Inspection on 17/10/05 for Ravelston Grange Care Home

This inspection was carried out on 17th October 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

Ravelston Grange Care Home 24/04/08

Ravelston Grange Care Home 25/07/06

Ravelston Grange Care Home 26/05/05

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

CARE HOMES FOR OLDER PEOPLE Ravelston Grange 10 Denton Road Eastbourne East Sussex BN20 7SU Lead Inspector Jason Denny Unannounced Inspection 17th October 2005 10:00 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 Ravelston Grange DS0000062737.V248983.R01.S.doc Version 5.0 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. Ravelston Grange DS0000062737.V248983.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ravelston Grange Address 10 Denton Road Eastbourne East Sussex BN20 7SU 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) 01323 728528 PJP Care Ltd Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Ravelston Grange DS0000062737.V248983.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated must not exceed twenty four (24). The service users will be aged sixty five (65) or over on admission. Date of last inspection 26th May 2005 Brief Description of the Service: Ravelston Grange is a Care Home registered for twenty-four older people. It is a three-storey building with a lift to the upper floors. The home is situated in The Meads, an attractive residential area of Eastbourne. The home is close to local shops, and a short drive away from the main town centre, shops, buses and the main railway station in Eastbourne. There is a homely, safe comfortable and friendly atmosphere provided by the home. There are fourteen single and five double bedrooms, which are individually furnished to reflect personal taste and preferences. Double rooms are offered to married couples or those who make a positive choice to share. PJP CARE LTD [Mr P and Mrs. J Piercy] owns the home as part of a group of two homes for older people, the other home being in St Leonards-on-Sea. Ravelston Grange DS0000062737.V248983.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced routine inspection [second of two planned before April 1st 2006], carried out by two inspectors, which took place between 10.00am and 3.40pm. The purpose of the inspection was to follow up on progress since the last inspection of May 26,2005 of which this report should be read in conjunction with. That inspection identified a number of areas, which needed improvement such as staffing, management, administration, health and safety, care-planning along with the upkeep of the environment. Since the last inspection the Commission has met separately with, and corresponded with, the homes owner. This Inspection found that of the 24 National Minimum Standards inspected, that 13 of these standards had been met with all others in the process of being met. The inspector’s started the inspection by speaking with Residents [10 in total] and visitors [1] and touring communal areas and visiting some Residents [3] in their rooms. A discussion with the new acting manager took place around progress since the last inspection. Care and staff records, medication, staffing and safety documentation were inspected. The Inspector received back comment cards from over half the residents all of which were positive about the care with some suggesting further improvements to activities. What the service does well: What has improved since the last inspection? A new experienced, skilled, and highly motivated manager started work in the home 5 weeks prior to the inspection. It was clear from talking to staff, residents, and looking at progress made since the last inspection that this person is having a highly beneficial effect and is now on course to meet most if not all standards by the next scheduled inspection [from April2006]. The owner of the home has played an important role in recruiting a suitable manager, allowing him to manage, and giving him the resources to do so. The acting Ravelston Grange DS0000062737.V248983.R01.S.doc Version 5.0 Page 6 manager who aims to become the permanent registered manager outlined clear plans to improve the home in all areas based on support from the owners. Staffing ratios have increased ensuring that at supper times there are two staff to respond to care needs whilst another is preparing supper. Infection control practices have improved. The manager has held staff meetings with further planned with residents and staff to ensure that the routines of the home are based on the needs and wishes of residents. Staff training has improved in relation to medication handling. Care-plans are in the process of improvement to help meet needs. The owners and manager of the home have improved the maintenance of the home and identified areas, which need prompt attention. Cleaning practices have improved. The owner of the home carries out monthly inspections and sends a report to the Commission. A clear plan has also been developed for all necessary maintenance work. The arrangements for new people moving in has improved. Staff indicated how they feel better supported in their roles through improved supervision from the new manager, higher staff numbers, and more stress on quality. 