Care Home: Riverview Lodge

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What the care home does well The home makes sure that personalised assessments are undertaken prior to a resident moving into the home. This ensures that the home understand the residents` needs and are confident that they can meet their assessed needs. The staff team have worked hard to implement new care planning and risk assessment documentation. Residents are protected by the home`s systems for managing medication. The home has undergone a period of change and adjustment over the last few months as the home transferred ownership in December 2007. The Management team have managed this transition well and have maintained good standards of care. The management and staff teams are welcoming and helpful and the home is well run. The home demonstrates a good understanding of equality and diversity Residents live in a clean and well-maintained home, which is homely, and comfortable which impacts positively on the well-being of the residents living in the home. What has improved since the last inspection? This was the home`s first key inspection following the change in the registered provider in December 2007. What the care home could do better: Risk assessment and risk management plans need to be in place for supporting residents who display challenging behaviour. It is important that staff have clear guidelines in place to make sure that they know how best to support the resident to express their needs and to meet these needs. The multi-agency policy for the protection of vulnerable adults needs to be followed to ensure the protection of residents. All windows above ground level need to be secured with window restrictors that are working properly. These restrictors must be checked regularly to minimise the risk of accidents and promote the safety of residents living in the home. CARE HOMES FOR OLDER PEOPLE Riverview Lodge Riverview Lodge Birchen Grove Kingsbury NW9 8SE Lead Inspector Ffion Simmons Key Unannounced Inspection 10:20 14th April 2008 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 Riverview Lodge DS0000070921.V361137.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. Riverview Lodge DS0000070921.V361137.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Riverview Lodge Address Riverview Lodge Birchen Grove Kingsbury NW9 8SE 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) 01332 296200 aslam.choudhury@mha.org.uk home.fxg@mha.org.uk Methodist Homes for the Aged Mr Aslam Choudhury Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Riverview Lodge DS0000070921.V361137.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Old Age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 32 Date of last inspection Brief Description of the Service: Riverview Lodge is currently registered to provide personal care to 32 older people. The registered provider is Methodist Homes for the Aged, who took over as the registered provider from Willow Housing in December 2007. The Registered Manager is Mr Aslam Choudhury, who has managed the home since 1999. Riverview Lodge is a purpose built home. The residents live in three small units with lounge and dining facilities. All the bedrooms are single with en-suite facilities. All the bedrooms have a view of a large enclosed garden. The home is situated close to the Welsh Harp reservoir, in a quiet residential area near Kingsbury and Neasden. There are a variety of local shops within a few minutes walk from the home. The fees range from £541-£585 per resident per week. The fee does not include Chiropody service, hairdressing or newspapers. Riverview Lodge DS0000070921.V361137.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The unannounced key inspection tool place over one day between 10:20 and 19:20 on the 14th April 2008. During the inspection, we spoke with residents to gain their views of the service and observed care practices. We tracked the care of three residents, and in doing so we checked their personal records. We met and spoke with the home’s Registered Manager, two of the home’s Team Leaders and the staff on duty. A number of records and documentation was checked during the inspection, including medication administration records, staff files, health and safety documentation and the home’s complaint records Questionnaires were sent to residents, relatives/carers and advocates, professionals and staff to comment on the service. We had a 20 return rate, which consisted of 8 resident questionnaires and 4 questionnaires from relatives/carers and advocates. We have used the information within these questionnaires to contribute to the content of the report. The designated Manager took time to complete and return the Annual Quality Assurance Assessment (AQAA), and has been used as evidence to inform this report. What the service does well: The home makes sure that personalised assessments are undertaken prior to a resident moving into the home. This ensures that the home understand the residents’ needs and are confident that they can meet their assessed needs. The staff team have worked hard to implement new care planning and risk assessment documentation. Residents are protected by the home’s systems for managing medication. The home has undergone a period of change and adjustment over the last few months as the home transferred ownership in December 2007. The Management team have managed this transition well and have maintained good standards of care. The management and staff teams are welcoming and helpful and the home is well run. The home demonstrates a good understanding of equality and diversity Residents live in a clean and well-maintained home, which is homely, and comfortable which impacts positively on the well-being of the residents living in the home. Riverview Lodge DS0000070921.V361137.