Inspection on 25/07/06 for Ravelston Grange Care Home

This inspection was carried out on 25th July 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ravelston Grange Care Home 24/04/08

Ravelston Grange Care Home 17/10/05

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 Key Unannounced Inspection 25th July 2006 09:30 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.V297269.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ravelston Grange DS0000062737.V297269.R01.S.doc Version 5.2 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 Broderick Sharman Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Ravelston Grange DS0000062737.V297269.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is twenty-four (24) Service users must be older people aged sixty-five (65) years or over on admission 17th October 2005 Date of last inspection 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. At the current time these rooms are generally being used as single’s meaning that numbers of those accommodated generally peaks at around 19 persons. [ 17 people at the time of inspection] 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. Information on the range of fees charged is within the homes current statement of purpose/service user guide and ranges from £359 to £443 per week. The higher rate of fee is based on room size and facilities. Charges for extras include personal items beyond the basic toiletries and activities provided by the home. Such items include newspapers, perfumes, chiropody, and hairdressing. Inspection reports are not routinely sent out to families and advocates after each publication although a copy is kept on display in the reception area of the home and can be obtained via the manager. A service user guide containing the most recent inspection report is sent to any interested person [or their representatives] looking to move into the home. Ravelston Grange DS0000062737.V297269.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced key Inspection, which included a visit to the home which took place between 9.30am and 3pm on July 25,2006.This inspection focused on the key major areas such as how needs are being met. Activities, lifestyles, environment staffing of the home, along with how the home is managed, and how concerns are dealt with, was looked at. During this inspection process, which covers the period since the last inspection October 4, 2005 and the week of the home visit, a number of social workers have been spoken with. Seven [7] questionnaires were received from relatives, and 13 from Residents prior to and after the inspection, with comments mainly positive, especially about the care, the manager, and the staff. Some visitors and 12 residents were spoken with, along with others observed during the inspection, which also included discussion with some staff and observation of care-practices. The focus of the inspection was looking at the four newest Residents who have moved in since the last inspection, and some who require higher levels of care. Some diversity and equality areas were explored in relation to lifestyles. Care records for five Residents along with health and medication needs were looked at. Discussions with management looked at progress since the last inspection. The inspector toured all communal areas of the home along with bedrooms. Meal arrangements were examined. A record of complaints was inspected. Staffing was looked at in detail along with the homes management, including measures to ensure quality for Residents. One [1] outcome area is Excellent, Five [5] areas are Good, and one [1] area is Adequate [ok] and in need of minor improvement. What the service does well: Residents benefit from an exceptionally well managed home, which fully involves them in how it is run. The service continues to raise its quality and actively encourages, and responds too, suggestions from residents. The homes management regularly reviews the service on offer with Residents at the centre of this ongoing process. Residents are kept well informed about all aspects of the home. The home manages well a range of complex behaviours beyond the usual reach of a home of this type. This enables people to remain as residents in the home as long as is safely possible, thereby maintaining their independence and type of freedoms which might not be possible in homes registered for more complex needs such as dementia or mental disorder. All Residents spoken with said that staff and management were helpful, they liked the rooms, standard of cleanliness and maintenance, the food, and activities on offer. A typical quote from residents was as follows “ quite happy, could not do better than here, well looked after”. The atmosphere of the home was Ravelston Grange DS0000062737.V297269.R01.S.doc Version 5.2 Page 6 found to be friendly and unhurried. There are regular activities in place, which are popular with most Residents. Additional events are organised such as a garden parties and trips out. The home always carries out its own assessment before someone new moves in. Residents were seen to be comfortable with one another. The service has been able to retain a hard core of experienced staff who are committed to improving the service. Staff are exceptionally well supervised and supported by the manager to ensure that Residents receive a quality service. The owner of the home visits at least weekly and carries out his own detailed inspections and works closely with the manager in developing the service in the best interests of residents. 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. Ravelston Grange DS0000062737.V297269.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ravelston Grange DS0000062737.V297269.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, & 3. