Inspection on 26/05/05 for Ravelston Grange Care Home

This inspection was carried out on 26th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 25/07/06

Ravelston Grange Care Home 17/10/05

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 26 May 2005 10:15 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. Ravelston Grange H59-H10 S62737 Ravelston Grange V217277 260505 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Ravelston Grange Address 10 Denton Road Eastbourne East Sussex BN20 7SU 01323 728528 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) PJP Care Ltd Vacant Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (OP) 24 of places Ravelston Grange H59-H10 S62737 Ravelston Grange V217277 260505 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users to be accommodated must not exceed twenty four (24) 2. The service users will be aged sixty five (65) or over on admission Date of last inspection 7 February 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. It is close to local shops, and a short drive away from the main town centre, shops, buses and railway station in Eastbourne. There is a homely, comfortable and friendly atmosphere and environment. 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. On the day of the inspection the external grounds such as the rear garden were found to be well maintained. The interior of the home including the main lounge, some hallways, and some rooms, were found to need refurbishment. The maintenance of the interior of the bulding needed more attention. PJP CARE LTD [Mr P and Mrs Piercy] own the home as part of a group of two homes for older people, the other home being in St Leonards-on-Sea. Ravelston Grange H59-H10 S62737 Ravelston Grange V217277 260505 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced routine inspection [first of two planned before April 1st 2006], carried out by two inspectors, which took place between 10.15am and 4.05pm. The Inspection found that of the 22 National Minimum Standards inspected, that 7 of these standards had been met with some others half met. The inspector’s started the inspection by speaking with Residents [9 in total] and visitors [2] and touring communal areas and visiting some Residents in their rooms. A discussion with the manager took place around progress since the last inspection. The kitchen was inspected. Care and staff records, medication and safety documentation were inspected. The inspectors spent time talking with the activity coordinator about future plans. This is the first inspection of the home since the new owners took over in October 2004. What the service does well: What has improved since the last inspection? The home was found to have generally met all requirements from the previous inspection. The home has organised for all contracts setting out the homes terms and conditions to be signed. Risk assessments have improved for a number of people. Medication practice has improved. The home has purchased a more effective washing machine. The induction of new staff has improved, as has other training such as National Vocational Qualifications. Most staff are receiving regular written supervision with all other staff planned to receive this important support. The home has recruited a staff person who also has a role in further developing activities in the home based on Residents wishes. Progress on redecoration and renewal of the home is slow but 3 of the 19 rooms were found to have been redecorated over the last 7 months. Some staff have done some training with further courses planned. Ravelston Grange H59-H10 S62737 Ravelston Grange V217277 260505 Stage 4.doc Version 1.20 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ravelston Grange H59-H10 S62737 Ravelston Grange V217277 260505 Stage 4.doc Version 1.20 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 Ravelston Grange H59-H10 S62737 Ravelston Grange V217277 260505 Stage 4.doc Version 1.20 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) 1,2,3 & 5 The inspector found, with some exceptions, that the home provides both prospective and existing Residents, with a good level of information. The way in which the home currently assesses prospective or existing Residents ensures, that it currently meets needs. Contracts were found to meet the standard but will benefit from clearer explanation, to avoid disputes, 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 but needs to record when this does not take place. 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 of 03/08/04. This report had been reproduced without the Commission’s permission in small print making it more difficult to read especially to those with visual impairment. The guide contained no resident’s views. Some Residents and visitors were found to be knowledgeable about their rights. The Inspector found that the home’s assessment information met the basic standard on newly admitted Resident such as one admitted on 11/05/05, and tallied up with his observations and discussions with the Ravelston Grange H59-H10 S62737 Ravelston Grange V217277 260505 Stage 4.doc Version 1.20 Page 9 individual Resident. The single line for each heading of the assessment information form had not yet been fully written up into a care-plan. No evidence was found that the home had written to the resident to confirm that they could meet assessed needs prior to admittance. The newest resident was found not have made a trial visit before moving in although her relative/advocate had done so. The manager stated that Contracts now meet the standard detailing full terms and conditions including the right to increase fees, and are signed by all parties. The manager stated that the owner kept these in his office and had sorted out this area when he took over the home. The owner confirmed that some Residents pay more than the standard fee if they choose a better room. 