Inspection on 07/12/05 for Riverswey

This inspection was carried out on 7th December 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Riverswey 16/01/07

Riverswey 21/06/05

Riverswey 24/01/05

Riverswey 03/08/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Riverswey Riverswey Newark Lane Ripley Surrey GU23 6DL Lead Inspector Sandra Holland Unannounced Inspection 7th December 2005 15:30 Riverswey DS0000013765.V254043.R01.S.doc Version 5.0 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 Riverswey DS0000013765.V254043.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 Adults 18-65. 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. Riverswey DS0000013765.V254043.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Riverswey Address Riverswey Newark Lane Ripley Surrey GU23 6DL 01483 224099 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) Care Solutions Limited Ms Louise Irene Palmer Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Riverswey DS0000013765.V254043.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be under 65 years of age 21st June 2005 Date of last inspection Brief Description of the Service: Riverswey is a home accommodating up to three younger adults who have a learning disability. It is situated in a semi-rural position on the outskirts of Ripley village, a few miles from Guildford and Woking town centres. Care Solutions Limited, which is part of the Care UK company, operates the service and Hyde Housing Association own and maintain the building. The home is a single storey building set in level gardens with fields to the rear. The accommodation consists of two single bedrooms, a communal lounge, a spacious kitchen/dining room and a bathroom. Incorporated within the house is a single, self-contained flat. This enables a service user to have supported independence. An office which is also used as a sleepover room for staff and a small laundry room are provided. The home has a car to transport service users and staff as there is no public transport immediately accessible. Riverswey DS0000013765.V254043.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was the second inspection to be carried out in the Commission for Social Care Inspection (CSCI) year April 2005 to March 2006. As this was an unannounced inspection, no-one at the home was aware that it was to be carried out. Mrs Sandra Holland, Lead Inspector carried out the inspection. Mr Peter Dodson, Support Worker was present representing the service and Mrs Beth Chapman, Deputy Manager, arrived later. A number of records and documents were examined, including individual plans, food records, staff training records and medication administration record (MAR) sheets. Areas of the home were seen and all three service users and two members of staff were spoken with. To fully assess how the home meets the requirements of the National Minimum Standards (NMS), it will be necessary to read the reports of both inspections carried out this year. The inspector thanks the service users and staff for their hospitality, time and assistance. What the service does well: What has improved since the last inspection? What they could do better: Riverswey DS0000013765.V254043.R01.S.doc Version 5.0 Page 6 The complaints procedure has not been changed to meet the needs of the service users. Some members of staff need to undertake training in the protection of vulnerable adults. Supervision of staff must be carried out at least six times each year. A system of reviewing the service provided, needs to be set up and maintained. The record of food served to service users must be completed for every day. The temperature of all hot food served must be recorded. 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. Riverswey DS0000013765.V254043.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Riverswey DS0000013765.V254043.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3. Staff at the home assess prospective service users, to ensure that it can fully meet their needs and aspirations and only offers a place once these needs are assured. EVIDENCE: From the records seen, it was clear that the most recently arrived service user, had been thoroughly assessed, and had made visits to the home, prior to moving in. Staff stated that this was to ensure that the service user’s needs could be met and to ensure her compatibility with the existing service users. It was clear that all aspects of the service user’s life had been assessed and that the assessment had involved the service user, her advocate, her care manager, the home’s manager and deputy manager. The service user had signed the assessment to show her involvement. It was pleasing to note from the service user’s plan, that an improvement had been noted in the service user’s behaviour since her arrival at the home, and that she had been more relaxed and communicative. Staff advised that the service user wished to change her activities and see more of a friend, and that they are looking into ways to support these needs. Riverswey DS0000013765.V254043.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this inspection. EVIDENCE: Riverswey DS0000013765.V254043.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15. Service users are fully supported to develop and maintain appropriate relationships. EVIDENCE: All three service users spoke of their contacts with their families and friends, including parents, friends outside of the home and neighbours. It was pleasing to hear that the deputy manager had made contact with a relative of the most recently arrived service user, even though the relative lives in Australia. The deputy manager stated that she had sent e-mails to the relative, including photographs of the service user with her new house mates and of her new home. One service user spoke of her boyfriend who she meets with at the day centre and proudly showed her selection of photographs of her friends and previous housemates. Staff advised that the service user is supported to keep in regular contact with some of her previous housemates, her family and boyfriend. Riverswey DS0000013765.V254043.R01.S.doc Version 5.0 Page 11 The deputy manager advised that personal change of address cards had been made with the new service user. These were seen and had very attractive pictures of the service user, her new home and included a short note from the service user printed inside. Riverswey DS0000013765.V254043.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20. Medication administration is managed appropriately. EVIDENCE: Medication is supplied to the service users by a local branch of a national pharmacy chain and the medication administration is effectively carried out. Individual medications are provided in “blister” packs, as part of a “monitored dosage system”, in which medication is supplied for a twenty eight day period, in visible packs, marked for each week and each day of the week. This system enables easy monitoring of the stock held. Medication administration record (MAR) sheets were seen and were accurately maintained. The amount of medication held in the home matched the records held. Riverswey DS0000013765.V254043.