Inspection on 15/06/06 for Ravendale Hall

This inspection was carried out on 15th June 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 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 05/01/06

Ravendale Hall 11/08/05

Ravendale Hall 28/01/05

Ravendale Hall 27/09/04

Ravendale Hall 27/02/04

Similar services:

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Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Ravendale Hall Ravendale Hall East Ravendale Grimsby North East Lincs DN37 0RX Lead Inspector Stephen Robertshaw Unannounced Inspection 15th June 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 Ravendale Hall DS0000035677.V296333.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. Ravendale Hall DS0000035677.V296333.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ravendale Hall Address Ravendale Hall East Ravendale Grimsby North East Lincs DN37 0RX 01472 823291 01472 823121 cynthiacommons@hotmail.com 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) Cleethorpes Care and Nursing Ltd Julie Hardy Care Home 34 Category(ies) of Dementia (5), Dementia - over 65 years of age registration, with number (5), Old age, not falling within any other of places category (34), Physical disability (6) Ravendale Hall DS0000035677.V296333.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th January 2006 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 include en- suite facilities. Many rooms offer views over the surrounding countryside. A large mature garden surrounds the home with seating provided. Ample parking is available. The home and its grounds are very well maintained. The current fee for the services provided at the home is £329 per week. Ravendale Hall DS0000035677.V296333.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this key inspection the inspector from the Commission for Social Care inspection (CSCI) undertook a site visit to the home. The inspection was unannounced and took place on 15th June 2006. The site visit was over a period of approximately seven hours. Twenty-eight service users were living at the home at the time of the visit. The manager of the home was on annual leave, however a director of the service was present. Whilst at the home, key documents such as care assessments, care plans, daily records and the home’s policies were looked at, and so were the rooms and garden. Four members of staff were spoken with, along with the director of the service, eight service users and five visitors to the service. Additional information was provided through four service user questionnaires that were returned to the inspector and three completed staff questionnaires. The manager had also completed a pre-inspection questionnaire. This had been returned to the Commission prior to the site visit taking place. What the service does well: The experiences of the service users appeared to be positive in relation to how their care needs are met at the home. The service users are provided with a homely and safe environment. The staff are friendly and appeared to know a lot about the people who live in the home. Staff helped the people who live there in a dignified and respectful manner and service users said that this made living in a communal home much better. One service user said that the staff were ‘excellent’ and were always very helpful. The staff working at the home are really caring towards the service users and have good working relationships with them. As a result of this life at the home is not too serious and the service users can relax in a homely environment. This creates a welcoming atmosphere for family and friends when they are visiting the home throughout the day. There are a lot of activities on a daily basis at the home. This means that all of the service users, at some point, will be able to join in activities that are of interest to them. The activity co-ordinator works hard in the home to determine what activities are needed and then to provide them. Ravendale Hall DS0000035677.V296333.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ravendale Hall DS0000035677.V296333.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 Ravendale Hall DS0000035677.V296333.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): 1,2,3,4 and 5 The quality outcomes in these areas are adequate. This judgement has been made from evidence gained both during and before the visit to the service. This means that the service users are usually provided with a choice to live at the home and their needs are fully assessed before they are admitted. However respite care service users do not always have their needs fully assessed before they are admitted in to the home. EVIDENCE: The home has an appropriate statement of purpose and service user guide that are available to the service users, their families and friends. The inspector looked at the care files for four of the service users living at the home. Three of the files were for service users that were permanently placed at the home and one of the files was for a respite care service user. The care files for the permanent service user showed that they had all had their needs assessed before they where admitted in to the home to make sure that the home could meet their needs. The assessments were a combination of the home’s pre-admission assessment and the service users’ care management Ravendale Hall DS0000035677.V296333.R01.S.doc Version 5.2 Page 9 assessments. The assessments were supported where appropriate with risk assessment and risk management plans. The respite service users’ care file showed that they were on a rolling respite plan, however it did not include any evaluation of the care needs when the service user was readmitted in to the home. This could mean that if the service users needs changed in between admissions, then they were not being fully met each time that they were admitted in to the home. Interviews with staff, and discussions with service users and visitors to the home showed that Ravendale could meet the assessed needs of the service users. Staff training records showed that they receive training to up date their skills and knowledge to make sure that they can appropriately support the service users in their care. Several of the service users said to the inspector that ‘the staff could not do anything more for them’ than they already do and that ‘nothing was too much trouble for the staff’. Service users spoken to by the inspector stated that they had been given the opportunity to visit the home before they were admitted to it. The home had clear policies and procedures for the admission of service users in an emergency situation. The home does not provide intermediate care dedicated to accommodate service users with intensive rehabilitation needs. Ravendale Hall DS0000035677.V296333.