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. The owner is also in discussion with the Care homes association about developing a standard contract suitable for all homes. Ravelston Grange H59-H10 S62737 Ravelston Grange V217277 260505 Stage 4.doc Version 1.20 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 standard(s) 7,8 & 9 It was not possible to evidence whether Residents health needs are fully outlined and met due to the poor presentation of Care-planning records. Care-planning records are not regularly reviewed and do not show how needs will be met in practice. This key area needs major input from the both management of the home and staff. It was evident that that the home has some ideas of how to improve careplans. Staff showed some understanding of the needs of Residents. Although there has been some improvement of risk assessments further progress is required to maintain Residents safety. Medication arrangements were generally sound with the exception of staff training. EVIDENCE: Both inspectors inspected four Individual plans of care. The most newly admitted resident admitted on 11/05/05 was found not have a plan of care except for some assessment information and handwritten notes. None of the care-plans showed how needs will be met in practice. There was evidence of occasional review of some aspects of the plans but this was not monthly and consisted of handwritten single lines across the existing plans. It was not always possible to assess what was being reviewed. One plan had some Ravelston Grange H59-H10 S62737 Ravelston Grange V217277 260505 Stage 4.doc Version 1.20 Page 11 reviews but no dates for these reviews. Care Plans were grouped into single folders for each floor of the three floors of the home. 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. One senior member of staff stated that she had recently attended a care-planning workshop and would implement learning into a new care-planning system. The inspector advised the home to bring all plans up to date with consideration to their presentation to assist staff in meeting needs. Plans will need to be rewritten after a sufficient number of reviews. The home was seen to have gathered a lot of information on a resident who carried an infection although this was not all in the care-plan or was there a explanation as to why she choose to remain in her room all day despite the home believing that she was not a risk to others. A resident who smokes on the third floor of the home was found not have a full risk assessment. Staff spoken to had some knowledge of the skills of the newest resident. This feedback corresponded with the Inspectors impression after speaking at length with the resident concerned. The home was found to be mindful of how to prevent the risk of falls. Medication arrangements were found to be in order with some minor exceptions. The storage of drugs and records were inspected along with a discussion with the Acting Manager. None of the staff that administers medication were found to have been trained. The Acting Manager stated that he is looking in this. The home was advised to explore both formal approved training and in house monitoring checklist to assess new staff’s competence. Ravelston Grange H59-H10 S62737 Ravelston Grange V217277 260505 Stage 4.doc Version 1.20 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 standard(s) 12 & 15 The home was found to provide a good range of activities based on resident preferences. The activity coordinator was found to be motivated, skilled, and committed to further developing activity opportunities based on individual needs. Routines were found to be flexible for Residents who are treated as individuals. Food is good, varied, healthy, and popular with Residents. EVIDENCE: 9 of the 14 Residents were found to be in the lounge during the morning of the inspection where some enjoyed listening to some reminiscence music. A weekly programme of activities was on display in the lounge although the writing was small. The activity coordinator stated that this is changed on a weekly basis. Some Residents confirmed that activities were regular such as Bingo, quizzes, and music. A popular exercise class has been suspended due to sickness of the instructor. The activity person who works on shift as a senior has been employed for the last 6 months and in consultation with the owner has organised a pantomime trip and other trips, along with an afternoon quiz event which was open to relatives and friends. A garden party for Residents and Friends was found to have been organised for the month following the inspection. The activity person showed written