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Riverview Lodge DS0000070921.V361137.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Riverview Lodge DS0000070921.V361137.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3, standard 6 is not applicable. People using the service experience good, outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home makes sure that personalised assessments are undertaken prior to a resident moving into the home. This ensures that the home understand the residents’ needs and are confident that they can meet their assessed needs. EVIDENCE: The Manager confirmed that residents’ needs are assessed prior to admission. The assessments are undertaken by the Team Leaders and Key workers. Information in the Annual Quality Assurance Assessment (AQAA) completed by the Registered Manager told us that “a full domiciliary assessment of resident’s care needs, abilities, interests, health and spiritual needs is carried out by a trained manager prior to admission.” We verified this through checking the personal files of residents, and found that pre-assessments were completed in a person centred way. New residents are offered an eight week trial period once they move in to ensure that the service is suitable for meeting their needs. Riverview Lodge DS0000070921.V361137.R01.S.doc Version 5.2 Page 9 The Registered Manager confirmed during the inspection that that the home does not provide intermediate care. The home does offer a respite service. On the day of the inspection, there were two residents at the home benefiting from this respite service, which normally lasts approximately six weeks, or more depending on individual circumstances. Riverview Lodge DS0000070921.V361137.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8. 9 & 10. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are care plans are in place, outlining residents’ needs and how staff can best support residents to meet their needs but they did not cover all care needs such as managing challenging behaviour. It is important to have clear guidelines in place to make sure that the team know how best to support the resident to express and meet their needs. Residents are protected by the home’s systems for managing medication. EVIDENCE: During the inspection, we tracked the care of three residents living at the home. Part of the case tracking process involved checking their personal records. We saw that the staff team have worked hard to implement new care planning and risk assessment documentation. We found that each resident has a comprehensive care plan in place. Associated risks are identified, the health and safety of residents is promoted through the use of risk assessments including manual handling risk assessments, falls risk assessments, Waterlow assessments (for assessing the risk of developing pressure sores) and a tool for assessing malnutrition. The staff team must ensure however that they Riverview Lodge DS0000070921.V361137.R01.S.doc Version 5.2 Page 11 have risk assessment and risk management plans in place for supporting residents who display challenging behaviour. Residents commented that they receive the medical support that they need. Information within the Annual Quality Assurance Assessment (AQAA) completed by the Manager informed us that, “residents are enabled to have access to specialist medical, nursing, dental, pharmaceutical, chiropody and therapeutic service and care from hospitals and community health services. Residents are also able to maintain the services of their usual GP or be registered with a GP of their choice”. The management of medication was checked during the inspection and we spoke with the Team Leader about how the home manages residents’ medication. We were told that only shift Managers (Team Leaders) are permitted to administer medication to the residents, following appropriate training. Information within the Annual Quality Assurance Assessment (AQAA), which was completed by the Registered Manager confirmed the “staff responsible for the administration of medication have appropriate, accredited training and undergo in-house competency assessment.” We saw that the home keeps a list of the names of these staff and their signatures so that they can identify the signatures for auditing purposes. The medication administration records (MAR) sheets were checked for two of the three units at the home, and these were well completed. The picture of the resident is with the MAR chart and any known allergies were noted. The drug Warfarin was being administered to a resident at the time of the inspection. We checked the latest blood test and found that the variable dose administered at the time was correct. It is a recommendation that the latest blood result is kept with the MAR chart for ease of reference and to ensure that the dose administered is correct. Medication is stored in a locked secure trolley and locked cupboards. At the time of the inspection, there was one drug that was being stored as a controlled drug as good practice. Separate, secure facilities are available to store controlled drugs. A controlled drugs register was in use at the home, and we saw that it was the home’s procedure when administering controlled drugs, to have one person administering the drug and another to witness the administration of the drug. To enable staff to find the correct page and to simplify the auditing of the controlled drugs, it is recommended that the controlled drugs in use are entered into the summary page of the register and that the summary is kept up-to-date. The Pharmacist visits the home and carries out a medication check on a quarterly basis. Riverview Lodge DS0000070921.V361137.