Inspection on 24/05/07 for Ravendale Hall

This inspection was carried out on 24th May 2007.

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

Ravendale Hall 15/06/06

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:

Abbey The

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 Mrs Kate Emmerson Key Unannounced Inspection 24th May 2007 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.V341587.R02.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.V341587.R02.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.V341587.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th June 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 £345 - £385 per week. Ravendale Hall DS0000035677.V341587.R02.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 24th and 25th May 2007. The manager and the director of the home were present during the inspection. 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. Three members of staff were spoken with, along with the directors of the service, the area manager, manager, cook and six service users. Additional information was provided through seven relatives, carers and advocates surveys, two care manager surveys and eleven staff questionnaires. Surveys were provided to the home for the service users but the Commission, at the time of writing the report, had not received any back. The manager had also completed a pre-inspection questionnaire. This had been returned to the Commission prior to the site visit taking place. Following the inspection the management provided additional information to evidence how they were meeting some of the requirements and the report has been adjusted to reflect this. What the service does well: The management had worked hard to meet all requirements and most of the recommendations from the previous inspection report. The experiences of the service users were positive in relation to how their care needs were met at the home. The service users were provided with a homely, clean and tidy and well-decorated environment. One service user stated that ‘ if they were a millionaire they wouldn’t go anywhere else’. The staff were friendly and knew a lot about the people who lived in the home. Staff helped the people who live there in a dignified and respectful manner. The staff working at the home were caring towards the service users and had good working relationships with them. A welcoming atmosphere was created for family and friends when they visited the home. There were a lot of activities on a daily basis at the home. This means that all of the service users, at some point, were able to join in activities that were of interest to them. The activity co-ordinator worked hard in the home to determine what activities were needed and then to provide them. Ravendale Hall DS0000035677.V341587.R02.S.doc Version 5.2 Page 6 The home obtained the views of all of the people who lived, worked and visited the home to make sure that it was doing a good job or to decide how it can change things to make it better for everybody. This gives service users a voice that is listened to about their home. The staff were supported as they were provided with individual time to talk to the manager about how well they were doing, or if they needed more training or support with their work. What has improved since the last inspection? What they could do better: They could provide more information about the services provided and lifestyle that can be expected in the home within the statement of purpose and service users guide. They must ensure that service users personal and health care needs and associated care plans are fully evaluated and up to date taking into account any incidents or changes over the previous month to ensure timely and appropriate interventions. They must provide evidence that service users or their representative have had the opportunity to see and agree their plan of care so that service users are enabled to make decisions about the care they are to receive. They must ensure that where care needs have been identified on risk assessments i.e. nutritional risk assessments that these are actioned to ensure that risks to service users health and welfare are minimised. They must ensure medication records are accurately maintained for all prescribed medications/creams and ensure that medications are stored as per instructions on medication advice sheets so that safe administration and storage of medication is maintained in the home. Ravendale Hall DS0000035677.V341587.R02.S.doc Version 5.2 Page 7 They must ensure that to protect the service users rights to refuse medication, medication is only crushed/given covertly when it has been agreed in a multi agency forum that this is in the best interest of the service user and signed agreement has been obtained from health professionals. Staff must have clear guidance on when to administer the medication in this way. They must fully investigate all complaints and maintain more detailed records of investigations. They must ensure that all staff have received training in safeguarding adults and that this is regularly updated to offer full protection to service users. They must minimise the risk of fire in the home by ensuring fire doors are not wedged open, staff training is provided regularly and the fire alarm is tested weekly. They must make sure that service users are not exposed to risks from freestanding radiators. They could check the lighting in the dining room is adequate at all times of the day. They must make sure that recruitment processes protect service users. They must obtain references before employment of staff and check the risks of employing staff with offences or cautions that appear on Criminal Record Bureau checks. They must make sure that the risk of assisting service users with mobility are reduced by ensuring all staff have had training to move and handle service users safely. They must make sure that service users health and safety is protected when using bedrails by competing full risk assessments and ensuring that the appropriate bed rail is used. They must ensure that service users at risk of falls are identified and accident records are completed fully. 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. The summary of this inspection report can be made available in other formats on request. Ravendale Hall DS0000035677.V341587.R02.S.doc Version 5.2 Page 8 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.V341587.R02.