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 and 11 The quality outcomes in these areas are adequate. This judgement has been made through evidence gained both during and before the visit to the service. This means that the service users’ health and personal care needs are all met at the home, however the recording of how they are met could be improved. EVIDENCE: The inspector observed the care files for four of the service users living at the home and four service user surveys were returned to the inspector. These all provided supporting evidence that the service users’ health and personal care needs are met at Ravendale Hall. The individual care plans for the service users included regular evaluations to ensure that the service users needs were continuing to be met through the home and to identify if there were any changing needs. The care plans had generally been signed by either the service user or their representatives to acknowledge their involvement in the development of them and their agreement to them. Ravendale Hall DS0000035677.V296333.R01.S.doc Version 5.2 Page 11 The care files also identified when the service users had contact with outside professionals who supported them with their healthcare needs. This included GP’s, district nurses, dentists and chiropodists. Service users spoken to by the inspector said that when they had appointments for their healthcare needs that these were always carried out in private. Visitors also confirmed to the inspector that when their relatives are ‘unwell’ the home always keeps them up to date on any changes in their condition. The home’s records for when service users see healthcare professionals could be improved. Currently they are very basic, for example they state when a chiropodist visits but not the outcome of the treatment or the service user’s attitude to receiving the service. The service users’ daily diary entries were also very limited in their content except to record in a clinical manner, for example ‘bathed’, ‘ate well’ etc. The diary entries did not include any individual personalities and traits. This makes it difficult for new people looking at the files, including care staff, to fully understand the personalities and qualities and needs of the individual service users. One service user said to the inspector that the care that they received at the home was ‘exceptional’ and ‘was over and above what is expected’. The home’s medication policies and procedures are appropriate to the needs of the service users. The inspector observed medication being administered to the service users and these practices had significantly improved since the last inspection. All of the individual medication records were observed to have been correctly completed. Medication in the home was also appropriately stored. There were no controlled drugs in the home at the time of the site visit, however the home has appropriate facilities to safely store and record controlled drugs. All staff that administer medication to service users at the home have received accredited medication training. Service users confirmed to the inspector that they were always treated with dignity and respect and the service users used their preferred term of address, knocking on their doors before they entered. This evidence was also observed to happen on the inspector’s tour of the premises. All of the individual care files seen by the inspector included the last wishes of the service users in the event of their deaths. Ravendale Hall DS0000035677.V296333.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 and 15 The quality outcomes in these areas are good. This judgement has been made from evidenced gained both during and before the visit to the service. This means that the service users are provided with the opportunity to become involved in a range of different activities at the home and in the community. EVIDENCE: The service users are provided with the opportunity to become involved in varied activities arranged through the activity co-ordinator. The activity coordinator works very hard to maintain the level of activities that are made available to the service users. One service user in their returned questionnaire stated that there were ‘regular outings’ at the home. Generally the service users are very happy with the activities made available to them. On the day of the inspection one of the service users was upset and did not understand why she had not been included in the afternoons outing in the minibus. A member of staff tried to explain that it was because she was unwell and wouldn’t be safe if she went out but the service user did not accept this. Visitors spoken to by the inspector stated that they are always made to feel welcome when they visit the home, that it was always clean and well presented and the staff always offered to provided them with drinks and Ravendale Hall DS0000035677.V296333.R01.S.doc Version 5.2 Page 13 refreshments. Local community activities and events are publicised on the homes notice board. Service users told the inspector that they are asked what interests they have to invite individuals and groups in to the home from the community to meet these needs. One of the service users at the home was of multi-cultural background, however the care that she wished to receive did not require the home to provide for any specific cultural or religious beliefs. The service user confirmed this to the inspector. Service users are encouraged to maintain their personal preferences and choices at the home. This evidence was supported in the individuality of the service users bedrooms. The inspector sampled the pocket money accounts for four service users. All of the records were up to date. The home provides a varied menu for the service users and choices are available at all meal times. Service users spoken to by the inspector all said that the quality of the meals was ‘very good’ and one service user said that having meals at the home was like ‘being in a hotel’. The inspector looked around the kitchen and found it to be very clean and there were good stocks of food in the fridge, freezers and stores. All of these were within their use by dates. There were no special diets required by the service users at the time of the inspection except low sugar and low fat diets. Discussions with cook identified that she had the knowledge of how to access any special dietary needs that were required by individual service users including cultural and religious needs. Ravendale Hall DS0000035677.V296333.