Inspection on 05/07/05 for Higher Ravenswing

This inspection was carried out on 5th July 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Higher Ravenswing 18/07/07

Higher Ravenswing 10/05/06

Higher Ravenswing 04/01/06

Higher Ravenswing 21/01/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Higher Ravenswing 251 Revidge Road Blackburn Lancashire BB2 6DT Lead Inspector Graham Oldham Announced 05 July 2005 10:00 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 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. Higher Ravenswing F57 F07 S61156 Higher Ravenswing V224285 050705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Higher Ravenswing Address 251 Revidge Road Blackburn Lancashire BB2 6DT 01254 670115 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ravenswing Homes Limited Mrs Valerie Dunning Care Home only Personal Care 14 Category(ies) of Old age, not falling into any other category (OP) registration, with number 14 of places Higher Ravenswing F57 F07 S61156 Higher Ravenswing V224285 050705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 Fourteen elderly service users requiring personal care can be accommodated at the home. 2 The home must, at all times, employ a suitably qualified and experienced manager registered with the Commission for Social Care Inspection. Date of last inspection 24 January 2005 Brief Description of the Service: Higher Ravenswing is a detached house situated on the outskirts of Blackburn. The home is located in a semi-rural position with views overlooking a golf course. Higher Ravenswing is a Ltd company with Mr George Daniels nominates as the Responsible Individual. Mrs Valerie Dunning is the registered manager although a new manager is being proposed for when she retires. The house has been converted to provide accommodation for up to 14 residents. Car parking facilties are provided at the front of the property. Gardens are accessible to residents. There are separate lounge and dining facilities for residents to choose company or privacy. There are ten single bedrooms and two shared rooms. There is a stair lift. Higher Ravenswing F57 F07 S61156 Higher Ravenswing V224285 050705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 5th July 2005. Much of the information gained was obtained from talking to residents and staff members. The views of residents were obtained on a variety of topics. Two residents were case tracked. Case tracking gave the inspector an overall view of the specific care for the individual resident by checking the plans of care, other documentation and talking to residents and staff. Some of the views have been reported collectively with specific comments contained within the body of the report. The inspector took detailed notes during the inspection, which have been retained as evidence. Staff were directly and indirectly observed carrying out their tasks and interacting with residents. Paperwork examined included plans of care, assessment documentation, policies and procedures or documents relevant to each standard. A tour of the building and grounds was conducted. What the service does well: Resident’s views of staff were good. Comments included “staff are very caring”, “on the whole staff are good” and “the girls are all right”. Two visitors were also complimentary to staff. The atmosphere at the home ensured residents were happy. The environment was being upgraded. Rooms had been decorated and a lot of equipment purchased to provide better facilities for residents. Personal support was given in a positive way with the inclusion of resident’s preferences. Staff training and supervision was ongoing to provide staff with better knowledge in caring for the resident group accommodated at the home. Recruitment procedures were good and protected residents from possible abuse. Higher Ravenswing F57 F07 S61156 Higher Ravenswing V224285 050705 Stage 4.doc Version 1.30 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. Higher Ravenswing F57 F07 S61156 Higher Ravenswing V224285 050705 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Higher Ravenswing F57 F07 S61156 Higher Ravenswing V224285 050705 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 4 Assessment documentation was available to ensure residents accommodated at the home had their needs met. A letter was available to confirm the home met a residents needs. EVIDENCE: No residents had been admitted since the last inspection. Two plans of care examined during case tracking contained completed assessment documentation. Once assessed it was confirmed in writing that their needs were met at the home. Good assessment of prospective residents ensured their needs were met at the home and the impact was minimal for incumbent residents, Higher Ravenswing F57 F07 S61156 Higher Ravenswing V224285 050705 Stage 4.doc Version 1.30 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 and 10 Plans of care detailed resident’s needs. Access to specialists and attending routine appointments ensured health care needs were met at the home. Privacy, dignity and the respect of residents was maintained by staff. Medication policies and procedures were not up to date. EVIDENCE: Two residents case tracked gave the inspector detailed information about the care given to residents. Plans of care contained the