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The home provides both prospective and existing Residents, with a good level of information. Moreover, the way in which the home assesses prospective or existing residents ensures, that it currently meets needs. Contractual terms and conditions are fair, transparent and agreed and signed by residents and their representatives at the point of entry into the home, with only some minor additional information needed 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 also contains a survey of resident’s views following completed questionnaires received in October 2005.This positive report also include a suggestion about improving laundry arrangements. The Ravelston Grange DS0000062737.V297269.R01.S.doc Version 5.2 Page 9 owner of the home also records resident’s views during his monthly inspection visits, with reports sent to the Commission. The 5 Residents files looked at showed that the home now writes to prospective new residents to confirm that they could meet assessed needs prior to admittance. Pre-assessments carried out by the manager were found to be thorough with additional information from social services also obtained by the home either prior to or on admittance. These assessments accurately described the needs of the residents concerned who the inspector met with. The manager was advised to indicate in the assessment information why the Individual is being accommodated in the home to assist staff when the reason is less obvious. Such as when the Resident is very able and is in the home because it would be unsafe for the person to live on their own, as was the case with one person spoken with. Since the last inspection the owner of the home has made copies of Residents contracts available to the manager who stores them on file. Each room has its own individual fee depending on size and facilities such as en-suite. It was positively noted that of the contracts looked at for the 4 newest Residents the one who is self funded pays less then those who are social services fully funded. It was also evident that variations in fees are also due to social services sometimes negotiating a lesser payment than the usual advertised charge for each room. Two minor improvements were recommended, that the contract terms and conditions shows that is responsible for paying the fee as this information had to be sought elsewhere. Secondly, that the contract also shows the intended fee to be charged alongside what is actually charged in case any Resident decided to challenge it. The home were found to be aware of amendment to Care Homes Regulations effective form September 2006 in relation to contracts. 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 Manager has introduced a form for recording when trial visits are offered and declined. A completed [inquiry] sheet was seen which is completed prior to a visit. Evidence was also seen of the home sending out its guide to prospective new Residents all of whom confirmed that they had opportunity to read the information before moving in. Ravelston Grange DS0000062737.V297269.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. The manager and staff are very aware of Residents needs and respond quickly to any changes. Although care-plans are much improved some further work is still needed to their detail, review, and to show Resident involvement. Medication arrangements have further improved and benefit from closer checks With just minor gaps in recording. Residents are treated with dignity and respect with their wishes respected. EVIDENCE: The inspector examined five Individual plans of care, four of which referred to the newest residents and one of a person who recently spent a month in hospital. In addition the inspector spoke with and observed all 5 Residents, spoke to some of their social workers, staff in the home and the manager about their needs and how they were being met. It was evident that all residents concerned and those social workers spoken with are pleased with their care and are proactively supported by the home to maintain their Ravelston Grange DS0000062737.V297269.R01.S.doc Version 5.2 Page 11 independence and have the best possible quality of life. In one case this has involved the home organising advocates to befriend one of the residents and detailed risk assessing to ensure a safe a presence in the local community. Care –plans have improved over the last 2 inspections and are now in a accessible, clear, and organised format which now shows clearer signs of review, and which contain some good information about the person s needs. The care-plans still lack some specific guidance, such as one, which states that the person needs support with a bath without being more specific. Although it was clear form staff what precise support is needed to support existing independence skills. The manager agreed to record strengths within the plans. Plans showed some evidence of review, however more detail is needed than one line or repeated phrases such as no change. In one case a resident had been in hospital for month and only returned to the home after careful risk assessment and a number of changes, which were itemised in parts of the care-plan assessment but not in the monthly review notes for July 4, 2006.It was also noted that the resident concerned enjoys a high level of independence which makes it more necessary for evidence of the Resident being involved in their care-plan and various agreements. Risk assessments were found to be comprehensive containing good up to date information. The new acting 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. The home was found to be mindful of how to prevent the risk of falls. Staff were observed dispensing and recording medication. Staff and records indicated that they have received training from the supplying pharmacist since the last inspection. Records and storage were found to be in order with the exception of there being 3 consecutive gaps where a double signature is needed for controlled