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service users were provided with basic information to assist them to make an informed choice to live at the home and they were provided with a written contract. Service users needs were fully assessed before they were admitted so that they could be assured their needs would be met by the home. EVIDENCE: The home had a statement of purpose, service user guide and a brochure that were available to the service users, their families and friends. Whilst these covered the basic points required to meet the regulations and the standards, the documents a were limited to very basic statements about the service and could be further developed to give information about the life style service users could expect if they lived in the home. Ravendale Hall DS0000035677.V341587.R02.S.doc Version 5.2 Page 10 The service users were provided with written contracts, which set out the terms and conditions of occupancy but did not include the room the service users would be occupying. Four care files were examined. The care files contained evidence that service users needs had been assessed before they were admitted into the home. The assessments were a combination of the home’s pre-admission assessment and the service users’ care management assessments. The assessments were supported where appropriate with risk assessment and risk management plans. The manager stated that where service users were admitted on a rolling respite programme they were now reassessed at each admission to ensure that the information was up to date. Most 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 manager stated that service users could visit the home for a day or an overnight stay (charges may apply) before making a decision. One relative commented that they had visited the home to view it before admission and was very satisfied and found staff very helpful. Although there were no written procedures the manager was able to describe the procedures for the admission of service users in an emergency situation. She stated that service users were only admitted in this way with the express permission of the management and after information regarding the service users needs had been obtained verbally from the placing authority. One service user stated that they were ‘admitted straight from hospital and that no one from the home had visited them before admission’. The home does not provide intermediate care dedicated to accommodate service users with intensive rehabilitation needs. Ravendale Hall DS0000035677.V341587.R02.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service users’ health and personal care needs were met at the home, however the very limited evaluation of the care provided would not ensure timely and appropriate interventions if there were changes in health or care needs. Medication was generally well managed in the home but service users right to refuse medication was not always appropriately managed. Service users felt they were treated with respect. EVIDENCE: Care files for four of the service users living at the home were examined. Ravendale Hall DS0000035677.V341587.R02.S.doc Version 5.2 Page 12 There was no indication during the site visit that service users health needs were not being met and there had been improvement in the level of detail recorded in care plans, diary records, evaluations and records of professional healthcare visits. However the information recorded was not always fully evaluated and changes in service users health or behaviour were not always identified. For example a service user had had aggressive outbursts, falls and had been refusing to take medication but the evaluation did not take any of this information into account. District nurse instructions although recorded were not always entered into the care plan, this means that over time the information/care instructions could go unnoticed and may put the service users at risk of needs not being met. For example in two cases the instruction for the service users feet to be elevated had not been included in the care plan. Whilst the service users nutritional status was assessed and level of risk identified these did not always provide a basis for care. For example the risk assessment in two cases identified the service user to be at risk and that the service users should be weighed twice monthly. One had been weighed consistently on a monthly basis and the other had not been weighed since November 2006. The manager was not able to identify any reason why the care instructions were not carried out. Standing and seated scales were available to assist in weighing service users. The care plans and risk assessments had not always been signed by either the service user or their representatives to acknowledge their involvement in the development of them and their agreement to them. Service users spoken to by the inspector said that when they had appointments for their healthcare needs these were always carried out in private. Visitors confirmed in surveys that when their relatives were ‘unwell’ the home always kept them up to date on any changes in their condition’. The home’s medication policies and procedures are appropriate to the needs of the service users. Medication records were correctly completed although there were a couple of gaps (no signature or code) in administration records where creams were to be applied. Medication in the home was appropriately stored except for some eye drops that required refrigeration and had been placed in the medication trolley. There were no controlled drugs in the home at the time of the site visit, however the home had appropriate facilities to safely store and record controlled drugs. There was evidence in a diary sheet that medication had been crushed on the GP’s instructions in order to assist the service user to take these during a period of illness, there was no evidence that this action had been discussed and agreed with the service user or their representative. Covert administration was discussed with the manager and she was advised that this Ravendale Hall DS0000035677.V341587.R02.S.doc Version 5.2 Page 13 practise must be discussed and agreed in a wider forum including the service user or their representative to ensure that the service users right to refuse medication is upheld and to ensure all options have been explored. Evidence from staff training records and staff discussion indicated that staff who administered medication to service users at the home had received accredited medication training. Service users confirmed to the inspector that they were always treated with dignity and respect and the staff used their preferred term of address, knocking on their doors before they entered. This was also observed to happen on the inspector’s tour of the premises. Ravendale Hall DS0000035677.V341587.R02.