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are able to take part in a range of activities, which are appropriate to their age and culture, but the home would benefit from an activities coordinator. They are able to keep in touch with their family and friends and the local community. Residents’ cultural and religious needs are met. Residents are offered wholesome, varied and appealing meals, which meet their individual needs and preferences. EVIDENCE: The Registered Manager told us that activities take place at 11am and 3pm every day including the week-ends. Some of the activities on offer include art and crafts, Tai Chi, quizzes and listening to music. In response to a suggestion at a Relatives meeting and consultation with residents, the home has purchased a large (50 inch) screen television and surround sound to create a film club in the home. The Registered Manager explained that two films per week are shown on this screen. Residents told us that when the weather is better, they have a barbecue in the garden. We were told by a resident that they had been out on a trip to Southend and the year before had a nice trip to Stratford-Upon-Avon. There is a garden centre close to the home, and a resident told us they enjoyed going out there. One of the Team Leaders is Riverview Lodge DS0000070921.V361137.R01.S.doc Version 5.2 Page 13 currently studying for a Diploma in reflexology, with the view of offering this therapy to residents when qualified to do so. Comments from some residents and relatives were less positive about the activities on offer and included “there needs to be more mental stimulation. The residents are left to just stare at the Television. There needs to be time for carers to interact with residents. A resident made the following comment when we asked about activity “I watch TV and fall asleep, nothing really goes on. We did have a game of Bingo here one day. They had a meeting and told relatives all sort of things would be taking place. All they (residents) do is sit in chair and fall asleep.” The Registered Manger confirmed that plans are in place for employing an Activity Co-ordinator who will focus entirely on providing opportunities and facilities for social care. The AQAA confirmed that “S/he will be assisted by a Volunteer Support Group who will take an interest in individual residents as well as organise activities.” The programme of activities on offer in the home is an ongoing item on the agenda for discussion at residents’ meetings. From checking the minutes of the last meeting in March 2008, those who were present commented that they were happy with the activities on offer. Residents told us that a Catholic mass takes place in the home on Fridays and a prayer service takes place on Sundays, should they chose to join in. The Manager confirmed within the AQQA, that “other religious requirements in addition to Christianity would be enthusiastically facilitated where possible and if required.” The AQAA also informed us that plans are in place to appoint a dedicated Methodist Chaplain to provide regular services in the home. During the inspection, we noticed that visitors were welcomed into the home by the Registered Manager and the staff team. Residents spoken with confirmed that their friends and relatives are able to visit at any time. Information within the AQAA informed us that staff “value very highly residents’ rights to as full a life as possible, to be part of the local community and to see (or refuse to see) visitors in private. During the inspection, we observed on one unit how residents were being supported at lunchtime. The mealtime felt relaxed and the staff interaction was good. We noted that residents were offered a choice of meal and encouragement was given where needed. We noticed that residents could if they wanted, have their meals in their rooms. The Manager confirmed within the AQAA that the home provides meals to suit residents’ life-style, culture and specific medical needs. “I liked my lunch, I like the breakfast very much Riverview Lodge DS0000070921.V361137.R01.S.doc Version 5.2 Page 14 One of the residents told us that the residents meet on a monthly basis, and one of the topics for discussion, is the meals on offer. Riverview Lodge DS0000070921.V361137.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure, accessible to its residents. Complaints from individuals are listened to and taken seriously. Policies and procedures for safeguarding people who use the service are in place. Staff would benefit from further briefings on the policies and procedures to ensure people living at the home benefit from a good level of protection. EVIDENCE: The home has a complaints policy in place, which was seen on display during the inspection. The AQAA told us that complaints and comments are welcomed and it was documented “we regard complaints as invaluable in improving our service.” Residents are given opportunities to raise concerns or to voice concerns during residents’ meetings, which a resident confirmed takes place on a monthly basis. We saw minutes of residents’ meetings, which outlined that residents said they understood how to make a complaint. We checked the complaints records during the inspection and noted that both written and verbal complaints are taken seriously and records of investigations and actions taken are maintained. The home has policies in place for the protection of vulnerable adults from abuse. A