evidence of consulting all Residents about their activity interests. The inspector formed the opinion that the standard will be exceeded once staffing levels return back to a satisfactory level. The activity person outlined future plans to increase Ravelston Grange H59-H10 S62737 Ravelston Grange V217277 260505 Stage 4.doc Version 1.20 Page 13 activities such as trips to garden centres. The introduction of quizzes was described as popular. The Acting Manager and staff stated that they have a flexible approach to the care with Residents treated as individuals. This was confirmed by discussions with visitors and 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. A tour of the kitchen found a wide range of fresh food, which was appropriately labelled and stored. Residents were observed to be seating in a well-lit separate spacious dining room. The Inspector observed the meal being served. Ravelston Grange H59-H10 S62737 Ravelston Grange V217277 260505 Stage 4.doc Version 1.20 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 standard(s) 16 & 18 The home operates in an open manner and has not had a formal complaint for over a year. 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 owner of the home was found to have organised for a senior member of staff to attend a social services organised, Prevention of Vulnerable Adults training event. This training will be used to update the homes practice. Evidence was seen of video training followed by marked exams. Staff who spoke with the inspector demonstrated a full and 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 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 over the last year. The last recorded complaint was 170404, which was fully dealt with as recorded in the complaints book. Ravelston Grange H59-H10 S62737 Ravelston Grange V217277 260505 Stage 4.doc Version 1.20 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 standard(s) 19,24 & 26 Given a high number of shortfalls the Commission requests an adequate plan for the renewal, redecoration, and refurbishment of the home. The home is in a sought after location but suffers from insufficient attention. Some small improvements to the homes décor have been made over the last 7 months. Accommodation is comfortable, spacious, and well lit. The homes entrance lobby and ground floor corridor along with the dining room are particularly homely. Other parts of the home such as main lounge do not create such a good impression. With the exception of the garden the home needs to be better maintained. Some areas of the home were found to be unsafe, needed cleaning, or renewal. EVIDENCE: 3 of the 18 bedrooms have been redecorated since October. The owners have taken responsibility for doing maintenance jobs. The rear garden was found to be well-maintained and popular with Residents. A number of carpets throughout the home were found to be worn, stained, or in need of more effective cleaning. Some carpets if left will become a potential trip hazard. 3 windows in the first floor bedrooms were found to need attention, as the restrictors were not working. Ravelston Grange H59-H10 S62737 Ravelston Grange V217277 260505 Stage 4.doc Version 1.20 Page 16 Some chairs in the lounge were very worn and need replacing. Some offensive odours were noted in some bedrooms. The home was found to be well lit ventilated, and spacious. The kitchen was found to be clean. Suitable laundry facilities are now in place with the purchase of a new washing machine complete with sluice facility. Some practices by the home such as leaving bars of soaps in bathrooms was found to breach infection control advice. Some Residents were found to need input in relation to hygiene practices. Residents were observed to move safely around the home aided by a working passenger lift. No Residents spoken too were found to have key to their room although only one person expressed an interest in this. The home was found to have no record to show whether this right had been offered with the resulting decision recorded. The management of the home stated a positive wish to address this areas some of which dated back to the period before the new owners took over. Ravelston Grange H59-H10 S62737 Ravelston Grange V217277 260505 Stage 4.doc Version 1.20 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 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 & 30 There was insufficient numbers of staff on duty on the day of the inspection to meet needs of resident’s along and other tasks. 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. The home needs to ensure that all times between inspections that staffing numbers is sufficient to meet assessed and changing needs. And that the rota is clear. EVIDENCE: Staffing levels include 2 per day shift plus the hands on Acting Manager and 2 additional staff, cleaner and cook, for the 14 Residents at the time of the inspection. The home has 1 waking night person. A cook works 10 to 2 or 3pm each day, along with a cleaner. The Acting Manager stated that the new owner had reduced staffing levels, as confirmed in records. 