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience good quality outcomes in this area This judgement has been made using available evidence including a visit to this service. The service users were provided with the opportunity to become involved in a range of different activities at the home and in the community. Visitors were made to feel welcome in the home. Service users were provided with good quality, varied meals that were appropriate to their needs. EVIDENCE: The service users were provided with the opportunity to become involved in varied activities arranged through the activity co-ordinator. The activity coordinator worked very hard to maintain the level of activities that were made available to the service users. Records and a plan of activities held in the home were available. One service user stated that they ‘went to the pub, had bus trips and played bingo’. On the second day of the inspection some of the service users went to a local pub for lunch to celebrate one of the service users birthdays. The home Ravendale Hall DS0000035677.V341587.R02.S.doc Version 5.2 Page 15 hires a bus suitable for the service users needs as required. One visitor stated that they had given their relative their ‘own part of the garden to look after’. Generally the service users were very happy with the activities made available to them. Visitors stated in surveys that they were always made to feel welcome when they visited the home. One relative stated that ‘they seem to bend over backward to keep my mother in touch with me’. Local community activities and events were publicised on the homes notice board. One visitor commented that ‘ the entertainment activities and outings were good’. ‘The staff try to involve residents friends and families in summer and Christmas fairs also inviting them to a Christmas party with entertainment and an excellent buffet.’ Service users were encouraged to maintain their personal preferences and choices at the home. Service users bedrooms were personalised and there were a variety of communal spaces for service users to enjoy although many enjoyed sitting in the large reception area and being involved in the daily routines in the home. A church service was held monthly in the home and one of the service users attended the local church on a regular basis. The home provided a varied three-week rotating menu for the service users and choices were available at all meal times. Service users had had input into the development of the menus. Service users spoken to by the inspector all said that the quality of the meals was ‘very good’ and one service user said that the meals ‘were just as she used to cook and you couldn’t get any better’. The lunch meal was observed during the site visit, this was well presented with good portion sizes and home baking was evident. Aids were provided to encourage service users to maintain independence where possible and staff assisted service users where required in a sensitive and discreet manner. The kitchen was clean and there were good stocks of food in the fridge, freezers and stores. Appropriate monitoring records for the storage and preparation of food were clearly maintained. 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 he had the knowledge of how to access any special dietary needs that were required by individual service users. Ravendale Hall DS0000035677.V341587.R02.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The lack of recorded detail in investigation of complaints and lack of staff training in safeguarding adults may leave service users at risk. EVIDENCE: The home had appropriate policies and procedures for dealing with complaints and for the protection of vulnerable adults. The complaints procedure was made available to service users in information provided and was also displayed in the home. The pre-inspection questionnaire indicated that the home had received one complaint and this was not substantiated. The complaints investigation records were examined; these were very basic. Due to the lack of information in the records it could not be assessed if a complaint of verbal abuse made in January 2007 had been fully investigated and appropriate action taken. The issues in the complaint would have required a safeguarding adults referral to the Local Authority Team but the service user had not consented to a referral being made. Information received after the inspection and signed by the Ravendale Hall DS0000035677.V341587.R02.S.doc Version 5.2 Page 17 service user indicated that they were satisfied with the outcome of their complaint and the action taken. There was a lack of staff training in safeguarding adults and records showed only eight of the twenty-seven staff employed had received training in this area since October 2005. One staff member was very vague on safeguarding adult’s issues and had last received updates in this training in October 2005. However in the surveys returned, all staff from the handyman to the senior care staff showed good knowledge of the procedures. The management provided additional information following the inspection to evidence that staff training in this area had been completed. The service users spoken with were very happy with the service they received. One service user who normally sat with the higher dependency service users stated ‘staff were very good and always patient and gentle when assisting service users with mobility’. Ravendale Hall DS0000035677.V341587.R02.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 25 and 26. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service users felt at home at Ravendale and the environment was suitable to their needs however there were some areas that may put the service users health and safety at risk. EVIDENCE: The inspector made a tour of the premises of the home. The home was exceptionally clean and tidy and free from any offensive smells. It was well decorated and maintained and furniture and fittings were very good quality. Ravendale Hall DS0000035677.V341587.R02.S.doc Version 5.2 Page 19 Several bedrooms had 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 had a clear maintenance and renewal plan and equipment used at the home had up to date maintenance and service records. There was no use of CCTV at the home. There were several lounges in the home that the service users could choose to socialise, or have some private time in. A room had also been developed to allow the service users to take part in art and craft activities. The toilets and bathrooms were all close to the communal and bedroom areas for the service users. All of the rooms in the home had a call bell system in them. Service users confirmed to the inspector that when the call bell is activated the staff were always quick to respond. The grounds of the home were large and very well maintained and service users stated they had a lot of pleasure from walking and sitting in the grounds. The heating and lighting in the home were domestic in character. Regular random checks were made on the hot water outlets to maintain the health and safety of the service users. Hot water temperatures were maintained close to 43° C. There were some areas, which were cause for concern and may put the service users comfort and health and safety at risk. There had been no changes to the lighting in the dining room even though it was considered inadequate at the last inspection. On the day of this inspection it was a bright and sunny and there were no immediate concerns however the management should review this at different times of the day. Although there were no indications of issues with the heating, seven freestanding radiators had been provided in the service users bedrooms. The heat source was not adequately protected and may put the service users at risk of accidental burns and as the radiators were not fixed and had trailing wires these could also be a trip hazard. The manager was advised that these must be made safe or removed. There was evidence that fire doors were wedged open in the home, one service user had wedged their door open and another asked if they could have their ‘door wedged open again yet’. Another fire door was sticking on the carpet Ravendale Hall DS0000035677.V341587.R02.S.doc Version 5.2 Page 20 and wouldn’t close properly. This would increase the risk of spread of fire in the home. (See standard 38) Ravendale Hall DS0000035677.V341587.R02.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staffing levels were appropriately maintained so that service users needs could be met. Not all staff had received training or updates in mandatory areas, which may put service users health and safety at risk. Recruitment checks had not been completed in all cases to ensure staff were safe to work in the home. EVIDENCE: The manager of the home stated she used the uses the Residential Forum guidance to determine the number of staff that were required for each shift at the home. Although there was no evidence of this the staffing levels in the home were appropriate to the dependency levels of the service users accommodated at the time of the inspection. All of the service users spoken to by the inspector said that there was always ‘enough’ staff available to meet their needs and comments included ‘ you couldn’t fault the staff’ and the staff were ‘very nice’. Three staff personnel files were checked and showed that two of the staff had received appropriate security vetting before they had been allowed access to Ravendale Hall DS0000035677.V341587.R02.S.doc Version 5.2 Page 22 any of the service users but references and had not been received in the third case. Where a Criminal Record Bureau check had cautions or offences recorded there was no evidence that the management had sought to explore this with the employee and there were no records of the decision making/risk assessment process for employment of staff in these cases. The management and care staff showed a good commitment to NVQ training. More than 50 of the care staff had achieved NVQ 2 in care or equivalent with eleven of the seventeen staff having achieved NVQ level 2 and two having achieved NVQ level 3. The manager kept an overview of the staff training to assist her in the planning of training in the home. Records showed that not all the staff had received training in mandatory areas. Thirteen of the seventeen care staff had completed moving and handling training in the last year and not all had received training/refreshers in fire training and safeguarding adults. Additional information was received following the inspection, which evidence that staff had now completed the training in fire safety and safeguarding adults. A training plan was also provided which shows how staff will be provided over the next twelve months. Six staff had accessed a Dementia awareness course via the local college, which a staff member stated had been very useful. There was evidence that the cooks had completed a food hygiene course. A visitor to the home stated ‘my relative can only be moved via a hoist and I have been very impressed with the ease which they move her’. Staff interviews and personnel files provided evidence that they are receiving the recommended minimum of six formal recorded supervision periods per year. Staff interviewed by the inspector and returned staff questionnaires provided evidence that they were happy working at the home and with the support that they received to carry out their tasks. The home had just received the new induction workbooks, which will assist them to meet the new requirements of the Common Inductions Standards. There was evidence that the majority of staff had completed induction to the home and care workers role. The manager stated that more recently employed staff would now complete the new workbooks to ensure a full induction had been completed. Ravendale Hall DS0000035677.V341587.R02.