Inspection on 11/08/05 for Ravendale Hall

This inspection was carried out on 11th August 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

Ravendale Hall 24/05/07

Ravendale Hall 15/06/06

Ravendale Hall 05/01/06

Ravendale Hall 28/01/05

Ravendale Hall 27/09/04

Ravendale Hall 27/02/04

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

CARE HOMES FOR OLDER PEOPLE Ravendale Hall East Ravendale Grimsby North East Lincs DN37 0RX Lead Inspector Stephen Robertshaw Unannounced 11t August 2005 h 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. Ravendale Hall J54 Ravendale s35677 v242632 090805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Ravendale Hall Address East Ravendale Grimsby North East Lincs DN37 0RX 01472 823291 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) Cleethorpes Care & Nursing Ltd Julie Hardy Care Home 33 Category(ies) of DE(5), DE(E)(5), OP(33) PD(6) registration, with number of places Ravendale Hall J54 Ravendale s35677 v242632 090805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: There are no conditions to the homes registration. Date of last inspection 28th January 2005 Brief Description of the Service: Ravendale Hall is a 40-bedded care home providing for the needs of older people, those suffering with dementia and also has 6 beds for the physically disabled. The home is situated in a rural position in a small village on the edge of the Wolds, approximately five miles from Grimsby. The building is set in extensive grounds and is in the style of an old manor house, it has maintained much of the character and original features and has had an extension provided in more recent years. The home is spacious and homely, with the accommodation based on two floors, a passenger lift is provided. There is a wide variety of day space, which includes three sitting rooms, two dining rooms and a library all on the ground floor. All the rooms are currently for single occupancy and includes en- suite facilities. Many rooms offer views over the surrounding countryside. The large mature garden surrounds the home with seating provided. Ample parking is provided. The home and its grounds are very well maintained. Ravendale Hall J54 Ravendale s35677 v242632 090805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The service users spoken to by the inspector stated that they were very satisfied with the care that they received at Ravendale, that the environment was very homely and the staff were very helpful to them. What the service does well: What has improved since the last inspection? The leaking conservatory roof has been repaired, and all of the radiators in the home have now been fitted with hot surface protection. The frequency of staff supervision has improved to ensure that the service users needs are being appropriately met. All risk assessments are all now supported with corresponding care plans. The medication records in the home are now accurately recorded, and appropriate codes are used on medication sheets. Ravendale Hall J54 Ravendale s35677 v242632 090805 Stage 4.doc Version 1.40 Page 6 All service user case files now include statements of terms of condition of the service users residency. Staff had received mandatory training including fire safety. Care plans indicate that the service users or their representatives have accepted them, however, this needs to be more clearly identified. Individual service users accidents at the home are more formally accounted for, and are audited on a monthly basis. Since the last inspection service users weights are now recorded on a monthly basis. Both seated and standing scales are available at the home. 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. Ravendale Hall J54 Ravendale s35677 v242632 090805 Stage 4.doc Version 1.40 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 Ravendale Hall J54 Ravendale s35677 v242632 090805 Stage 4.doc Version 1.40 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) 1,2,3,4 and 5 The home does not provide intermediate care therefore standard six is not applicable. The service users needs are all assessed before they are admitted in to the home. Service users are offered the opportunity to visit the home, and have trial periods there before making a commitment to a longer term placement at the home. EVIDENCE: The inspector observed the homes statement of purpose and service users guides. These met all of the requirements of schedule 1. the inspector suggested that a date should be added to this document to identify when it had been updated. Four service users case files were observed by the inspector and these all included full assessments of the service users needs completed before they Ravendale Hall J54 Ravendale s35677 v242632 090805 Stage 4.doc Version 1.40 Page 9 were admitted in to the home. The assessments included information including race, religious and cultural needs. The home has the capacity to meet the needs of the service users. This was confirmed though observations of the staff whilst they were working, interviews with staff to identify their underpinning knowledge of the service users, and discussions with service users and visitors to the home. The written records in the home also confirmed that service users individual healthcare needs are met through professionals that are based in the community, and good communications are maintained between the outside professionals and the homes staff. Service users stated to the inspector that they had been given the opportunity to visit the home before they made a decision to move there on a more permanent basis, however not all of them had taken on this opportunity. The home does not meet nursing care needs of service users, and does not provide intermediate care. Ravendale Hall J54 Ravendale s35677 v242632 090805 Stage 4.doc Version 1.40 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 and 9 The service users care plans reflect all of the identified needs form their original assessment of care needs. EVIDENCE: The inspector observed the care plans for four service users. All of the care plans could be identified as meeting the needs of the service users that were included in their