CARE HOME ADULTS 18-65
Ahava Ravenswood Village Nine Mile Ride Crowthorne Berkshire RG45 6BQ Lead Inspector
Tracy McGuire Brown Unannounced Inspection 17th January 2006 10:00 DS0000011409.V275060.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 DS0000011409.V275060.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. DS0000011409.V275060.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Ahava Address Ravenswood Village Nine Mile Ride Crowthorne Berkshire RG45 6BQ 01344 755592 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) bucketsandspades@norwood.org.uk Norwood Ravenswood T/A Norwood Mrs Janet Louise Pell Care Home 6 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (1) of places DS0000011409.V275060.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 9th August 2005 Brief Description of the Service: Ahava is one of seventeen homes for adults with learning disabilities located at Ravenswood Village. Ahava provides accommodation for six service users in three first floor, separately approached two bedroom flats, each with selfcontained kitchen, bathroom and lounge/diner. There is a staff office based in one of the flats. The accommodation and staff deployment supports the semiindependent living arrangements for the men who live there. DS0000011409.V275060.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection, which took place over a 2 and half hour period. The Inspector was shown around the flats by staff and residents. The Inspector spent some time talking to some of the residents; time was also spent talking to the Manager and staff. The Inspector was made welcome by residents and staff and had the opportunity to meet relatives who were visiting. What the service does well: What has improved since the last inspection?
Since the previous inspection there has been some redecoration and replacement of worn sofas in all 3 flats. The kitchens in flats 5 and 6 and the tumble driers have been relocated to reduce concerns previous risks. Issues between 2 residents have been addressed and a clear action plan has been developed to support issues arising. There has been a new member of staff recruited to the team. DS0000011409.V275060.R01.S.doc Version 5.1 Page 6 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. DS0000011409.V275060.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 DS0000011409.V275060.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): These Standards not assessed on this occasion. EVIDENCE: DS0000011409.V275060.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These Standards not assessed on this occasion. EVIDENCE: DS0000011409.V275060.R01.S.doc Version 5.1 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These Standards not assessed on this occasion. EVIDENCE: DS0000011409.V275060.R01.S.doc Version 5.1 Page 11 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): These Standards not assessed on this occasion. EVIDENCE: DS0000011409.V275060.R01.S.doc Version 5.1 Page 12 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): 23 Service users are protected from abuse. EVIDENCE: There are detailed policies inn place in respect of the protection of vulnerable adults. The home has had some vulnerable adults issues and these have been dealt with immediately, according to policy and good practice. DS0000011409.V275060.R01.S.doc Version 5.1 Page 13 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. The home is safe and comfortable with a homely feel. Internally the home is generally well maintained and is clean and tidy throughout EVIDENCE: The Inspector was shown around the premises by staff and Service Users. The home is generally well presented internally; the home is decorated and furnished to a good standard. Since the previous inspection worn furnishings have been replaced, each flat now has new sofas. There has been some improvement in the maintenance issues identified at the previous inspection. The bathroom and kitchen in flat 4 have been improved and the kitchen in flat 5. Tumble driers have been relocated to reduce risk from their previous location. There are still some areas requiring attention, the bathroom in flat 6 needs attention, the walls need redecorating and the tiles are broken (this was identified at the previous inspection). The kitchen in flat 6 would also benefit from some new kitchen units. The Manager has identified these areas to maintenance and informed the Inspector that the organisation have assessed the works required to rectify this. The flats are clean and tidy throughout and the laundry arrangements are satisfactory. DS0000011409.V275060.R01.S.doc Version 5.1 Page 14 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 Service users are supported by competent and qualified staff. EVIDENCE: The home has recently recruited an additional member of staff. The Inspector viewed the staff file. Discussions with staff demonstrate that the team has varied skills, qualities and experience relevant to the needs of the current service users. Staff were observed working with service users in a professional manner. The home has a low turnover of staff and the team have extensive experience and knowledge of the current service users. Staff undertake relevant and regular training to improve and develop their knowledge and skills. DS0000011409.V275060.R01.S.doc Version 5.1 Page 15 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): 37 and 42 The home is well managed. Health and safety is promoted but needs to be reviewed. EVIDENCE: The home Manager has worked in the home for a number of years and has sound Knowledge of the Service User group The Manager has gained the NVQ level 4 in care and has completed the Registered Managers award. The Manager has continued to improve and develop the good practice in the home. The Inspector observed the staff team working well and the Manager has sound working knowledge of the service users. The Manager is aware of the roles and responsibilities of a Manager and undertakes regular ongoing training. Staff and service users are positive about the management of the home. The Manager maintains good contact with all relevant professionals and keeps the C.S.C.I updated on any relevant issues in the home. The home is extremely well run and organised. A health and safety poster is on display in the office. Health and safety policies, procedures and risk assessment are in place; some risk assessments
DS0000011409.V275060.R01.S.doc Version 5.1 Page 16 were due for review. Regular health and safety checks are completed in the home, records were seen for; fridge, freezer, water temperatures, fire drills, emergency lighting and equipment tests, gas and electrical testing, some records were not fully up to date although evidence of these checks having been completed was available. The Inspector discussed with the Manager the need to review the Health and Safety file and checks. DS0000011409.V275060.R01.S.doc Version 5.1 Page 17 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 X 2 X 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 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X 4 X X X X 2 X DS0000011409.V275060.R01.S.doc Version 5.1 Page 18 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 YA24 Regulation 23(2) Requirement That identified maintenance issues are attended to in each flat (timescale extended from previous report, some works completed within original timescale) That the health and safety file and checks are reviewed. Timescale for action 31/03/06 2 YA42 23 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000011409.V275060.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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