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The complaints procedure needs to be suited to the needs of the service users. All staff need to be trained in the protection of vulnerable adults. EVIDENCE: The complaints procedure that is available, is in a written or diagram format, which does not meet the needs of the service users. The deputy manager explained that the home is obtaining an audio version of the procedure for ease of use by service users, but the computer disc to enable this has not yet been made available at Riverswey. A previous requirement that the complaints procedure must be appropriate to the needs of service users, has not been met. Discussion took place about the use of a pictorial format. The inspector advised that until a suitable format was obtained, staff should explain the procedure to service users and document this in their individual plans. Service users who are able to sign should be asked to do so, to show that the explanation took place. Staff stated that training in the protection of vulnerable adults had been arranged for the previous day, but that this had been cancelled because the trainer was ill. The training was indicated on the staff rota, along with other training sessions, which had also been cancelled. To ensure staff are aware of their role in protecting service users, it is required that the training is rearranged as soon as possible. Riverswey DS0000013765.V254043.R01.S.doc Version 5.0 Page 14 Staff members spoken stated that they felt able and would report any concerns they had about service users, to the manager or deputy. If their concerns involved these people, staff would report to the regional manager or a member of staff at head office. Visitors to the home under regulation 26, could also be advised of any worries. Regulation 26 states that the home must be visited on a monthly basis, by a representative of the owners or organisation running the home. The visits must be unannounced and the visitor must speak to service users and staff and look at the premises. A short report must be written to note the visitors findings and a copy of this must be kept at the home. Requirements have been made. Riverswey DS0000013765.V254043.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. The home was clean, well presented and attractively decorated for Christmas. EVIDENCE: All areas of the home that were seen, were very clean, tidy and decorated in a colourful way. The home had been decorated for Christmas, both inside and out, in a festive manner. A Christmas tree was the main attraction in the lounge, with a large, musical Santa Claus in the hall. The outside of the house had been decorated with a number of Christmas lights which created a warm welcome. The home is in keeping with other properties in the area and is presented in a homely and domestic style. Riverswey DS0000013765.V254043.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Staff receive appropriate training. Supervision of staff needs to be carried out more frequently. EVIDENCE: The staff team were observed to be committed and motivated to the support of the service users and were seen to interact with them in friendly, but appropriate ways. A number of staff have undertaken or are undertaking, training for a National Vocational Qualification (NVQ) in care, at level 2 or 3 and the home is on target to achieve the required 50 or more, of staff with NVQ. The deputy manager stated that as the staff team was stable, with few changes, no staff had been recruited recently. Staff stated that an individual training record is maintained for each person and a training plan is also drawn up. These were seen to cover training required by law, such as first aid, fire safety and moving and handling, as well as other training to develop knowledge and skills, such as challenging behaviour, bereavement and sexuality. From the records seen, it is clear that supervision of staff is not taking place as often as required. The National Minimum Standards (NMS), state that Riverswey DS0000013765.V254043.R01.S.doc Version 5.0 Page 17 supervision should be carried out at least six times each year. It was noted that for some staff, supervision had only been carried out once during the past year. A requirement has been made. Riverswey DS0000013765.V254043.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 41 and 42. A system of reviewing the service provided needs to be set up. The record keeping in relation to food served needs to be improved to ensure the safety of service users. EVIDENCE: The deputy manager stated that the service users’ views of the service provided is usually obtained at service users’ meetings. These are held with service users from other homes in the group, but do not involve others from outside the homes. It is recommended that a survey of the service provided, is developed and extended to those people outside the home to include those involved in the support of service users. Families, general practitioners, day service providers care managers and others should be invited to comment on how the home is meeting service users’ needs. Riverswey DS0000013765.V254043.R01.S.doc Version 5.0 Page 19 From the records seen, it was clear that the record of food served to service users, was not being completed for every day. A number of gaps in the record were noted. Similarly, the record of the temperature of hot food that was served, has not been recorded on a daily basis. The form used for the recording of food temperatures, states that there should be a “daily test for high risk foodsmeat, rice etc.” It would appear that the temperature of only the weekly, roast meat has been recorded. Requirements have been made. Riverswey DS0000013765.V254043.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 x x Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x x x x x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 3 16 x 17 Standard No 31 32 33 34 35 36 Score x 3 x N/A 3 2 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Riverswey Score x x 3 x Standard No 37 38 39 40 41 42 43 Score x x 2 x 2 2 x DS0000013765.V254043.R01.S.doc Version 5.0 Page 21 YES 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 YA22 Regulation 22 Requirement The registered person must establish a complaints procedure that must be appropriate to the needs of service users. UNMET FROM 23/09/05. The registered person must ensure that persons employed to work at the care home receive training appropriate to the work they are to perform. Specifically, all staff must be trained in the protection of vulnerable adults. The registered person must ensure that persons working at the care home are appropriately supervised. The registered person must establish and maintain a system for reviewing and improving the quality of care provided at the care home. A report of any review conducted must be made available to service users or their representatives and a copy supplied to CSCI. The system established must provide for consultation with service user and their representatives. The registered person must DS0000013765.V254043.R01.S.doc Timescale for action 03/03/06 2 YA23 18 (1) (c) 03/03/06 3 YA36 18 (2) (a) 06/01/06 4 YA39 24 03/03/06 5 Riverswey YA41 17 (2) 07/12/05 Page 22 Version 5.0 Sch 4.13 6 YA42 13 (4) (c) maintain in the care home the records specified in Schedule 4. Specifically, a record of the food served to service users, must be maintained. The registered person must ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. 07/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Riverswey DS0000013765.V254043.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Riverswey DS0000013765.V254043.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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