details staff required to look after the residents. Residents confirmed the care in the plans was as agreed and delivered by staff. Information taken from the plans of care tied in with the information given by residents, such as “I see a psychiatrist , chiropodist and social worker” confirmed health care needs were met. Medication policies and procedures had not been reviewed as required at the last inspection. A requirement and several recommendations made at the last inspection had not been completed. When the requirements and Higher Ravenswing F57 F07 S61156 Higher Ravenswing V224285 050705 Stage 4.doc Version 1.30 Page 10 recommendations are completed the control and administration of medication will better protect the health and welfare of residents. Residents said personal care was given privately and that staff were careful to “treat personal care privately” and “they don’t make you feel anything is any trouble”. Personal care was given in a dignified way. Higher Ravenswing F57 F07 S61156 Higher Ravenswing V224285 050705 Stage 4.doc Version 1.30 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 and 15 Residents said they were satisfied their social, religious and recreational needs were met. Contact with family and friends was maintained. Meals provided were to the liking of residents and provided a well balanced diet. Residents had choices in their routines and retained some control of their lives. EVIDENCE: Two residents case tracked said, “I get up and go to bed when I like” and “we can as we choose”. The information gained from residents about their routines demonstrated the home allowed choice in many aspects of life and allowed residents to retain some independence. Residents said visiting was allowed at any time and could be held in private if they wished. The inspector talked to two visitors during the inspection. They said “the staff cannot do enough for him they are wonderful. He is enjoying the meals and they are making him better” Staff treat us very well and we come to visit whenever we like”. The responsible person said he “liked to have regular contact with families” Contact with families and friends was promoted at the home. Higher Ravenswing F57 F07 S61156 Higher Ravenswing V224285 050705 Stage 4.doc Version 1.30 Page 12 Residents described their outings and activities, which were varied and different for each person. One resident case tracked enjoyed “watching television especially football and going out to the stroke club”. The other resident case tracked preferred to sit with a friend, chat and watch television. The responsible person said he intended to buy a minibus in the future to assist residents go on outings. Activities and outings were provided to stimulate and occupy residents. Residents questioned were satisfied with their meals. Both residents case tracked enjoyed the food and said, “food is very good” and “the food is all right”. The inspector took a meal and found it to be tasteful and nutritious. The meal was observed to be given in an unhurried way and any assistance staff gave was discreet and dignified. There was a choice of meal. The cook also attended the meal to ask residents if they were satisfied with the quality. From the comments taken during the inspection the inspector was satisfied that choice and quality of food met resident’s expectations. Higher Ravenswing F57 F07 S61156 Higher Ravenswing V224285 050705 Stage 4.doc Version 1.30 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Systems were in place to protect residents from abuse. The complaints procedure was available for residents to access and met current Commission for Social Care (CSCI) Guidelines. EVIDENCE: Policies and procedures were available for staff to follow for abuse issues. The home used the Blackburn with Darwen adult abuse procedures to follow a local initiative. Members of staff were aware of abuse issues. From the information gained from staff and documentation examined, resident’s protection from abuse was safe-guarded. Resident’s said they felt able to complain if they wished. Two residents case tracked said they had no complaints but would complain to a member of staff or the manager. No complaints had been made to the service or the CSCI since the last inspection. The open atmosphere and complaints procedure gave residents an opportunity to complain. Higher Ravenswing F57 F07 S61156 Higher Ravenswing V224285 050705 Stage 4.doc Version 1.30 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 - 26 The home was warm, clean and comfortable. Furnishings and equipment was domestic in style and met residents needs and individual tastes. Toilets and bathrooms were of a type that met residents needs. Shared space was provided to give a variety of activities and uses for residents. EVIDENCE: The inspector conducted a tour of the home during the inspection process. All communal areas and most bedrooms were inspected. Residents said “my room is nice. I have brought one or two ornaments and my bits and bobs”, “I have a nice room but I like to sit outside if the weather is nice” and “my room is all right”. Other residents commented they liked their rooms and the communal space. Rooms were clean, tidy and contained sufficient equipment to provide residents with a stimulating environment. The laundry was