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. Ravelston Grange DS0000062737.V248983.R01.S.doc Version 5.0 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 Ravelston Grange DS0000062737.V248983.R01.S.doc Version 5.0 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 the following standard(s): 1, 2, and 5. The inspector found, with some minor exceptions, that the home provides both prospective and existing Residents, with a good level of information. Contracts have been previously found to meet the standard but will benefit from clearer explanation as to the variation in fees charged. The home encourages prospective new Residents and their families to visit the home before deciding to move in, with this offer now recorded. EVIDENCE: A copy of the home’s service user [Residents] guide including a complaints procedure is on display in the reception area along with the most recent Inspection report. The guide contained no resident’s views. The new acting manager confirmed that the owner has recently [over the last 2 weeks] conducted a survey of resident’s views with the report awaiting to be published. The owner of the home has also sought resident’s views during his monthly inspection visits, with reports sent to the Commission. . The new acting manager showed the Inspector a letter that has been introduced which is sent to prospective new residents to confirm that they could meet assessed needs prior to admittance. Ravelston Grange DS0000062737.V248983.R01.S.doc Version 5.0 Page 9 The acting manager indicated that contracts are organised by the homes owner and that he was not aware of the current fee being charge to a respite user. Contracts are currently kept in the owner’s own office with the owner not available during this unannounced inspection. At the last inspection the owner confirmed that some Residents pay more than the standard fee if they choose a better room. There is a also variation in what social services pay regardless of what the basic rate is. The owner stated that he wants to promote transparency and will amend contracts to detail the room occupied and why the fee is higher in some cases. Contracts will be looked at the next inspection with the home having the option of sending copes to the Commission. The manager was aware that residents had the right to have their own copy. No residents highlighted any concerns in relation to contracts during the inspection. Residents spoken with confirmed that they had opportunities to have trial visits before moving in although in the main they relied on their relatives to make a decision. The new acting manager has introduced a form for recording when trial visits are offered and declined. A completed [inquiry] sheet was shown to the inspector. Evidence was also seen of the home sending out its guide to prospective new residents. Ravelston Grange DS0000062737.V248983.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9, and 10. The home was found to be in the process of transferring care-planning records into a more suitable format. A link between assessed needs and how these needs will be met in practice will be evidenced once the necessary improvements are made. Care-plans are now benefiting from regular attention from both the deputy and new acting manager although much work is still needed. Although there has been some improvement to risk assessments further progress is required to maintain Residents safety and keep upto date with resident’s changing needs. Medication arrangements were generally sound with most staff recently having training. It was evident that residents are treated with dignity and respect with their wishes respected. EVIDENCE: Both inspectors’ examined four Individual plans of care. Most plans looked at continued the same shortfalls identified in the last inspection report [May 26,2005]. Some of these plans had a range of statements written across them undated with the potential for confusion. The new acting manager showed the inspectors an example of a care-plan on a respite user in the new improved Ravelston Grange DS0000062737.V248983.R01.S.doc Version 5.0 Page 11 format. This plan was detailed and showed how needs were being met, reviewed and monitored with clear instructions for staff. The manager and the inspector agreed a timescale extension of by the end of the year where all care-plans [currently 17] will be transferred into the new format. This new format was found to be wholly useful The home’s management indicated that each resident would have their own single folder to assist the organisation of records and support an individualised approach. The deputy manager who has a dedicated 7 hours weekly administration and responsibility for the care-plans and who has attended a care-planning workshop is applying a key role in this improvement process. New risk assessments were found for two smokers who now smoke outside the home. The manager is reviewing this in relation to winter months. A particular resident is in the process of being assessed by a district nurse on the request of the new acting manager. The new acting manager has already identified that a new risk assessment is needed for this person due to being wheelchair bound. Other mobility risk assessments were in need of review The home was found to be mindful of how to prevent the risk of falls. Staff were observed dispensing and recording medication. Staff indicated that they have received training from the supplying pharmacist since the last inspection. Records and storage were found to be in order. Several residents were found to exercise their wish to refuse medication with no written system in place of what actions are then taken. The new acting manager has identified the need for medication to be more regularly reviewed including stocks. Both inspectors observed how staff interacted and supported residents. Residents spoken with all praised how staff treated and supported them. Ravelston Grange DS0000062737.V248983.