Inspection Report on

Old Rectory LL68 0PY

Mae’r adroddiad hwn hefyd ar gael yn Gymraeg

This report is also available in Welsh

Date Inspection Completed

01/08/2019 Welsh Government © Crown copyright 2019. You may use and re-use the information featured in this publication (not including logos) free of charge in any format or medium, under the terms of the Open Government License. You can view the Open Government License, on the National Archives website or you can write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: [email protected] You must reproduce our material accurately and not use it in a misleading context. Description of the service Yr Hen Rheithordy (The Old Vicarage) is a detached house in the centre of the village of Llanfechell near Amlwch, on the Isle of , North . Cartrefi Cymru Co-operative Ltd is registered to provide a Care Home Service at Yr Hen Rheithordy. The home is registered for a maximum of five people with a diagnosis of learning /physical disability. The responsible individual (RI) is Adrian Roper. There is a manager in place who is not yet registered with Social Care Wales (SCW).

Summary of our findings

1. Overall assessment

People receive a good quality service which is tailored to meet their individual needs. The staff team are caring and are motivated to provide a range of experiences to extend the life skills of the people who stay at the home. People can contribute to decisions that affect their lives and participate in meaningful and varied activities. Person centred care and support is provided in a timely manner. People are protected from harm and abuse and are supported to remain active and healthy. Improvements are required to raise the quality and cleanliness of parts of the environment to promote positive self-esteem and well-being.

2. Improvements This was the services first inspection for the service under the Regulation and Inspection of Social Care Wales Act 2016.

3. Requirements and recommendations

Section five of this report sets our recommendations to improve the service and the areas where the care home is not currently meeting legal requirements. These include the following:  Environment.  Infection control and cleanliness of some areas of the home.

The recommendations include the following:  The provider must ensure documents are available in the home at all times for inspection purposes.  The manager needs to register with Social Care Wales.

1. Well-being

People are positively encouraged to engage in rewarding and meaningful activities and are fulfilled emotionally and socially. During our visit, two people were attending a local group; another person was being supported in outside activities. When we examined individual plans, we saw information regarding people’s likes, dislikes and preferences. We were shown activity files and photographs of activities people had undertaken. The activities were varied and meaningful to the person including meals out and visits to local attractions. Based on our observations and findings we conclude that people are experiencing meaningful and varied activities.

Practises and processes in the service protect people from abuse and neglect. The service has a robust recruitment system. Staff receive support, guidance, and training and have access to policies and procedures to enable them to understand their responsibility to safeguard and protect vulnerable individuals. A positive and constructive approach is adopted to support resident’s behaviour and positive risk taking. The service followed statutory principles and provisions of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. We find that systems in operation protect people from abuse and neglect.

The service promotes and supports people to maximise their physical and emotional well- being. Staff provided good care and support and individual plans accurately reflect people’s current care and support needs. People were given a choice of healthy meals. The home had been awarded a five star “very good” food hygiene rating, by the Food Standards Agency. The home had a range of specialist equipment and facilities to enable people to remain as independent as possible. Safe storage and administration of medication were in place. The service had general oversight of individual health needs. Policies, procedures and guidelines enabled staff to understand how they should provide care and support. We find that people receive good care and support to remain healthy and active.

People live in a safe and homely environment. We saw sufficient internal and external space for people to relax in and to move about independently. Safety checks and maintenance of equipment was carried out on a regular basis. Individual rooms were decorated in bright colours and clean. Improvements are required in the maintenance and upkeep of some parts of the home. We find that the accommodation provided enables people to feel safe and at home, achieving a sense of well-being. 2. Care and Support

People are able to access opportunities to learn, follow interests and develop skills. People are provided with short break care, which is tailored to meet their individual needs and to extend their life skills and follow an active support programme, which looks at specific tasks for each individual and the outcomes needed. There is an emphasis placed on gaining life skills, and people are encouraged to help with household tasks including cooking, washing up and laying the table. We saw photographic evidence of people involved in preparing and cooking a meal, laying the table and washing up after a meal. We saw that people had been able to complete some of the tasks set as part of the active support programme. This system helps people to be as independent as possible with staff providing prompts where necessary. As this is a short break service, an emphasis is placed on providing people with opportunities to be supported to go out and enjoy their leisure time. We spoke with a person who enjoyed gardening and showed us the vegetable patch in the garden. People are provided with the quality of care and support they need in line with their personal wishes.