3 staff previously worked the morning and an extra staff worked 5-9pm to assist with care and doing the Supper/Teas. The Manager stated that although resident numbers had reduced form 19 to 14 it was now harder to meet needs. From 3pm there is 2 carers on shift one of whom has to do the supper/Teas this leaves 1 staff person for 14 Residents over 3 floors of a large home. The inspector informed the homes owner that this was unsafe and that he required within 28 days, a plan to rectify this. The owner stated that both himself and the manager also help out. On the day of the inspection the manager was on shift with one carer from 2pm, so was not additional. The owner is not in the home every day and is not on the rota. The Acting Manager is not always in the home as sometimes he was found to be out on Ravelston Grange H59-H10 S62737 Ravelston Grange V217277 260505 Stage 4.doc Version 1.20 Page 18 assessments. The hours the manager works on shift and the hours worked as the manager were not indicated on the homes rota. The manager stated that he is also working week-ends in addition to 40 hours a week management time. The manager stated that recruitment and staffing levels is the responsibility of the owner who explained that he had advertised for a temporary member of staff. The inspector took the view that this was insufficient to address shortfalls. Given the number of shortfalls in the home it was evident that the manager needed to be freed up from working shifts to support staff and focus on the administration of the home. Given the difficulty of covering shifts the home could not be considered safe to admit further Residents within existing staffing levels and was ill advised to release staff if it intended to bring up resident numbers up towards 24. It was not evident to Inspectors that the owner was fully competent in assessing what staffing levels should be. Three staff was found to have achieved at least NVQ Level 2 with one with Level 3, a figure below the recommended 50 . Some other staff were found to be on these courses. Two newer staff was found to have began TOPSS inductions along with in house inductions, which were not dated. The manager stated that the owner does the TOPSS induction with new staff. In addition the Inspector saw a blank TOPSS workbook. Ravelston Grange H59-H10 S62737 Ravelston Grange V217277 260505 Stage 4.doc Version 1.20 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 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) 31,32,33,36 & 38 The management of the home is positive, motivated and attentive to Residents needs but lacks experience and sufficient skills. The Acting Manager who is a very experienced carer needs to be able to make decisions in the best interests of Residents. The home was found to be conducted in an open and friendly manner. Staff are supported to carry out their roles with written regular supervision. The overall management of the home needs to more regularly record the views of Residents and staff, to ensure that quality is maintained and improved upon. Some areas of health and safety such as fire protection practices needs to improve. EVIDENCE: The home has since the last inspection been taken over by new registered owners effective from October 2004. The new owners have no background or qualifications in care. It was therefore agreed at registration that they had to recruit a suitably qualified and experienced manager. The owners in their Ravelston Grange H59-H10 S62737 Ravelston Grange V217277 260505 Stage 4.doc Version 1.20 Page 20 business plan planned a budget for this. The Commission received a week before the Inspection, an application from the homes Acting Manager to be registered. The Acting Manager has worked in the home as a deputy for over 3 years and overall for 8 years. The Acting Manager stated that he is yet to commence any management training and at present conducts staff supervision with the owner neither of whom have any training. The manager stated a willingness to get to grips with the number of administration and health and safety areas of the home. The Acting Manager stated that he was not previously aware of how the home was managed due to the previous experienced owners/managers doing all of this, with the deputy as effectively a senior staff member. The Acting Manager stated that he is looking to enrol on a suitable management course [NVQ 4]. The manager stated that a recently employed staff person had received the national TOPSS induction, which had been carried out by the home’s owner. The Acting Manager indicated the various ways in which the owner ran the home ranging from recruitment, setting staffing ratios, health and safety, training, and budgets. It was evident that the Acting Manager had no clear managers job description or role benefiting someone looking to be registered. The manager stated that team staff meetings took place and that he believed that the owner who ran these meetings took minutes although he and staff had not seen these. At the end of the Inspection the owner of the home showed the Inspector his own typed minutes of a staff meeting 27.4.05, which stated that the manager was responsible for staffing levels, and had agreed with the Owner’s decision to cut staffing. Residents indicated that they had open access to the owner and manager but presently have no meeting forums. No survey of resident’s views was found to have taken place. Written supervisions are now occurring for all but 2 staff. Sickness and other reasons had prevented this taking place. A day staff person indicated that she received now this at least every 2 months. She stated that she found this useful as a regular way of her giving her feedback on her performance, setting goals, and discussing any needs she had. The Inspector saw a calendar sheet on display, which advertised which staff were due for supervision form one month to the next. The supervisory format was found to be complete. 