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 15. The home was found to provide a good range of activities based on resident preferences and which are advertised and reviewed by a staff person with special responsibility for this. However 4 residents questioned the amount of activities being organised with records showing that these do not occur daily. Some comment cards completed by residents requested more suitable activities. It was recommended that given some changes in the resident group that an updated survey of views in this respect will be helpful. The activity coordinator has been found to be motivated, skilled, and committed to further developing activity opportunities.. Routines were found to be flexible for Residents who are treated as individuals. Morning Routines are currently being reviewed by the manager to ensure that they meet current needs. Food is good, tasty, varied, and healthy, in good portions and is popular with Residents. EVIDENCE: The last inspection report indicates the range of activities on offer with residents previously consulted about their views. No activities took place on the morning of the inspection although a staff member was observed consulting residents about the advertised cards activity. Residents choose a bingo activity to occur in the lounge. The lounge had a number of residents Ravelston Grange DS0000062737.V248983.R01.S.doc Version 5.0 Page 13 who conversed with each other did word puzzles or knitting. Residents confirmed that staff and the new acting manager regularly chat with them on a daily basis. The new acting manager stated that he wants all staff other than the activity coordinator to be able to organise activities as there are gaps at week-ends or when the activity co-ordinator is not on shift. This was also evidenced in records looked at .A residents meeting was found to be advertised for the day after the inspection where the agenda showed that activities were to be discussed. The owners of the home also play in a role in organising garden parties and bus trips. The new acting manager stated that part of the review of activities will assess timings so that they are flexible to meet needs. The new acting manager stated that he is currently reviewing morning routines to ensure that tasks are not hurried and meet the current needs of residents. This review will look at breakfast timings and locations as well as medication timings to ensure flexibility for residents. The inspectors found 4-weekly menus on display. Although there is no advertised choice Residents confirmed that alternatives are offered if they do not like the meal to be served. The Cook also interviews new Residents as to their preferences when they arrive at the home. It was recommended to the home that some options are advertised to promote choice and that greater clarity is provided rather than simply stating that three times week supper will be sandwiches. The Inspector took a meal. Ravelston Grange DS0000062737.V248983.R01.S.doc Version 5.0 Page 14 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 the following standard(s): 16 and 18 The home operates in an open manner and has not had a formal complaint for over 18 months or since the new owners took over. The home maintains a clear record of complaints made. Staff continue to demonstrate a sound understanding on how to prevent and report abuse in accordance with the homes policy. All Residents and visitors are made fully aware of how to complain or raise concerns. EVIDENCE: The home has a comprehensive complaint policy. This procedure and forms are in the reception area to the home. There was no record of any complaint made to the home since 170404, which was fully dealt with by the previous owners and is recorded in the complaints book. All staff cover the homes policy on adult protection and prevention of abuse during their induction. Evidence was seen of video training followed by marked exams for the staff team as a whole. Staff who spoke with the inspector demonstrated a full understanding of all the issues involved, including whistle blowing and who to report concerns too. All Residents spoken too confirmed the sensitive care they receive and were knowledgeable about whom to report concerns too. Staff were observed by the inspector to operate in an appropriately caring and patient manner. The new acting manager indicated that he plans to do a Protection of Vulnerable Adults course to keep himself up to date and cascade further training to staff. Ravelston Grange DS0000062737.V248983.R01.S.doc Version 5.0 Page 15 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 the following standard(s): 19, 23, 24, 30 The owner of the home has developed an comprehensive plan for the renewal, redecoration, and refurbishment of the home. The new acting manager has contributed to the plan which if realised within the timescales indicated will result in positive benefits for residents creating a home which looks attractive and well maintained throughout. The plan identities current shortfalls such as bedroom hallway, and stairway carpeting which needs replacing. Recordation and refurbishment of identified areas such as the main lounge where some chairs needed replacing The home is in a sought after location and has a well-maintained and attractive garden along with nice