People can feel confident the service providers have an accurate and up to date plan for how their care is to be provided in order to meet their needs. We reviewed two peoples care files. There was a comprehensive range of highly person centred documents to help care staff know a person’s needs and to support them in a consistent manner. These included a one-page profile, and an easy to read service delivery plan, which identified people’s aims and desired outcomes and described their perfect day and not so perfect day. These were supported by protocols, which gave detailed instructions on how to support individuals with each aspect of their care and support needs. These included a wide range of needs, from how to support with different aspects of personal care, communication, and how to access different activities, both in the community and within the home. Care staff told us that they had time to read the information provided and it really helped to provide the individualised support that each person needed. People can be confident that care staff have access to accurate and up to date plans for how their care is to be provided to meet their individual needs.

People, are treated with warmth, kindness and compassion in their day-to-day care. We saw there was a natural familiarity between staff and people living at the home. The home maintained a stable staff team, with a high number of staff having worked at the home for a significant period. We saw that staff had a good knowledge of people, and always referred to people in a positive light. We heard staff discussing a range of subjects with people, and it was clear they knew the people they supported very well. We spoke to staff and they were all very passionate about the individuals they cared for and had an understanding of how to support individuals to best meet their needs. We observed lots of friendly banter between staff and residents. The active support programme was used to measure the levels of engagement between staff and people using the service to demonstrate that there are opportunities for conversations with people. They are involved in setting tasks and in discussion about what leisure activities to do whilst they are at the home. 3. Environment

People live in a comfortable environment which meets their individual needs but improvements are required to further enhance their safety. The home was secure from unauthorised access upon our arrival. A member of staff greeted us, checked our identification and we were asked to sign the visitor book in line with fire safety procedures. We viewed the whole building and saw it contained sufficient internal and external space to meet people’s needs. The lounge area was large and uplifting with several sofas and a television viewing area. The dining room had one large table which provided opportunities for people to enjoy a meal together. The dining room had a large comfortable sofa and in between meal times was used as a quiet area. People’s rooms contained basic furniture and provided them with a private area and they told us they enjoyed spending time there. We saw five bedrooms had recently been decorated and new carpets had been fitted. A new bathroom had been installed upstairs and a ceiling hoist had been fitted. However, we were told people could not use the bath, as it was too high for people to get in and out of. We saw some parts of the home were in need of attention such as the windows on the upper floor. We saw the putty was not adequate to hold some of the glass safely and in parts, the putty had turned to dust. Therefore we have issued a non-compliance notice in relation to facilities and services. Details of which are set out in the non-compliance notice attached to this report.

People can be confident the necessary health and safety checks are undertaken to protect them from harm in the home. The manager told us records to evidence regular testing of electrical equipment, fire safety, legionella and hoists were now kept in head office and he would forward copies to CIW once they were available in the home. The reports and safety certificate were emailed to CIW after the inspection. The appointed manager was reminded that all documents of this nature must be made available for the inspector at all times. The kitchen had received the highest possible score of five (very good) following a local authority inspection. Hoists had been serviced to ensure they were operating safely. Health and safety documentation was examined and contained a selection of documentation including gas safety certificate, fixed and portable electrical testing certificates and equipment maintenance checks. We saw they had been completed within the required timescales. We saw evidence of regular environmental risk assessments being undertaken. The annual fire risk assessment was completed; appropriate weekly, monthly and annual fire safety checks had been carried out and recorded. Personal emergency evacuation plans were in place for residents. We find that the service takes appropriate action to ensure people are cared for in a safe environment. Systems are in place to ensure the environment and its equipment is safe.

People cannot always be confident the home is as clean as it should be. We observed some areas of the home were dirty. We found cleaning schedules were not in place to ensure all areas of the homes were germ free. We saw one en-suite bathroom could not be used by the person as it had cobwebs and dust over it. We found the main fridge had food spillage and required a deep clean. The only freezer had old food spillages and was dirty, there was also excess ice in the compartments. The deep fryer had old cooking oil and it was clear it had not been cleaned in a long time. We saw the wet room on the ground floor required a deep clean as the grout and tiles were discoloured with mould. This was pointed out to the manager. He advised that the deep fryer would be thrown. Therefore we have issued a non-compliance notice in relation to infection control and cleanliness of the service. Details of which are set out in the non-compliance notice attached to this report. 4. Leadership and Management

People can access information to help them understand the care, support and opportunities available to them. This is because we saw a Statement of Purpose and service user guide available within the home. These documents described what the home provides. We saw that there were robust company policies and procedures for staff to follow. We looked at a selection of policies, medication, whistleblowing and safeguarding, and noted that they had been reviewed. We observed staff working in a way that upheld this evidence as we observed staff interact with people in a respectful, friendly and patient way. The values and vision of the service are clear.