original assessments. The care plans could include greater detail of how individual services users needs must be met. Most of the care plans had been evaluated on a minimum of a monthly basis, however some of the care plans did not show any evidence that they were being regularly reviewed. Medication was observed being administered to the service users and this was appropriate to the relevant legislation and good practice guidelines. The medical records sheets were all up to date, and were accurately recorded. The inspector recommended that abbreviations included on the MARS sheets must be identified to ensure that all individuals reading them were aware of the meaning of the abbreviations. Ravendale Hall J54 Ravendale s35677 v242632 090805 Stage 4.doc Version 1.40 Page 11 Service users care plans included regular recording of their weights. Any major changes in weight were noted and appropriate healthcare professionals were contacted for advice. Ravendale Hall J54 Ravendale s35677 v242632 090805 Stage 4.doc Version 1.40 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) 12,13, 14 and 15 The service users are supported and encouraged to make decisions, and choices for themselves during the course of their daily activities. The service users are provided with good quality meals, and a choice is provided at all meal times in the home. EVIDENCE: Discussions with service users, and observation of their case records provided evidence that they are encouraged to make decisions for themselves in all aspects of their daily lives. This included times to rise from and retire to bed, what to eat and where to eat it. Service users and visitors stated that the home maintains good communications with and provides clear access to the local community. The service users stated that the home has regular activities for them to become involved in, but it is their choice if they wish to become involved in them or not. Ravendale Hall J54 Ravendale s35677 v242632 090805 Stage 4.doc Version 1.40 Page 13 The inspector ate lunch with the service users and they were all very positive in relation to the quality, and choice of the meals that are provided for them. This standard was exceeded. An observation of the kitchen and food stores found them to be very clean, was well stocked, and were very well organised. Staff were seen to offer appropriate levels of support at mealtimes to individual service users. The meal times were observed to be unhurried, and the service users stated that they enjoyed all of their meals, and that it was a good time to speak to and socialise with other service users. Ravendale Hall J54 Ravendale s35677 v242632 090805 Stage 4.doc Version 1.40 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) 16,17 and 18 The home provides a safe environment for the service users and has a clear process for any complaints to be registered. EVIDENCE: The homes records indicated that there had been no complaints registered in the home since the last inspection. The homes complaints policy had been updated to include the change of contact address for the local Commission for Social Care Inspection office. Service users confirmed to the inspector that they had made no formal complaints to the home, but they knew how to do this, and believed that any complaints made would be dealt with fairly and professionally. The manager was able to produce an electoral register for the home, and stated that at the recent elections local councillors from the different political parties visited the home to canvas the service users for their votes. Service users spoken to by the inspector stated that they had been supported by the staff at the home to vote at the elections. Protection of Vulnerable Adults training had been provided to the staff team through the local authority. Staff interviewed by the inspector were aware of the different forms of abuse, and how suspected abuse should be reported to the appropriate authorities. All of the staff working in the home had received clearances from the Criminal Records Bureau with the exception off one wellestablished care worker at the home. Her CRB had been submitted but had not been received back at the time of the inspection. Ravendale Hall J54 Ravendale s35677 v242632 090805 Stage 4.doc Version 1.40 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) 19,20,21,23,24,25 and 26 Ravendale provides a very homely atmosphere, and the decoration and fittings are domestic in character. Service users are encouraged to personalise their rooms to their own tastes and preferences. EVIDENCE: The general environment is very homely, and well maintained. A tour of the premises found them to be very clean, tidy and free of any offensive smells and discussions with service users identified that this was the usual practice for the home. The grounds of the home were well maintained and the conservatory roof had been repaired since the last inspection. There was documentary evidence to support this. The home had up to date fire and environmental certificates. Ravendale Hall J54 Ravendale s35677 v242632 090805 Stage 4.doc Version 1.40 Page 16 Ravendale consists of a choice of three lounges for the service users, an ornate library, a conservatory area and 34 single bedrooms. Individual service users care plans identify if they do not have any of the furniture and fittings as required by national minimum standard 24.2 and if appropriate this care plan is supported by a risk assessment. Some service users invited the inspector to look at their rooms and these had all been personalised to their needs. This included inclusion of small pieces of furniture, pictures and ornaments. The furnishing and fittings throughout the home are domestic in character. The home provides one shower room and six bathrooms this ensures that the service users can have a choice of how they would prefer to bathe. There are an additional six separate toilets in the home. These are all close to the communal and bed areas of the home. The radiators in the home have now been protected with low temperature surfaces to ensure the safety of the service users. The home does not have sluicing facilities however