Inspection on 17/02/06 for Rydal House

This inspection was carried out on 17th February 2006.

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 no outstanding requirements from the previous inspection report, but made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Rydal House 22/02/07

Rydal House 15/09/05

Rydal House 24/03/05

Rydal House 02/11/04

Rydal House 15/12/03

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Rydal House 6 Spratslade Drive Dresden Stoke-on-Trent Staffordshire ST3 4DZ Lead Inspector Rachel Davis Unannounced Inspection 17th February 2006 10:00 Rydal House DS0000029772.V284105.R01.S.doc Version 5.1 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 Rydal House DS0000029772.V284105.R01.S.doc Version 5.1 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. Rydal House DS0000029772.V284105.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Rydal House Address 6 Spratslade Drive Dresden Stoke-on-Trent Staffordshire ST3 4DZ 01782 330854 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) Mr Alan John Bradshaw Mrs Joy Bradshaw Miss Gaynor Rowley Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Rydal House DS0000029772.V284105.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th September 2005 Brief Description of the Service: Rydal House is a registered care home for up to eight adults with learning disabilities. It is one of three homes owned by Mr and Mrs Bradshaw. Gaynor Rowley is the care manager for this home. The level of need amongst the residents varies but generally the residents in this home are relatively independent and able to access local facilities with minimum support. Rydal House DS0000029772.V284105.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over 6 hours by one inspector who used the National Minimum Standards for Younger Adults and Adult Placements as the basis for the inspection. This visit only covered a small number of the national minimum standards, to ascertain a full picture this report should be read alongside the unannounced inspection held on 15th September 2005. During this visit all of the 8 service users were spoken to, as were the staff on duty, to varying degrees. A relative also kindly made their views about the service known. What the service does well: What has improved since the last inspection? The Statement of Purpose has been individualised to the service offered, only minor additions are now required. Generally care planning has continued to improve; risk assessments are now in place to support the residents in their chosen activities. Rydal House DS0000029772.V284105.R01.S.doc Version 5.1 Page 6 The staff now report being regularly supervised by the manager. Staff spoken to reported being well supported by the management team within the home. Staff have been given a copy of the General Social Care Council code of conduct, as previously required. Since the last inspection medication training for staff administering medication has been provided. Assessments for service users who self medicate are also now in place. Care plans are being fully reviewed twice yearly. The manager has been offered some time to fulfil her managerial role and complete the tasks expected of her, rather than always working “on shift”. This must be regularly reviewed to ensure the time offered is satisfactory. Staff files now contain all the necessary information. Future recruitment procedures have been strengthened to meet requirements. 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. Rydal House DS0000029772.V284105.R01.S.doc Version 5.1 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 Rydal House DS0000029772.V284105.R01.S.doc Version 5.1 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): 1 and 2 Whilst it was established that introductory visits would be offered to prospective service users, other information that should be available to them via the Statement of Purpose and Service User Guide was not as comprehensive as is required. This means that permanent and prospective users of the service may not be aware about how the home deals with important issues that may affect their day-to-day life. EVIDENCE: Both a Statement of Purpose and Service User Guide were available. The Statement of Purpose has been individualised to the home since the last inspection. However, whilst most of the required information was available such as the number of people the home caters for, links with the community, staff training, arrangements around consultation, it was not quite to the level required. Other important information required within the Service User Guide, such as the complaints procedure, terms and conditions, the address of the Commission were not included at all, this document requires further work. The registered person should consider dating the Statement of Purpose and Service User Guide to assist with the timing of the required annual review. Rydal House DS0000029772.V284105.R01.S.doc Version 5.1 Page 9 There have not been any new residents at Rydal in three and a half years, the manager if confident that the homes’ needs assessment documentation that would require completion if a vacancy became available meets the requirements. It is strongly recommended that the management team streamline some of their information to ensure that it is absolutely clear about what the home does and does not provide and what the residents may be expected to finance themselves. Rydal House DS0000029772.V284105.R01.S.doc Version 5.1 Page 10 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): 6 and 9. Holistic care plans are in place these are supported by written risk assessments in some but not all instances. EVIDENCE: One persons care records were examined, record keeping has much improved. Plans are now in place for various areas of the service users lives and risk assessments have been undertaken to support all activities. The service user and the care worker had signed the risk assessments. The entries on the care plans were made enthusiastically and regularly, the staff must continue to record the action taken to help the service users meet their goals and aspirations. Examination of the individual plans, highlighted that the home does have a policy relating to ageing, illness and