concerns are repeated from the previous inspection. Five Residents had balance sheets for monies stored at the home but each one checked did not relate to the amount of money stored. Each one was inaccurate and had lower amounts to what the balance sheets showed. It was acknowledged through discussions with the administrator and Manager that some Residents monies are also stored in the company account. It was unclear how much as no records or balance sheets or statement of the company account was provided. The Manager explained that one Resident had money taken from the account to pay a deposit for a bed. There was no evidence of a deposit record or evidence of permission being sought. All necessary equipment for Residents must be supplied by the home unless a Resident had requested to buy anitem of choice. This must be reviewed by the Provider to make sure all procedures are in the best interest of the Residents and in line with the homes own policies. The Manager acknowledged the areas needing review and felt the role was too large to manage and would arrange for all next of kin to take over the role of managing their own Relatives finances. A complete review of how Residents finances are managed must take place and be fully accessible to the Commission and Residents at all times. All Residents must receive their full personal allowance payable into their own personal account or advice taken from them as to where they would like their money stored. Action must be taken to ensure that any procedures for managing finances are in line with the c Care Home Regulations 2001 and National Minimum Standards and to show that Residents have the protection of detailed and clear management policies. Some concerns around the management of finance records were also shared with the local Sefton contracting team under the COMMISION for SOCIAL CARE INSPECTION’s sharing of information policy. Riverslie DS0000059055.V336307.R01.S.doc Version 5.2 Page 24 Staff are not always being provided with one to one supervision especially new Staff recently employed. This is evident in records and through discussions with Staff. An action plan must be developed to ensure appropriate action is taken to meet the National Minimum Standards and to endure all Staff have regular 1 to 1 time to discuss their needs and developments. This is a repeated concern following the previous inspection. Various maintenance certificates were produced showing some evidence of improvement and appropriate checks to facilities at the home to show the home is safely managed in these areas. However there was no evidence of an update to the homes main electrical installation certificate, the last one was dated 28/2/02 and no updated in house checks to the fire system. The last recorded in-house fire check was dated 24/1/07. The Provider to the ongoing management and safety of the home must produce evidence of these checks as a matter of priority to ensure the health safety and well being of everyone at the home and to show an appropriate and responsible approach. Risk assessments are in place at the home but updated assessments must be in place for doors wedged open, uneven ripped flooring so that actions can be taken to minimise risks to Residents, Visitors and Staff at the home. A review of the laundry should also take place so that protective clothing, aprons are provided and steps taken to reduce any potential risks of cross infection. The laundry area needs storage for clean and dirty linen as some linen was stored on the floor and machines and the assistant had no protective clothing. Riverslie DS0000059055.V336307.R01.S.doc Version 5.2 Page 25 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 1 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 1 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 1 X X 1 Riverslie DS0000059055.V336307.R01.S.doc Version 5.2 Page 26 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 OP3 Regulation 14 1(a)2(a)( b) Requirement Timescale for action 29/05/07 2. OP12 16 n The Provider must make sure that all new Residents admitted to the home have been appropriately assessed and that the care home can meet the Residents needs. (repeated from previous inspection) To consult Residents about what 29/05/07 activities they would like and make arrangements to support Residents with their social needs. 29/05/07 3. OP18 18 (1) a c 4. OP35 20 a b 5.
Riverslie OP38 Reg The home must have competent and trained Staff to meet the Residents needs at all times. Staff must have training in, moving and handling, abuse awareness, activities and induction. (repeated from previous inspection) The management of finances 29/05/07 must be reviewed so that clear and accurate records are kept for all Residents finances. Residents monies must not be stored in a company account. (repeated from previous inspection) The Provider must conduct 29/05/07
DS0000059055.V336307.R01.S.doc Version 5.2 Page 27 23(1)(2)b )(c)Reg 13 4 a)c) regular health and safety inspections of the home. They must show how they will make the home safe for Residents and carry out regular repairs uneven ripped flooring, lounge furniture, doors wedged open, broken recliner chair, updated maintenance on the electrical installation and fire safety systems at the home. (repeated from previous inspection) The owner must undertake monthly visits to the Home. report must be accessible to the Manager and Commission for Social Care Inspection. (repeated from previous inspection) 29/05/07 6. OP33 24 (1) (2) (3) 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. Refer to Standard OP12 OP9 Good Practice Recommendations Activities should be further planned and developed to meet Residents social needs. To develop regular minuted Residents/Relative meetings. Medicines must be stored at the appropriate temperature. Staff must be informed of the date of the fridge being replaced so appropriate arrangement can be arranged. The Staffing levels should be kept under review in order to make sure that Staffing levels are appropriate to the needs of the Residents .To publish the homes Staffing commitment for each day in the statement of purpose. 3. OP27 Riverslie DS0000059055.V336307.R01.S.doc Version 5.2 Page 28 4. OP32 5. OP30 6. OP19 To continue with ongoing Staff meetings and develop the implementation of supervision and appraisals. To ensure all parties are aware of the Companies “whistle blowing” policy. To continue developing and updating training records and provide evidence of 3 days paid training for all Staff each year. To develop an overall training and development plan for the home based on both the identified Staff training needs and Service Users needs including the trained Staffs clinical needs.. The Provider should continue with development of NATIONAL CARE QUALIFICATION training so as to meet the target of 50 by 2005 To develop and share a maintenance decorating and refurbishment programme with Residents, Staff and Visitors. The maintenance programme should give details of future developments about their home eg dining room provisions, lounge area, day space, communal areas for decoration. Riverslie DS0000059055.V336307.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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
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