the washing machines in the laundry are programmable to disinfection and sluicing standards. Ravendale Hall J54 Ravendale s35677 v242632 090805 Stage 4.doc Version 1.40 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 and 29 The home employs a staff group that has an appropriate skill mix to meet the needs of the service users. EVIDENCE: Observation of the staff rota system, and discussions with service users, and staff identified that there are appropriate numbers of staff available at all times in the home. The service users stated that the staff were always available to them and that they were able to meet their needs. The staff and management at the home are committed to meeting their requirement to have 50 of the care staff to have achieved NVQ 2 or equivalent by 31st December 2005. an external NVQ assessor was in the home on the day of the inspection and stated that she believed that the home would meet its NVQ targets on time. All new staff to the home receive induction training that meets the National Training Organisations workforce training targets. This training is provided to the home through an external training provider. Staff training records indicated that they meet all of the statutory training required by care staff and interviews with staff confirmed that they receive in excess of the three days paid training per year that are required by the national minimum standards. Ravendale Hall J54 Ravendale s35677 v242632 090805 Stage 4.doc Version 1.40 Page 18 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) 31,32,33,34,35,37 and 38 The management approach to the home is very open and positive, and encourages the staff and service users to air their views on how the services at the home could be improved. EVIDENCE: The manager of the home has completed an NVQ 3 in care and is currently working towards the Registered Managers Award. With her current progress on the award this should be completed before 31st December 2005. Interviews with staff and discussion with service users and visitors to the home provided evidence that the management of the home is very open and accessible, and that all parties involved believe that any anything raised to the manager will be dealt with promptly, professionally and in confidence where Ravendale Hall J54 Ravendale s35677 v242632 090805 Stage 4.doc Version 1.40 Page 19 appropriate. The standard for the management approach to the home was exceeded. The quality assurance and monitoring system for the home is still incomplete. Questionnaires are sent out to service users, carers, staff, and outside professionals. The information received back is beginning to be evaluated and plans are being made at the home to publish the results and the action plans created from the surveys. A business and financial plan was open for inspection and this indicated the financial viability of the home. An annual report was also available and this included a twelve month financial projection for the home. The inspector sampled the pocket money accounts for three service users. The records for the accounts were all up to date and were accurately recorded. Where appropriate receipts were included with individual accounts. This made sure that all service users monies were properly accounted for. Staff supervision in the home had improved in frequency since the last inspection. The supervision records for three members of staff were observed not all of these met the minimum requirements of six formal supervision periods per year. This standard must be improved to monitor the skills and abilities of the staff working with the service users, and identify any training required by individual staff members. The inspector observed the routine maintenance and service records for the home. All of the homes health and safety requirements were met. The home had current certificates to verify the safety of the gas and electrical systems in the home. The call system, and fire systems all had up to date maintenance records. There was evidence that ten of the homes care staff had recently undertaken fire safety training. Contracts were observed to be in position for the disposal of clinical waste. Water temperatures at the hot water outlets were recorded on a weekly basis at the home and indicated that they are maintained close to 43 degrees Celsius. Ravendale Hall J54 Ravendale s35677 v242632 090805 Stage 4.doc Version 1.40 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION 3 3 3 x 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 2 1 4 2 3 3 2 3 3 Ravendale Hall J54 Ravendale s35677 v242632 090805 Stage 4.doc Version 1.40 Page 21 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 15, and 13.4 Requirement The registered person must ensure that all individual care plans are evaluated in the home on a minmum of a monthly bais. Initially requirement for 30 april 2005 not met. The registered person must ensure that all staff working in the home have full enhanced CRB clearances. The registered person must ensure that a minimum of 50 of the care staff have achieved NVQ 2 or equivalent. The registered person must ensure that the manager of the home has achieved the Registered Managers award or equivalent. The registered person must ensure that the home has an effective quality control and monitoring system. The registered person must ensure that all staff working in the home including the manager the minimum of six formal recorded supervision periods per year. Timescale for action 30th November 2005 2. 18 and 28 18 11th September 2005 31st December 2005 31st December 2005 30th november 2005 30th December 2005 3. 28 19 4. 31 9 5. 33 24 6. 36 19 Ravendale Hall J54 Ravendale s35677 v242632 090805 Stage 4.doc Version 1.40 Page 22 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 Good Practice Recommendations Ravendale Hall J54 Ravendale s35677 v242632 090805 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Unit 3, Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Ravendale Hall J54 Ravendale s35677 v242632 090805 Stage 4.doc Version 1.40 Page 24 - 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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