death of a service user, and that these issues have been discussed with the service users and their relatives, where appropriate. The registered person should consider exploring the Person Centred Planning approach PCP, to see if it appropriate for this service. Rydal House DS0000029772.V284105.R01.S.doc Version 5.1 Page 11 In-house evaluation of the care plans was taking place; the manager had formally reviewed the care plans seen within the last twelve months. The manager confirmed that service users participate in some of the decision making in the home within the forum of ‘house meetings’. They are also involved in their care planning and reviews. There was no evidence that the service users were involved in the developing or understanding the home’s policies and procedures or recruitment process, this should be recorded to verify practice. Rydal House DS0000029772.V284105.R01.S.doc Version 5.1 Page 12 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): 17. Service users enjoy an active lifestyle, integrating into the local community. Meals were considered to be good; the home empowers service users to ensure that meals and mealtimes are gratifying. EVIDENCE: As part of the inspection process lunch was taken with the service users, this was prepared by them with minimal staff support. Mealtimes are pivotal and the staff team ensured that this time was suitable for every individual. A varied menu is available for service users with alternative meals where needed. Service users spoken to confirmed the food was good and that drinks and snacks were readily available. Most of them were involved with going to the supermarket or the corner store, everyone appeared happy with the arrangements. It was recommended that night staff are offered Basic Food Hygiene training, this ensures service users may have food prepared between 10pm and 8am if necessary. Rydal House DS0000029772.V284105.R01.S.doc Version 5.1 Page 13 Catering standards were good and all the documentation regarding food probe temperatures and fridge and freezer temperatures were seen to be up-to-date and correct. Food storage areas were clean, tidy and suitably stocked. All areas of the kitchen were well presented; crockery and cutlery were of a good standard. Rydal House DS0000029772.V284105.R01.S.doc Version 5.1 Page 14 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): 18. Service users are enabled and supported to engage in local community activities. Daily routines are dependent on individual choice, age and ability and staffing is provided accordingly. EVIDENCE: The standard of support given to each individual must be flexible, reliable, consistent and responsive. Evidence to confirm this practice was in place was available on the inspection. Service users were supported when required but enabled and encouraged to do things for themselves, there was evidence to confirm goals and aspirations were considered and met. It was agreed that this must be clearly documented within individual care plans. Rydal House DS0000029772.V284105.R01.S.doc Version 5.1 Page 15 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): These standards were not assessed on this occasion; please refer to the last inspection report. EVIDENCE: Rydal House DS0000029772.V284105.R01.S.doc Version 5.1 Page 16 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 Rydal provides a pleasant home for the service users, but some attention is needed to aspects of safety and an increased emphasis is required relating to infection control management. Attention to these areas will further promote the comfort and safety of all those living at the home. EVIDENCE: The environment was not fully inspected on this occasion, a brief tour was taken to check previous requirements had been met and service users bedrooms were visited as they were enthusiastic to show the inspector their rooms and possessions. No concerns were raised regarding standard 25 or 26. The kitchen fire door was propped open by a door wedge, the Commission require this practice to cease, the safety of service users, staff and visitors alike should not be compromised by promoting this practice. The laundry was visited on this occasion, no concerns were raised and appropriate facilities were in place. The laundry is in the cellar and risk assessments must be in place as stairs are steep and ceilings low. Rydal House DS0000029772.V284105.R01.S.doc Version 5.1 Page 17 The home does in the majority of instances offer liquid soap and paper towels however, it is not available in all communal areas and this must be addressed. The home needs to provide suitable sanitary waste bins for service users and staff, individual’s privacy and dignity must be upheld. Rydal House DS0000029772.V284105.R01.S.doc Version 5.1 Page 18 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): 34, 35 and 36. Staff receive sufficient supervision and service users are adequately supported and protected by improved recruitment procedures. Further mandatory training is still required to ensure an effective well trained staff team are in place at all times. EVIDENCE: Two staff files were chosen on a random basis to be inspected, the homes’ application form has been strengthened and the manager is aware of her responsibilities in this field. Evidence of POVA First and a CRB enhanced disclosure were available in each case, as was a declaration regarding the individual’s physical and mental health. The manager has ensured that all elements of Schedule 2 of the national minimum standards are in place. Staff had now been supplied with the General Social Care Council Code of Conduct leaflet, as is required. There is a stable staff team within this home which gives residents confidence, on the day of inspection one member of staff was leaving which saddened the service users but another member of staff who already works at Rydal was increasing their hours to meet the shortfall and ensuring continuity. Rydal House DS0000029772.V284105.R01.S.doc Version 5.1 Page 19 One visitor’s comments confirmed that: “The staff without exception are caring and friendly and most helpful.” All the service users were very positive about the staff team and the manager. Although mandatory training has improved some areas still