whistle-blowing policy is also in place, which has two free-phone confidential 24 hour lines (one for staff, and one for residents) both run by external agencies. A copy of the local multi-agency policy for the protection of vulnerable adults from abuse was also available for staff reference. Staff can Riverview Lodge DS0000070921.V361137.R01.S.doc Version 5.2 Page 16 access the local authority’s training programme on protection of vulnerable adults. The Manager confirmed that protection is an ongoing item on the agenda of staff meetings to highlight its importance. During the inspection whilst checking the incident and accident records, we came across an example where an allegation was made by a resident, against another resident but the protection policies had not been followed. This incident was discussed with the Registered Manager and the Team Leaders at the time of the inspection and we were assured that this was a genuine oversight. Staff must ensure that they follow the adult protection procedures and receive further training to make sure residents receive a good level of protection. Riverview Lodge DS0000070921.V361137.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): 19 & 24. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a clean and well-maintained home, which is homely, and comfortable. The home is accessible and meets the specific needs of the people who live there. EVIDENCE: During the inspection, we toured the building so that we could assess the quality and safety of the environment. Riverview Lodge is a purpose built home. The residents live in three small units with lounge and dining facilities, which enhances person centred care and promotes a more homely environment. All the bedrooms are single with en-suite facilities. All the bedrooms have a view of a large enclosed garden, which was seen to be well maintained. During the inspection, we noted that some windows above ground level could be opened widely as the window restrictors were not working and/or had been overridden. This poses a risk to the safety of the residents. Riverview Lodge DS0000070921.V361137.R01.S.doc Version 5.2 Page 18 We found the home to be clean and odour free during out tour of the building. Residents commented that their home is fresh and clean. They told us “I’m happy with my room, they keep it nice and clean” and “my room is nice”. Relatives, carers and/or advocates also commented positively on the environment and said “the care home is well maintained and my relative’s room is comfortable and clean, with a pleasant outlook.” Riverview Lodge DS0000070921.V361137.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from receiving care from staff who are trained and understand their individual needs. The home’s recruitment policy and practices are robust and protect residents living in the home. The home demonstrates a good understanding of equality and diversity throughout the recruitment, induction and training of staff. People using the service are generally satisfied with the care they receive although the shortness of staff they are currently experiencing is likely to be impacting on the quality of their care. EVIDENCE: We checked the staffing rotas during the inspection, and saw that there is a minimum of five care staff on duty on the early and late shifts. In addition, there is a team leader allocated to oversee the care on each shift. There are separate kitchen, cleaning and administrative staff employed. There are three vacancies in the staff team at the home at the moment. The home does not employ agency staff and the current vacancies are currently being filled by staff working overtime. Shifts are also offered to staff at other homes run by the Methodist Homes for the Aged. Some staff commented that felt under pressure to work extra shifts and that this is making them feel tired a and under pressure. Relatives commented, “there is a shortage of staff, one carer on a floor of eight. Sometimes staff are tired and stressed, therefore can not give their best” “In the past 2 months there is less staff an it is very noticeable. Riverview Lodge DS0000070921.V361137.R01.S.doc Version 5.2 Page 20 A relative said “tired stressed staff is not good for the residents. No time for chats and games and there used to be. Residents are bored and therefore not happy.” Residents commented “staff are very busy to do too much” and “staff are alright – short of staff at the moment. The Manager confirmed that the home is in the process of recruiting to fill these permanent positions and that the organisation is in the process of setting up a bank of temporary staff. The staff were very helpful during the inspection. The Manager confirmed within the AQAA that the home has a very high level of staff retention, which is impacting positively on the continuity of care for residents. We checked the personal files of two members of staff who have recently been recruited. There was evidence that applicants are required to complete an application form and to attend a face-to-face interview. Two professional references had been obtained and there was evidence that an enhanced criminal records bureau (CRB) check and check against the protection of vulnerable adults list had been undertaken. Staff who provided feedback on the service also confirmed that the employer carried out checks such as CRB and references before they started work. The staff training was discussed with the Manager and we checked the information within the AQAA. The ratio of staff qualified with NVQ level 2 or above is currently 75 and will raise to 80 once the staff currently on training complete the course. This figure is commendable. Staff are required to complete induction training which is in line with the Skills for Care Foundation guidelines. The AQAA informed us that equality and diversity is incorporated into Methodist Homes for the Aged ’s values statement, which is given to staff. It also confirmed that all staff are made aware of the standards and expectations with regards to equality and diversity in their induction programme. Riverview Lodge DS0000070921.V361137.