medication. This was considered a minor lapse as all other records were full a process now aided by the regular auditing of medication by both the manager and his deputy. The manager is currently organising for medication information sheets for reach resident to be made available so that staff understand what medication they are giving and the side effects. Several residents were found to have exercised their wish to refuse medication since the last inspection. The manager was found to have introduced a written system to record and respond to this as seen in records where the GP was promptly involved and all precautions taken by the home including in one case a period of hospitalisation. District nurses spoken with during the inspection praised the care by staff and confirmed how the home had managed the removal of a pressure sore which one resident entered the home with. Records showed how promptly health needs are met. The inspectors observed the helpful way staff interacted and supported residents. Residents spoken with all praised how staff treated and supported them. This was also confirmed in comment cards received from those relatives and residents who completed them. Ravelston Grange DS0000062737.V297269.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, & 15. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The home provides a good range of activities based on resident preferences and which are advertised and regularly reviewed with residents Routines are flexible for Residents who are treated as individuals with exceptional lengths taken to cater for their choices and suggestions, and, involve them in the running of the home. Food is under constant review and is good, tasty, varied, and healthy, in good portions and is popular with Residents who have a range of choice. EVIDENCE: Residents choose a bingo activity to occur in the lounge from 11am on the day of the inspection, this was also the advertised activity. Other regular activities include quizzes, seasonal outings and other social events organised by a staff person [deputy] who is the named activity co-ordinator. All residents spoken with expressed satisfaction with the number and range of activities on offer. The lounge had a number of residents who conversed with each other did word puzzles or knitting. The manager organised a community trip for one resident where the home has liaised with a number of advocates to meet the person Ravelston Grange DS0000062737.V297269.R01.S.doc Version 5.2 Page 13 social needs. Some other residents went out with relatives, whilst some relaxed in the patio area or other areas of their choice. Residents confirmed that staff and The Manage regularly chat with them on a daily basis to ascertain their views and choices. The minutes of two monthly resident meetings and the owner’s monthly inspection visit showed how activities are regularly discussed. This showed how suggestions such as rearranging the timing of some activities are taken into account. Overall resident involvement in the home was found to be exceptional as confirmed in residents discussions with all stating how well informed they are with the manager visiting each of them each morning Residents expressed pleasure at a recent Garden evening which relatives were invited too, and which involved a range of activities including a juggler and a range of raffles and other entertainments. Residents expressed satisfaction with the monthly outings, which have started this Summer with a local organisation who supply a mini- bus. Staff were seen throughout the inspection to encouraging opportunities for Residents to socialise and feel involved in the home. Morning routines were found to be unhurried and met the current needs of residents. The manager conducted with Residents a recent review of breakfast timings and locations as well as medication timings to ensure flexibility for residents. All residents who want a key to their room and lockable storage have this right respected with some being supported to move to larger rooms to sore their personal furniture The inspectors found 4-weekly menus on display with the introduction of advertised choices on both the menus and the notice board. The cook was observed to be consulting each resident as to his or her supper 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. An entry in the homes suggestion box namely that liver should be introduced to the menu was found to being acted upon by the manager in liaison with the head cook. The Inspector took a meal at the last inspection and found it to be tasty and wholesome. Ravelston Grange DS0000062737.V297269.R01.S.doc Version 5.2 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, & 18. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The home operates in an open manner and has not had a formal complaint about the care of Residents for over 2 years since the new owners took over. The home maintains a clear record of complaints made and advertises a clear procedure which Residents and visitors are aware of. Staff continue to demonstrate a sound understanding on how to prevent and report abuse in accordance with the homes updated policy. 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. Since the last inspection there have been two concerns expressed to the home manager by residents although neither of these were about the care of Residents or allegations of abuse. One concern was linked to deterioration in the mental health of the Resident who raised an unfounded suspicion after declining to take medication. The other concern was about the behaviour of a staff person who although not directly harming residents was seen by Residents, openly flouting the homes disciplinary procedure. The home promptly dismissed the person concerned following an investigation triggered Ravelston Grange DS0000062737.V297269.R01.S.doc Version 5.2 Page 15 by the manager after being informed of a residents concern during his daily consultations with each resident. Although both concerns were recorded with the homes care-plans the manager agreed that in future some reference will be made in the homes complaint or concerns file to assist the central storage of information in one place. In each case no evidence was found to show that any residents were at risk, with good care being enjoyed by all. It was also evident that the manager’s promotion of an open culture has encouraged residents to feel confident about raising any issues. 