front entrance and front hallway. Some improvements to the homes décor have been made over the last 12 years months along with carpet cleaning and purchasing of new equipment. Accommodation is comfortable, spacious, and well lit. The home has recently appointed an effective maintenance man. The home has made safe identified areas from the last inspection such as window restrictors. Overall the home was found to be clean and free form offensive odours aided by improvements to the cleaning schedules with more hours dedicated to these important tasks. Ravelston Grange DS0000062737.V248983.R01.S.doc Version 5.0 Page 16 EVIDENCE: One of the inspectors toured the home including bedrooms and communal areas. The homes maintenance, refurbishment, redecoration, and renewal plan was examined and found to be on schedule with all identified work on course to be finished by April 2006. The owner of the home has released additional budget and given the manager opportunity to contribute to the plan where safety aspects have taken priority over decoration in the best interests of residents. Staff were seen to wear distinctive and separate coloured aprons when working in the kitchen and when supporting residents such as with toileting. A staff member stated how the new acting manager has insisted on adherence to infection control practices. Further infection control training other than the new staff induction was found to be planned. The new acting manager had also identified that bed linen and towels are in need of replacement. The newest resident respite user was found to have signed for, and had her right to a bedroom key respected with a secure facility to assist her to selfmedicate. Ravelston Grange DS0000062737.V248983.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28, 29, and 30. There are now sufficient numbers of experienced staff on duty at all times to meet the needs of resident’s. Overall staff numbers have improved giving the home a greater flexibility of experienced staff. A clear rota is also maintained The new acting manager demonstrated that he has both the skills and autonomy to adjust staffing levels where appropriate to meet needs The new acting manager demonstrated that the home carries out a robust and tight recruitment procedure to ensure the protection of residents Staff training has improved in relation to inductions for new staff and National recognised qualifications. All Residents and visitors praised the quality of the staff. EVIDENCE: Staffing levels as found at the last inspection are detailed fully in the last report dated May 26, 2005. A key period of the day [Supper time] was found to have been addressed by observations during the inspection speaking to the new acting manager and examining the rota. This relates to there now being 3 staff available during the supper period, enabling two staff to be present for service users whilst one prepares or serves the supper. Service user numbers have increased since the last inspection peaking at around 19 ,being 17 at the time of the inspection with two in hospital. The New acting manager demonstrated how staffing levels are adjusted to meet need as evidenced on the rota which is clearly maintained and shows the capacity of each person with a master rota and copy of the rota worked which also includes the Ravelston Grange DS0000062737.V248983.R01.S.doc Version 5.0 Page 18 managements hours. The New acting manager indicated that the home plans to have at least 50 of its care staff enrolled on National Vocational qualification course by December 2005 in line with Government guidance. As reported at the last inspection three staff have at least NVQ level 2. The recruitment records of the two most recently employed staff where found to contain all necessary information including ID checks and police CRB’s. These staff were also found to have started their TOPSS induction under the supervision of the new acting manager. The staff concerned had taken their workbooks home to work on. Supervision records showed the progress being made. The New acting manager show the inspector a training matrix for staff members, with plans to address gaps to bring everyone up to a similar standard within the next 6 months. The new acting manager is also an NVQ assessor, which staff stated was assisting them to make quicker progress. Ravelston Grange DS0000062737.V248983.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 38 The management of the home was found to be highly motivated, competent and is sufficiently experienced. The new acting manager was found to be giving the home clear leadership which both staff and residents were finding highly supportive. The new acting manager identified plans to more fully involve residents in the running of the home. The home was found to be operating in a open and supportive manner with all residents and staff having regular access to a supportive manager. The overall management of the home was found to have made improvements to the overall quality assurance systems with resident’s views in the process of needing publishing after being recently canvassed. Record keeping in relation to the management of service user finances was found to need more attention with the new acting manager having plans to address this along with all other areas. Supervision was found to have improved in the interests of staff. Some areas of health and safety have improved with areas such as fire protection practices needing priority. Ravelston Grange DS0000062737.V248983.R01.S.doc