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 home were advised to recruit a suitable maintenance person or ensure that safety checks occur more frequently given the shortfalls already reported such as window restrictors. Ravelston Grange H59-H10 S62737 Ravelston Grange V217277 260505 Stage 4.doc Version 1.20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 2 3 x 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 1 x x x x 2 x 1 STAFFING Standard No Score 27 1 28 2 29 x 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 1 2 2 x x 3 x 2 Ravelston Grange H59-H10 S62737 Ravelston Grange V217277 260505 Stage 4.doc Version 1.20 Page 22 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 7 Regulation 13[4][b]& [c] Requirement That Risk assessments are produced based on the protection of service users with clear and detailed guidance on all hazardous actitvties, such as smoking. 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 accesible to staff and Service users [Residents]. That staff who handle medication receive appropriate training and ongoing guidance. That the Registered Person ensures that the home is kept in a good state of repair. That a programme of routine maintenance and renewal of the fabric and decoration of the premises is produced and sent to the Commission by the date indicated. That the home must be kept clean and free from offensive odours Timescale for action 26/08/05 2. 7 15[1] 26/08/05 3. 4. 9 19 13[2] 18[1] 23 26/08/05 26/08/05 5. 26 16[j] & 23[d] 26/08/05 Ravelston Grange H59-H10 S62737 Ravelston Grange V217277 260505 Stage 4.doc Version 1.20 Page 23 6. 27 18[1] 7. 33 26 8. 38 13[4] 9. 38 23[4][d] That the Registered person must ensure that having regard to the size of the home, the statement of purpose and the number and needs of service users [Residents] THAT AT ALL TIMES SUITABLY QUALIFIED AND COMPETENT AND EXPERIENCED PERSONS ARE WORKING IN SUCH NUMBERS AS ARE APPROPRIATE FOR THE HEALTH AND WELFARE OF SERVICE USERS [Residents]. That the Registered Person sends the Commission a new Rota to indicate an increase in staff numbers by the date shown. That staffing numbers on duty are at least in line with the numbers of staff on duty when the Owner took over the home in October 2004. That the Organisation which owns and manages the home must make arrangements for section 26 monthly visit reports carried out by the owner, or their representative, including evidence of named interviews with sufficient numbers of service users, their representatives, and staff, in order to form an opinion on the quality of care being provided. That this report includes an inspection of the premises and records, with an action plan to show how any shortfalls will be rectified, and by whom. That this report is sent to the Commission without delay on a monthly basis. That all windows fitted with restrictors are made safe and then regulary inspected to protect Service users [Residents] That staff must receive suitable Fire Training by an appropriately 26/06/05 26/08/05 02/06/05 02/06/05 Page 24 Ravelston Grange H59-H10 S62737 Ravelston Grange V217277 260505 Stage 4.doc Version 1.20 qualified person. 10. 38 23[4][e] That Regular Fire Drills must be carried out with an evaluation also completed. 02/06/05 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. 10. 11. 12. 13. Refer to Standard 1 2 5 24 26 26 27 27 32 32 33 Good Practice Recommendations That the Homes service user guide is updated and includes all necessary information. That Contracts include the Room to be charged and an explanation for variation in fees from the standard charge. That the home records when trial visits by the prospective new Resident are declined stating the reason why. That the home records that Residents are offered their own bedroom door key with the decision recorded. That staff receive Infection control training. That the homes cleaning schedules are reviewed. That the Rota records both the management administration, and care hours worked by the Manager. That the owner of the home records on the Rota when he works in the home and in what capacity. That residents are supported to have regular house meetings. That the minutes of staff team meetings are maintained in the home available for inspection and to the manager and staff. That Residents views are regulary surveyed with the outcome of this published in the homes guide. Ravelston Grange H59-H10 S62737 Ravelston Grange V217277 260505 Stage 4.doc Version 1.20 Page 25 Commission for Social Care Inspection 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 H59-H10 S62737 Ravelston Grange V217277 260505 Stage 4.doc Version 1.20 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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