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 Manager has since the last inspection undertaken a Protection of Vulnerable Adults course to keep himself up to date and cascade further training to staff. The homes policy in that area was updated in January 2006 with all staff signing the updated policy, which includes the relevant contact numbers. Ravelston Grange DS0000062737.V297269.R01.S.doc Version 5.2 Page 16 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, 24, & 26. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The home is benefiting from continuous investment in its fabric with the main work of replacing carpets and redecoration complete with remaining items on schedule. Resident’s indicated satisfaction with improvements to bedrooms and the overall environment. The home was found to be clean and free from offensive odours aided by continuous improvements to the cleaning schedules. EVIDENCE: The inspector 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 2007. The owner of the home has over the last year released Ravelston Grange DS0000062737.V297269.R01.S.doc Version 5.2 Page 17 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. Since the last Inspection carpets in the dining and lounge area have been replaced and are regularly cleaned as seen during the afternoon of the inspection. Carpets have been replaced in those bedrooms requiring it with all necessary bedrooms redecorated involving residents in the choice, with one choosing magnolia. Newer residents have also had their rooms decorated with one using an alternative room initially whilst her chosen room was decorated. Carpets have also been replaced in corridors and on the first and second floor landings along with room made en-suite and the kitchen redecorated. Before April of 2007 staff will have a designated room to assist training events The rear garden is popular with Residents, which like the front of the home is well maintained. An established resident expressed pleasure that the home has recently fitted a handrail in her room at the right height to assist her. This also involved the home liaising with an occupational therapist. All residents spoken with praised their rooms, the views afforded, as well as their cleanliness and appearance. 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 Manager has insisted on adherence to infection control practices. Infection control training is also covered in new staff inductions as well as in the home’s updated policy. The Manager has also replaced all bed linen and towels. The manager in liaison with the owner has organised additional cleaning hours and improved the schedules, which ensures that some weekend cleaning cover is now provided. The home was found to be clean and fresh throughout The newest Residents who requested a room key were found to have signed for, and had this right respected. Ravelston Grange DS0000062737.V297269.R01.S.doc Version 5.2 Page 18 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, & 30. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of experienced staff on duty who are well supervised and who continue to benefit from increased training. Staff are on course to meet all training targets in the near future. Tight recruitment and disciplinary procedures are followed to protect the interests of Residents All Residents and visitors praised the quality of the staff. EVIDENCE: Staffing levels are matched to the needs of the 17 Residents as evidenced during the inspection. The crucial improvement introduced after the inspection in May 2005, relating to there being 3 staff available during the supper period, enabling two staff to be present for service users whilst one prepares or serves the supper, has been maintained. The Manager again 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 management hours. The acting deputy also has administration time each Tuesday to assist with careplanning. The manager continues to act promptly when the home can no longer safely meet developing nursing needs within existing staffing levels. Ravelston Grange DS0000062737.V297269.R01.S.doc Version 5.2 Page 19 Staff were observed to be meeting needs throughout the inspection in an unhurried manner while residents confirmed that their needs are promptly met day and night. The Manager indicated that the home plans to enrol 2 further staff on the National Vocational qualification course in Care as soon as possible, in line with Government guidance that at least 50 have this qualification by the extended guideline April 2008. At present 30 of care staff have the National Vocational Qualification with two further staff in the process of completing the course. [one staff with the qualification has left since the last inspection with one achieving the qualification]. The recruitment records of the three most recently employed staff where found to contain all necessary information including ID checks and Police CRB’s. All staff work under full supervision after passing their Protection of Vulnerable Persons Register check and before the Police CRB comes back clear. These staff were also found to have started or finished their TOPSS induction under the supervision of the manager. Supervision records showed the progress being made, along with close monitoring of performance and development needs. The Manager showed the inspector a training