require attention, moving and handling, equal opportunities and disability equality training are required. Specialist training also needs to be considered. Discussions confirmed that Gaynor was the approved first aider for the home but nominated appointed persons were not in place, this must be addressed. An appointed person is someone you choose to: take charge when someone is injured or falls ill, including calling an ambulance if required; and look after the first-aid equipment, e.g. restocking the first-aid box. Appointed persons should not attempt to give first aid for which they have not been trained, though short emergency first-aid training courses are available. The registered person should consider offering short emergency first-aid training courses to the homes appointed persons. An appointed person should be available at all times people are at work on site, this may mean appointing more than one. Rydal House DS0000029772.V284105.R01.S.doc Version 5.1 Page 20 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): 38, 41 and 42. It was clear that the views of the service users and their families are sought and important to the all the staff. Diligent and efficient management systems and more robust recording of information must be in place to ensure the safe operation of Rydal House. EVIDENCE: There is an experienced manager in post who confirmed that she was undertaking the Registered Managers Award. Gaynor has been offered time to complete her managerial duties, but this is only one day a week and must be closely monitored. The registered manager has demonstrated her commitment to involving service users and their relatives in the provision of the service by holding regular reviews, informal meetings, and ensuring that service users and their relatives were made aware of any planned inspection by the Commission. Rydal House DS0000029772.V284105.R01.S.doc Version 5.1 Page 21 The Commission considers that the right approach is in place on which to build, documentary evidence must be introduced to corroborate transparency and inclusion. Whilst checking records it was revealed that the home needs to consult with the authority responsible for environmental health in relation to Legionella. Fire risk assessments also need to be put into place. The home must ensure that a record of all visitors to the home, including the names of the visitors is in place to comply with fire regulations. Although emergency lighting was checked regularly the longer tests were not executed. The home must leave emergency lighting for 1hour every 6 months and for 3 hours once a year. If the batteries will not sustain a 3 hour period they must be replaced. The home had up to date gas and electrical tests, their insurance certificate was in date and on display. Fire drills with staff and service users were undertaken regularly. The registered person must ensure they complete the required regulation 26 visits and send a copy to both the manager and the Commission. Rydal House DS0000029772.V284105.R01.S.doc Version 5.1 Page 22 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 Standard No Score 1 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X X X X 3 X X 2 1 X Rydal House DS0000029772.V284105.R01.S.doc Version 5.1 Page 23 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 YA1 Regulation 4 Requirement The Statement of Purpose must include all items listed under Schedule 1. Previous requirement part met. A Service User Guide must be produced and offered to all residents and /or their significant other. Previous requirement not met. Radiators must be individually risk assessed. Generic risk assessments require strengthening in some areas and some require review. Both a towel dispenser and a sanitary bin are required in the bathroom and the latter should be made available to the staff. Mandatory training must be offered to all staff. Previous requirement part met. The registered person must identify appointed persons for health and safety purposes. DS0000029772.V284105.R01.S.doc Timescale for action 17/03/06 2. YA1 5 17/03/06 3. YA24 13(4)(a) 31/03/06 4. YA30 16(2)(j)(k) 31/03/06 5. YA35 18(1)c)(i) 30/04/06 6. YA35 13(4)(b) 30/03/06 Rydal House Version 5.1 Page 24 7. YA41 26. 8. YA42 13(4)© 9. YA42 23(5) 10. 11. YA42 YA42 23(4)(a) 17(2) 12. YA42 23(4)©(5) The responsible individual must undertake an unannounced visit to the home every month and provide a written response to the Commission and the registered manager. The registered person must remove door wedges from under the fire doors throughout the home. The registered person must undertake appropriate consultation with the authority responsible for environmental health in relation to Legionella. The registered person must complete a fire risk assessment. The registered person must ensure that a record of all visitors to the home, including the names of the visitors is in place. The registered person must ensure that emergency lighting tests meet the requirements. 30/03/06 24/02/06 30/03/06 28/02/06 28/02/06 28/02/06 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 YA1 Good Practice Recommendations It is advised that the management team streamline some of their information to ensure that it is absolutely clear about what the home does and does not provide and what the residents may be expected to finance themselves. The registered person should consider dating the Statement of Purpose and Service User Guide to assist with the timing of the required annual review. 2. YA1 Rydal House DS0000029772.V284105.R01.S.doc Version 5.1 Page 25 3. 5. 6. 7. YA6 YA35 YA35 YA35 The registered person should consider exploring the Person Centred Planning approach PCP, to see if it appropriate for this service. The registered person should consider offering specialist training to further assist staff in meeting the needs of the people who live at Rydal. The registered person should consider offering night staff training in basic food handling. The registered person should consider offering short emergency first-aid training courses to the homes appointed persons Rydal House DS0000029772.V284105.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Rydal House DS0000029772.V284105.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!