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a home, which is well managed by a person who has the required qualifications and experience. The home has good quality assurance systems in place, which include gaining residents’ views. The health and safety and welfare of residents and staff are generally well promoted. The lack of well-fitted window restrictors above ground level could however be putting residents at risk. EVIDENCE: The Registered Manager has worked in the home for over eight years. He has an NVQ level 4 and a City and Guilds in Advanced Management in Care. The home has undergone a period of change and adjustment over the last few months as the home transferred ownership in December 2007. Despite some apprehension and anxiety amongst staff, residents and relatives, the Riverview Lodge DS0000070921.V361137.R01.S.doc Version 5.2 Page 22 Management team have managed this transition well and have maintained good standards of care. A relative commented that the Manager “is always willing to listen and makes note of criticisms”. During our inspection we noted the Management team’s commitment to ensuring good quality of care to residents and we noted their eagerness to make sure that any issues bought to their attention are resolved. The AQAA outlined the home’s systems for ensuring the quality of the service to residents. The programme includes an annual self-assessment carried out by senior advisers within the organisation and six monthly internal audit involving residents and junior staff, as well as annual resident satisfaction survey. The Manager told us that the quality assurance programme will commence shortly. Residents are encouraged to express their views during monthly residents’ meetings, which are chaired by the Registered Manager. The Registered Manager explained within the AQAA that “we work hard at fostering a relaxed and open environment wherein residents may feel as free as possible to express their needs, problems or wishes.” The home has a policy for the management of residents’ money, valuables and financial affairs. The home has a safe for the safe keeping of residents’ money and lockable facility is available in each room. The AQAA confirmed that the home does not generally handle residents’ money or finances and prefer for residents to remain independent. There are systems in place for when residents require support. The systems were checked and discussed during the inspection and include keeping a clear record of transactions undertaken on behalf of the residents. The home has health and safety policies and procedures in place. The AQAA informed us that the organisation has a Health and Safety Advisor who ensures that health and safety policies are up-to-date and monitors compliance. Health and safety records were checked during the inspection and were seen to be up-to-date. Staff training records demonstrated that all staff are up-to-date in their training in safe working practices. During the our tour of the building, we came across a number of windows above ground level, that we were able to open widely. There is an urgent need to ensure that all windows above ground level are secured with window restrictors that are working properly. These restrictors must be checked regularly to minimise the risk of accidents and promote the safety of residents living in the home. Riverview Lodge DS0000070921.V361137.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Riverview Lodge DS0000070921.V361137.R01.S.doc Version 5.2 Page 24 NA 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 OP7 Regulation 12 & 15 Timescale for action Risk assessment and risk 01/06/08 management plans must be in place for supporting residents who display challenging behaviour. It is important to have clear guidelines in place to make sure that the team know how best to support the resident to express and meet their needs. The multi-agency policy for the 01/06/08 protection of vulnerable adults must be followed to ensure the protection of residents. Urgent steps must be taken to 01/06/08 make sure that all windows above ground level are secured with window restrictors that are working properly. These restrictors must be checked regularly to minimise the risk of accidents and promote the safety of residents living in the home. Requirement 2. OP18 18 (1) c (1) 13 (4) & 23 3. OP38 Riverview Lodge DS0000070921.V361137.R01.S.doc Version 5.2 Page 25 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 OP9 Good Practice Recommendations The latest International Normalised Ratio (INR) blood result should be kept with the MAR chart for ease of reference and to ensure that the dose of Warfarin administered is correct. To enable staff to find the correct page and to simplify the auditing of the controlled drugs, it is recommended that the controlled drugs in use are entered into the summary page of the controlled drugs register and that the summary is kept up-to-date. 2. OP9 Riverview Lodge DS0000070921.V361137.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Riverview Lodge DS0000070921.V361137.R01.S.doc Version 5.2 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. 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