matrix for staff members, with most gaps to bring everyone up to a similar standard now complete. The Manager is also an NVQ assessor, which staff again stated was assisting them to make quicker progress. Ravelston Grange DS0000062737.V297269.R01.S.doc Version 5.2 Page 20 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): 31,33, 35, 36, 38. Quality in this outcome area is Excellent. This judgement has been made using available evidence including a visit to this service. The management of the home is highly competent and provides clear leadership. An exceptional range of Quality assurance measures are regularly carried out based on Residents being fully involved in the running of the home. Record keeping such as service user finances and health and safety is good. The home is advised that any allegation of staff misconduct is immediately reported to the Commission to ensure timely accountability. EVIDENCE: The Manager has been registered on three occasions [most recently in December 2005 for Ravelston Grange] and has the skills, experience, and motivation suited to managing the home as evidenced by the positive Ravelston Grange DS0000062737.V297269.R01.S.doc Version 5.2 Page 21 comments of Residents and the rapid improvements to the home over the last 9 months. The manager has the necessary qualification of the Registered managers award which was achieved in 2003 and which included units on both care and management equivalent to National Vocational Qualification 4. Overall quality assurance measures are exceptional. The inspector saw minutes of recent staff meetings along with detailed residents meetings, which occur every two months, which began in October 2005, and which are advertised with minutes circulated to all residents. Residents remarked that they are impressed with how they are kept informed and have their views regularly sought and taken seriously such as on 22/07/06 when a suggestion about what biscuits are purchased was actioned. 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. A detailed survey of resident’s views took place in October 2005 with the results published in the home’s service user guide. The overall outcome was highly positive for the home. The Manager, with the support of the owner of the home, carries out detailed audits on the home with improvements identified, such as the recent refurbishment of the home. Policies and procedures were found to be under regular review with policies such as that on recruitment and adult protection recently updated. Service user financial records maintained by the home were looked at during the last inspection. The manager confirmed that he has audited and improved the system he inherited with a transparent process now in place with accurate running total and clear paperwork now maintained. The supervision of staff was found to be exceptional as evidenced in the quality of the detailed supervision notes of meetings with staff which occur at least every two-months or sooner depending on need. The home dismissed a staff person since the last inspection following an allegation of misconduct, a fact, which should have been reported to the Commission at the time. This was made an immediate requirement. A recent fire drill was found to have taken place in April 2006 with a full evaluation carried out. The Manager who is an experienced fire safety instructor recently undertook a refresher one- day fire course and then delivered the training to staff on the same day as the drill. The maintenance and safety of the home was found to be Good with a new maintenance person due to start with senior staff person carrying out minor repairs with more major works promptly attended to by contractors. The manager confirmed in the pre- inspection questionnaire that all necessary equipment used by the home is within its safety schedule. Staff who handle food have recently passed food hygiene training with first aid training planned for those staff who require it. All care staff receive Moving and Handling training before supporting Residents. Ravelston Grange DS0000062737.V297269.R01.S.doc Version 5.2 Page 22 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 3 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 4 X 2 Ravelston Grange DS0000062737.V297269.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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 That the Registered Person must ensure that Care-Plan’s set out in detail the specific action to be taken by care-staff to meet all needs, as well as promote independence and strengths. That all needs are recorded such as preferred routines. That monthly review of plans indicates actual changes. That the plan shows involvement by the individual’s service user [Resident] concerned. Timescale for action 25/10/06 2. OP38 37.1[g] That the Registered Person must 25/07/06 with immediate effect ensure that any allegation of misconduct against anyone working in the home is reported to the Commission without delay. Ravelston Grange DS0000062737.V297269.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP2 Good Practice Recommendations That the statement of terms and conditions [Contract] shows who is responsible for paying the fee. That the usual room fee is shown alongside the actual fee charged/negotiated. That the homes completed pre-assessment form on prospective new service users [Residents] indicate why the person is to be accommodated That all controlled drugs administered indicate double signature. That at least 50 of staff obtain National Vocational Qualification at level 2 or equivalent as soon as possible and by the Government extended deadline of April 2008. 2. 3. 4. OP3 OP9 OP28 Ravelston Grange DS0000062737.V297269.R01.S.doc Version 5.2 Page 25 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.V297269.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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