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): 16,17 and 18 The quality outcomes in these areas are good. This judgement has been made through evidence gained both during and before the visit to the service. This means that the service users have their rights and needs supported and protected at the home. EVIDENCE: The inspector’s discussions with the director of the service and the returned pre-inspection questionnaire identified that since the last inspection there had been two complaints made in relation to the services provided through Ravendale Hall. One of these complaints was made directly to the Protection of Vulnerable Adults team based with the local authority. None of the issues relating to the POVA were upheld and the home was vindicated on all aspects of the complaint. There were however some recommendations that the home maintained more in depth records to identify how individual service users’ care needs are met on a daily basis, this remains an area for improvement. The home has appropriate policies and procedures for dealing with complaints and for the protection of vulnerable adults. Staff interviewed by the inspector were all aware of how to report suspected abuse. The complaint made directly to the home had been dealt with in accordance with the home’s policies and procedures. The care files observed by the inspector supported the evidence that the service users are provided with the appropriate assistance to vote at local and national elections. Ravendale Hall DS0000035677.V296333.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,2324,25 and 26 The quality outcomes in these areas are adequate. This judgement has been made through evidence gained both during and before the visit to the service. This means that the service users felt at home at Ravendale and the environment is suitable to their needs however there were some concerns safety for the service users within the general environment EVIDENCE: The inspector made a tour of the premises and the grounds of the home. A new sign has been put up in the grounds of the home identifying that it no longer receives service users with nursing care needs. This had been an outstanding requirement. The outside of the home has been improved. All of the door and windows had been painted and this gave a better impression of the home on arrival. The dining room has been decorated but it still appears to be a little dim. The management should consider the lighting in the room. This would also benefit Ravendale Hall DS0000035677.V296333.R01.S.doc Version 5.2 Page 16 the administration of medication as the medication sheets would be clearer to see. Several bedrooms have recently been decorated and had new carpets and furniture added to them. Service users spoken to by the inspector were very happy with the environment provided for them at Ravendale Hall. Individual service users’ rooms had been decorated and furnished to their own tastes and preferences. The home has a clear maintenance and renewal plan and all of the equipment used at the home had up to date maintenance and service records. There is no use of CCTV at the home. There are several lounges in the home that the service users can choose to socialise, or have some private time in. It was pleasing to see that the service users are now making better use of these rooms. A room has also been developed to allow the service users to take part in art and craft activities. The inspector was invited to look at several of the service users’ bedrooms. These had all been personalised with their own pictures, ornaments and included some of their own furniture. The domestic staff working at the home work very hard to maintain the environment from any offensive smells. The toilets and bathrooms are all close to the communal and bedroom areas for the service users. Two service users said that these areas are ‘always very clean’. The sluice room door was left open and unattended during the site visit. This could place the service users at risk of infection if they entered the room and also from scalds as the waters in the sluice area are not regulated. All of the rooms in the home have a call bell system in them. Service users and visitors confirmed to the inspector that when the call bell is activated the staff are always quick to respond. The grounds of the home are well maintained however there was a bare wire on the outside wall of the home. The proprietor must ensure that this is not live and has the appropriate safety measures for it. The heating and lighting in the home are domestic in character. Regular random checks are taken on the hot water at the outlets to maintain the health and safety of the service users. These are maintained close to 43° c. Ravendale Hall DS0000035677.V296333.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 The outcomes in these areas are good. This judgement was made through evidence gained both during and before the visit to the service. The staff are all provided with the recommended minimum formal supervision per year. This means that their work with the service users is regularly monitored to ensure that their needs are being met. EVIDENCE: The manager of the home uses the residential forum to determine the number of staff that are required for each shift at the home. All of the service users spoken to by the inspector said that there was always ‘enough’ staff available to meet their needs. Visitors to the service also commented on the abilities of the staff and their promptness and effectiveness to support the service users. There were no staff under twenty-one working at the home. The staff personnel files showed that all of the staff had received appropriate security vetting before they had been allowed