People benefit from management who are visible and approachable. The manager was based at the home on most days, although not yet registered with SCW he was supported by the area manager. The manager was knowledgeable and had a clear understanding of people’s needs. We saw that people knew the RI and the interactions between them were friendly and relaxed. The staff were complementary of the service and the manager’s support. Their comments included “I can go to the manager for anything”, “love working here” and “great team, we all get on”. We saw evidence of regular visits undertaken by the RI in recordings. We conclude the RI and manager of the home are visible and approachable and there are clear lines of accountability and leadership.

People are supported by appropriate numbers of staff who have a range of skills and qualifications to meet individual’s needs. The Statement of Purpose included information on the numbers of staff employed, their roles and qualifications. We saw evidence that staff were safely recruited, including Disclosure and Barring Scheme (DBS) checks, and receipt of two references, prior to commencement of employment. From rotas and discussions with staff we found that individuals benefitted from being supported by a consistent staff team. We saw training records that evidenced care staff received regular training and refresher courses on a range of topics, including medication, nutrition, autism, dementia, food safety, health and safety and active support and were supported to carry out nationally recognised care qualifications. The organisation placed great emphasis on staff training to ensure the best outcome for people. We saw supervision records that demonstrated that people receive regular and meaningful supervision, and clearly dealt with issues that would help improve support for people. People are supported by staff who are suitably fit and have the knowledge, skills and qualifications to carry out their roles.

People can be confident that there are policies and procedures in place which are appropriate and relevant to the service. We sampled some of the policies in place which included safeguarding, medication, complaints and the management of behaviour and physical restraint. Based on the policies sampled we conclude that the service provider has policies that support a culture of openness and transparency. 5. Improvements required and recommended following this inspection

5.1 Areas of non compliance from previous inspections This is the first inspection following re-registration with Care Inspectorate Wales under the Regulation and Inspection of Social Care (Wales) Act 2016.

5.2 Recommendations for improvement  The provider must ensure that documents are available at all times for the purpose of inspection.

 The manager is to register with Social Care Wales and update CIW once this this has been done. 6. How we undertook this inspection

This was a full inspection undertaken as part of our inspection programme. This inspection was carried out under the new regulations – Regulation and Inspection of Social Care (Wales) Act 2016. The unannounced inspection took place on the following date 1 August 2019 between the hours of 09:30 am and 15:00 pm.

The following methods were used:  We considered the information held by us about the service, including the last inspection report and notifiable events received since the last inspection.  Discussions with one resident, one staff member and the manager.  We toured the home, observed staff and resident interaction and considered the internal and external environment.  Examination of two resident personal plans and associated monitoring charts.  Examination of three staff personnel files and staff training statistics.  Consideration of the home’s statement of purpose.  Consideration of staff supervision records.  Consideration of staff induction.  Consideration of the home’s internal auditing reports.  Consideration of the health and safety records, including fire safety.  Consideration of the last responsible individual visit report.  Consideration of the home’s policies and procedures.

We are committed to promoting and upholding the rights of people which use the care and support services. In undertaking this inspection, we actively sought to uphold people’s legal human rights. https://careinspctorate.wales/sites/default/files/2018- 04/180409humanrightsen.pdf

Further information about what we do can be found on our website: www.careinspectorate.wales About the service

Type of care provided Care Home Service

Service Provider Cartrefi Cymru Co-operative Ltd

Manager There is manager in place but is not registered with Social Care wales (SCW)

Registered maximum number of 5 places

Date of previous Care Inspectorate First inspection following re-registration of the Wales inspection service.

Dates of this Inspection visit(s) 01/08/2019

Operating Language of the service Both

Does this service provide the Welsh Yes Language active offer?

Additional Information:

Date Published 13 September 2019 Care Inspectorate Wales

Regulation and Inspection of Social Care (Wales) Act 2016 Non Compliance Notice

Care Home Service

This notice sets out where your service is not compliant with the regulations. You, as the registered person, are required to take action to ensure compliance is achieved in the timescales specified.

The issuing of this notice is a serious matter. Failure to achieve compliance will result in Care Inspectorate Wales taking action in line with its enforcement policy.