well equipped to provide a good service to residents. New equipment had been provided. One residents said “we put our clothes out and Higher Ravenswing F57 F07 S61156 Higher Ravenswing V224285 050705 Stage 4.doc Version 1.30 Page 15 it gets done”. Policies and procedures were in place for the control of infection and helped protect the health and welfare of residents. Toilets, bathrooms and communal space had suitable adaptations for the residents accommodated at the home. Health and safety adaptations such as restricting the opening of windows, controlling water temperatures and covering radiators had been completed to protect residents from possible injury. Higher Ravenswing F57 F07 S61156 Higher Ravenswing V224285 050705 Stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 The numbers and training of staff ensured resident’s needs were met. The recruitment practices at the home were good and protected the health and welfare of residents. Training, including NVQ training was provided for the benefit of staff and residents. EVIDENCE: Two staff files contained all necessary documentation. Recruitment procedures ensured a thorough check was made prior to employing any new staff to protect residents from possible abuse. Induction training was provided for new staff. Some staff had taken an accredited medication course. Staff qualified to NVQ standard was above the 50 threshold. The responsible person had a training and development profile for staff members to highlight areas training was needed. The training undertaken ensured staff had the knowledge to look after the resident group accommodated at the home. The inspector examined the staff rota and discussed staffing with the responsible person and was satisfied staff were employed at the home in sufficient numbers and skill to ensure residents needs were met. Higher Ravenswing F57 F07 S61156 Higher Ravenswing V224285 050705 Stage 4.doc Version 1.30 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35 and 38 The procedures for handling the financial affairs of residents were good. Quality assurance systems had not been developed to fully gain the views of residents, family, friends and stakeholders. Health and safety policies, procedures and gas and electrical equipment checks protected residents from harm. EVIDENCE: Residents said they could get their money if they wished. One resident case tracked had money handled via a solicitor. The responsible person said the home was not responsible for handling the financial affairs of residents. Residents were protected from financial abuse. Meetings were held between staff and residents at the home. Other aspects of quality assurance had not been developed. Views need to be obtained from all Higher Ravenswing F57 F07 S61156 Higher Ravenswing V224285 050705 Stage 4.doc Version 1.30 Page 18 interested parties at the home and a summary developed. Quality Assurance standards will be attained when this has been completed and give the registered person an opportunity to improve aspects highlighted as needing attention and maintain aspects that are good. The inspector examined health and safety documents. Gas and electrical appliances and installation certificates were up to date. Mobility equipment was up to date. There was a health and safety statement and policies. There had been an independent fire risk assessment and environmental risk assessment documentation had been completed. The responsible person said any recommendations had or were being attended to. The attention to health and safety legislation protected the welfare of staff and residents. Higher Ravenswing F57 F07 S61156 Higher Ravenswing V224285 050705 Stage 4.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 2 x 3 x x 3 Higher Ravenswing F57 F07 S61156 Higher Ravenswing V224285 050705 Stage 4.doc Version 1.30 Page 20 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 OP9 Regulation 13(2) Requirement Timescale for action 30/8/05 2. OP33 24 The registered person must ensure policies and procedures be reviewed in line with the Royal Pharmaceutical Guidelines to address all aspects of medicines management including administration outside the home, oxygen and dealing with drug errors. Policies must reflect current practice. Extended from 31/03/05 The registered person must 31/10/05 ensure quality assurance meet current guidelines 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. 2. 3. Refer to Standard OP9 OP9 OP9 Good Practice Recommendations The registered person should ensure two members of staff witness hand written entries in the Medication Administration Records. The registered person should ensure the temperature of medication storage areas be recorded on a regular basis. The registered person should ensure all members of staff administering medication complete an accredited F57 F07 S61156 Higher Ravenswing V224285 050705 Stage 4.doc Version 1.30 Page 21 Higher Ravenswing 4. OP9 medication course. The registered person should ensure copies of patient information leaflets for all medication entering the home be obtained. Higher Ravenswing F57 F07 S61156 Higher Ravenswing V224285 050705 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 1st floor, Unit 4 Petre Road Clayton-Le-Moors, Accrington Lancashire. 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