access to any of the service users. The management and care staff show a good commitment to NVQ training and are working well towards the homes commitment to 50 of the care staff to have achieved NVQ 2 in care or equivalent. The management also maintain the mandatory training for the staff team and include specialist training in relation to the care of elderly service users. Service users spoken to by the inspector stated that they believed that the staff had the skills and knowledge to meet their needs. Two visitors to the home stated that they had experience of other Ravendale Hall DS0000035677.V296333.R01.S.doc Version 5.2 Page 18 care homes and that the staff at Ravendale appeared to be more professional and approachable than the other staff that hey had encountered. Staff interviews and personnel files provided evidence that they are now all receiving the recommended minimum of six formal recorded supervision period’s per year. The personnel files also showed that equal opportunities are provided in the employment practices of the home and the procedures protect the service users from possible abuse. This includes POVA first and CRB clearances. The staff that were interviewed by the inspector and returned staff questionnaires provided evidence that they are happy working at the home and with the support that they receive to carry out their tasks. However it was recognised that the staff meetings at the home need to be held on a more regular basis. Staff induction to the home is linked to the national standards for induction training. Ravendale Hall DS0000035677.V296333.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36 and 38 The outcomes for these areas are adequate. This judgement has been made from evidence gained both during and before the visit to the service. This means that the management of the home ensure the safety of the service users and makes sure that their needs are met at the home. EVIDENCE: The manager was not available on the day of the site visit. However the director of the service stated that the manager has now almost completed the Registered Managers Award. Service users and visitors spoken to by the inspector said that the manager of the home has an open door policy and is very approachable. Staff stated that the manager has strategies to enable staff and service users to affect the way in which services are delivered at the home. Ravendale Hall DS0000035677.V296333.R01.S.doc Version 5.2 Page 20 This is supported through the home’s quality assurance and monitoring systems. The manager completes monthly ‘quality audits’ throughout the service provided at the home. Recent questionnaires were distributed in relation to the meals provided to the service users and personal care (bathing). The returned questionnaires had been collated and analysed but at the time of the inspection had not been publicised. Monthly audits are also completed by the manager to collate visiting patterns to the home and to receive any comments from the visits. The home has an activity fund however this needs to be more formally recorded to ensure that the monies are being appropriately accounted for. In relation to equality and diversity in the home the service users recognised through questionnaires and individual contact with the activity co-ordinator that they would like to be able to access craft materials more. Therefore an IT and craft room was developed in the house. One service user links in with a local church every week and parishioners pick her up to take her to events at the church and in the community. All of the home’s safety and maintenance certificates were up to date and were open to inspection. Records and interviews with staff identified that they are now receiving the recommended minimum of six formal recorded supervision periods per year. However staff meetings are not held as often as they should be. This could mean that they are not always as up to date with new policies and procedures and care plans as they should be. Ravendale Hall DS0000035677.V296333.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 1 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 1 2 3 3 3 3 3 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 2 3 2 3 3 2 X 3 Ravendale Hall DS0000035677.V296333.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 (2) Requirement The registered person must ensure that all service users have their needs fully assessed before they are admitted in to the home. This includes service user on rolling respite programmes (requirement for 30/01/06 was not met) The registered person must ensure that the daily diary records in relation to the service users include detail to their personal attributes and not just clinical interventions. The registered person must make sure that the care staff fully record any contact that service users have with professionals that are based in the community. The registered person must ensure that the exposed electrical wire on the outside of the building is made safe and is either removed or is safely ‘capped off’ Timescale for action 30/08/06 2. OP8 16 (2m) 14/08/08 3. OP8 17 (1,2,3) 14/08/08 4. OP19 23 (2b,c and o) 30/07/06 Ravendale Hall DS0000035677.V296333.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP19 OP20 OP28 Good Practice Recommendations The registered person should make sure that the service users do not have access to the sluice areas of the home. The registered person should assess the lighting provided in the dining area of the home and identify if this needs to be improved. The registered person must continue with their commitment to NVQ training and 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 as a minimum the Registered Managers Award or equivalent. The registered person must continue to review the home’s quality assurance and monitoring to ensure that Ravendale has an effective quality assurance and monitoring system in position. The registered person should make sure that staff meetings are held at the home on a regular basis to identify areas of training required and to acknowledge good working practices in the home. 4. OP31 5. OP33 6. OP36 Ravendale Hall DS0000035677.V296333.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hessle Area Office First Floor, 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. 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