Further advice and information is available on CSSIW’s website www.careinspectorate.wales

Yr Hen Rheithordy

Amlwch

Date of publication: 13 September 2019 Welsh Government © Crown copyright 2019. You may use and re-use the information featured in this publication (not including logos) free of charge in any format or medium, under the terms of the Open Government License. You can view the Open Government License, on the National Archives website or you can write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: [email protected] You must reproduce our material accurately and not use it in a misleading context. Environment Our Ref: NONCO-00008141-XRSV

Non-compliance identified at this inspection

Timescale for completion 02/12/19

Description of non-compliance/Action to be taken Regulation number

The registered person is not complaint with regulation 44 (4)- 44(9)(a) (a) (d) (g) (h), (9) (a). Evidence People are living in an environment where potential hazards are not always recognised, removed and addressed which could compromise people’s safety. We found there were not sufficient arrangements in place to ensure immediate repairs and works arising were identified, reported and action undertaken in response to the level of urgency. During inspection of the premises, we identified a number of hazards that could place people at risk. These included; - • The manager told us there was no cleaning schedule in place and it was the responsibility of all staff working in the service to ensure the environment was clean. We could not see that there was oversight by the manager in ensuring the cleanliness of the home was maintained. • The tiles in the downstairs shower room are in need of re -grouting and the shower screen and seat were mouldy and stained. There was mould on the shower room ceiling. This room requires a deep clean as the floor was dirty in areas. This does not promote positive self-esteem and well-being for the people who use the service and is an infection control risk. • There were no pedal bins or disposable hand towels in any of the communal bathrooms and toilets. A communal washable hand towel was in place for all the residents to use. • The main fridge required a deep clean as we saw spilled food on the shelves. The fridge contained a water container which could be accessed by everyone. It was unclear when the drinking water in this container had been last refilled with fresh water. • The upright freezer required urgent attention as there was a build-up of excess ice in the storage compartments. The floor of freezer required cleaning as we saw some food had been spilled and it was dirty. The handle on the door was loose and it was very difficult to open due to the build-up of ice. • The floor in the kitchen required cleaning as we saw the edges were dirty and there was a build up dirt. • The deep fat fryer required immediate attention as the oil inside was old and there was a build-up of congealed fat around the edges. The frying basket also had a build-up of congealed of fat in the mesh. The manager said the fryer would be disposed of. • The current cleaning arrangements are not adequate and could increase the risk of infection control and cross-contamination to individuals using the service, visitors and staff. • We saw a shower chair had old stains and dust on it and required cleaning. • The kitchen work surfaces are worn and chipped in places. This poses an infection risk. This was identified as an area for improvement during the last Environmental Health inspection on 26 March 2019 and this had been recommended during our last inspection in November 2016. • Extractor cooker fan in the kitchen required a deep clean or replacing as it was old. This was also identified as an area for improvement by the Environmental Health inspector. They strongly advised the extractor hood be replaced, as it is defective and not east to clean. • The upstairs sash windows were in need of urgent repair/replacing. The timber and putty holding the glass panes had decayed and the glass panels were at risk falling out. The manager said the window cleaner had to be very careful when he cleaned the windows, as he feared the glass panels would fall out. This could compromise people’s safety and result in an accident and injury if the glass fell out. • We saw there were gaps in the bottom of the upstairs bedroom fire doors. This had also been identified as an area for improvement during an annual maintenance survey carried out in March 2019 by the maintenance person. It had not been actioned at the time of this inspection in August. • The wallpaper in the porch area had come away, which looked unsightly. • Repairs had been made to a doorframe in the dining room. There was newly plastered walls and it was in need painting or wallpapering as it looked unsightly. • There was dried flaky paint on the ceiling and wall in the corner of the kitchen and there was evidence of damp on the ceiling. • We found that some areas of the home was poorly maintained. We were told during the inspection that the main lights in the lounge and dining area had not worked for over a week. This had been reported to Anglesey County Council several times and at the time of the inspection, they had not sent an electrical engineer to investigate the faults with the lights. We received confirmation after the inspection that an engineer had visited the property and fixed the lights. • The manager and staff we spoke to were fully aware of the maintenance issues and repairs and confirmed that the kitchen would also benefit from being replaced, as it was dated. When we spoke to the manager, they informed us that an environmental survey of the property had been carried out in March 2019 and forwarded to Anglesey County Council. They had not received any response by the time of this inspection. We saw a new communal bathroom had been installed. The manager and a staff member told us that the residents were unable to use this new bath as it was too high for people to get in and out of safely. They were awaiting a new step to be built so people could enjoy a bath if they wished. There was only one other bath at the home, which we could see had not been used for some time. People only had access to a shower room.

The registered person must ensure that the maintenance of the home is carried out in a timely manner to ensure that people will be able to continue to use the facilities at the home and they are protected from harm from faulty equipment. It is the registered person’s responsibility to ensure the service operates with due care and diligence. The registered persons should ensure there is clear oversight of the quality, safety and effectiveness of the service, including the premises.