Version 5.0 Page 20 EVIDENCE: The new acting manager has been registered on two occasions by the Commission and has skills and experience suited to manage the home. The new acting manager has the necessary qualification of the registered managers ward which was achieved in 2003. The new acting manager will go forward for registration once his probationary period ends in November. This person has been in post for 5 weeks with clear evidence presented by records, discussions, observations, discussions with staff and residents which indicate the significant improvements, which had already been achieved. The inspectors saw minutes of recent staff meetings along with detailed supervisions. A residents meeting was advertised to take place the day following the inspection All of these forums were organised to occur regularly. The owner of the home sends the commission detailed reports on a monthly basis of one of his visits this includes checks around the home along with discussions with staff and residents. The owner has over the last two weeks carried out a survey of resident’s views. At the time of the inspection a report was being produced for future publication in the home’s guide. Shortly after the inspection, a report of this survey was sent to the commission, which indicated good levels of satisfaction. The new acting manager was found to have carried out a detailed audit on the home with improvements identified. Service user financial records maintained by the home were looked at. In some cases the running total did not correspond to what monies were being maintained, some receipts went back several years and needed organising along with some records, which lacked clarity. The inspector was satisfied that this was more about the system needing more regular review check and up to date record keeping. The last fire drill was found to have taken place before October 2004. The home were advised to also carry out an evaluation of regular fire drills and ensure that staff have training from a suitably qualified person. The new acting manager indicted that he will prioritise this area and also deliver training based on his own experience and training from social services. It was evident the improvements to the homes maintenance following the appointment of an experienced person who does weekly checks and address requests made with all window restrictors found to be safe. Ravelston Grange DS0000062737.V248983.R01.S.doc Version 5.0 Page 21 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 2 2 X X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X 3 2 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 2 3 X 2 Ravelston Grange DS0000062737.V248983.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? YES 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 15[1] Requirement Timescale for action 31/12/05 2 OP7 13[4][b]& [c] 3 OP19 23 4 OP38 23[4][d] That the Care-Plan sets out in detail the action which needs to be taken to ensure all assessed needs are met. That the plan of care meets clinical guidelines and is regularly reviewed at least monthly. That the care-plan is clearly organised and in a format accessible to staff and Service users [Residents]. Requirement of the last 2 inspections. Requirement first made 26/05/05.Timescale expired 26/08/05 That Risk assessments are 31/12/05 produced based on the current mobility needs of service users and with attention to the tissue viability and skin care of a particular service user [Resident] That the Registered person 31/03/06 replaces bedroom and communal area carpets along with lounge furniture identified at the inspection, during the timescale indicated That staff must receive suitable 30/11/05 Fire Training by an appropriately qualified person. Requirement DS0000062737.V248983.R01.S.doc Version 5.0 Ravelston Grange Page 23 5 OP38 6 OP38 of the last 2 inspections. Requirement first made 02/06/05.Timescale expired 26/08/05 23[4][e] That Regular Fire Drills must be carried out with an evaluation also completed. Requirement of the last 2 inspections. Requirement first made 02/06/05.Timescale expired 02/06/05 12[1][a][ That all care Staff receive up to b] & 18[1] date and appropriate, First Aid, food hygiene, Health and Safety, along with Moving and Handling training, within the timescale indicated. 30/11/05 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. 1 2 3 4 5 6 7 8 9 Refer to Standard OP1 OP2 OP9 OP12 OP15 OP26 OP28 OP33 OP35 Good Practice Recommendations That the Homes service user guide includes all necessary information. That Contracts include the room number and fee to be charged with an explanation for variation in fees. That written evidence is available to show how medication is reviewed and audited when medication is refused. That all residents’ views are consulted in relation to activity provision. That the advertised menus and board indicate what choices are available. That staff receive Infection control training. That sufficient care staff are enrolled on a NVQ course by December 2005. That Residents views are published in the homes guide. That an accurate running total is maintained in relation to service user monies managed by the home. That such financial records are transparent, organised, and regularly audited. Ravelston Grange DS0000062737.V248983.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ravelston Grange DS0000062737.V248983.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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