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 People who use the service experience adequate quality outcomes in this area This judgement has been made using available evidence including a visit to this service. An experienced registered manager runs the home. The service users were included in the quality monitoring processes and their views were considered and acted upon in the development of the service. The service users individual financial interests were safeguarded but records of the residents fund lacked clarity. The staff were provided with supervision on a regular basis. Deficiencies in the management of health and safety may put service users and staff at risk. EVIDENCE: Ravendale Hall DS0000035677.V341587.R02.S.doc Version 5.2 Page 24 The manager stated that she had now completed the Registered Managers Award. The home had systems to monitor the quality of the care provided in the home. This included service user, staff and visitors surveys and monthly auditing of systems in the home. Records showed the actions that had been taken to address any shortfalls identified in the process. The manager stated that the results of surveys were published and made available for service users but was unable to provide evidence of this. Records where the home was assisting service users with finances were clearly maintained with receipts held for any transactions on behalf of the service users. Those checked balanced with the cash held. There was a lack of clarity in the record keeping for the resident’s fund, which was managed by the activities coordinator, manager and service users relative. From the records it could not be assessed if there monies were being appropriately managed. Information received form the home following the inspection showed that record keeping in this area had been addressed. There was evidence that the equipment in the home had been serviced regularly and at appropriate intervals. The handyman completed regular checks of hot water temperatures in the home, which were found to be within an acceptable range on the tour of the building. Seven service users had bedrails fitted. There were records to evidence that the handy man checked these weekly and there was evidence that risk assessments were completed and regularly reviewed. However the risk assessments were very basic and did not always inform practise. In one case the need for bedrails had been identified on assessment in July 2006 but the manager stated these were not in use when the service user had two falls in February 2007. The records did not identify a reason for this. One service user who required an extra mattress placed on their bed to protect them from pressure sore development but also required bedrails had not had appropriate height bedrails fitted which meant that the service user would still have been at risk of falls. There were some deficiencies in relation to fire safety, there was evidence that some fire doors were or had been wedged open, one fire door did not operate correctly as it was catching on the carpet and the fire alarm had not been tested weekly between 13 February 2007 and 16 April 2007. Although there was evidence that the regular fire drills were held in the home there were no records of the staff attending and the manager could not provide evidence in training records that all staff had received at least annual refresher training in this area. Ravendale Hall DS0000035677.V341587.R02.S.doc Version 5.2 Page 25 Some service users had been provided with additional freestanding radiators in their rooms. These could be a hazard, as the surface temperature could not be adequately controlled to safe limits to prevent accidental scalds and cables could be trip hazard. (See standard 25) Records of accidents did not always contain sufficient information about an accident that a service user had suffered and an outcome was not always recorded. Not all the accidents in the home were recorded, on three different occasions accidents had been recorded in service users diary sheets or on evaluation sheets but accident records could not be found. Ravendale Hall DS0000035677.V341587.R02.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 3 3 X X X 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 2 Ravendale Hall DS0000035677.V341587.R02.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement Timescale for action 01/08/07 2 OP7 15 12(2) 3 OP8 15 12(1) 4 OP8 13(4) 12(1) The registered person must ensure that service users personal and health care needs and associated care plans are fully evaluated taking into account any incidents or changes over the previous month to ensure timely and appropriate interventions. The registered person must 01/08/07 provide evidence that service users or their representative have had the opportunity to see and agree their plan of care so that service users are enabled to make decisions about the care they are to receive. 01/08/07 The registered person must ensure that where care instructions have been made by a visiting health care professional the care plan is updated to reflect these to ensure timely and appropriate care is provided. The registered person must 01/08/07 ensure that where care needs have been identified on risk assessments i.e. nutritional risk DS0000035677.V341587.R02.S.doc Version 5.2 Ravendale Hall Page 28 5 OP9 13(2) 6 OP9 13(2) 13(6) 12(2) and (3) 7 OP16 22 8 OP18 13(4) 22 9 OP19 13(4) 23(4) 10 OP25 13(4) assessments that these are followed to ensure that risks to service users health and welfare are minimised. The registered person must ensure medication records are accurately maintained for all prescribed medications/creams and ensure that medications are stored as per instructions on medication advice sheets so that safe administration and storage of medication is maintained in the home. The registered person must ensure that to protect the service users rights to refuse medication, medication is only crushed/given covertly when it has been agreed in a multi agency forum that this is in the best interest of the service user and signed agreement has been obtained from health professionals. Staff must have clear guidance on when to administer the medication in this way. The registered person must ensure that all complaints are fully investigated and detailed records of investigation maintained. The registered person must provide a full report to the Commission on the investigation and actions taken regarding the complaint of verbal abuse made in January 2007. The registered person must ensure that fire doors are not wedged open and can operate freely to prevent the spread of fire in the home and minimise risks to service users. The registered person must ensure that freestanding radiators in bedrooms are safe DS0000035677.V341587.R02.S.doc 01/08/07 01/08/07 01/08/07 01/08/07 01/08/07 24/05/07 Ravendale Hall Version 5.2 Page 29 11 OP29 19 12 OP30 18(1) 13 OP38 13(4) for service users and do not provide a trip or accidental scalding hazard or they must be removed from the bedrooms. The registered person must 24/05/07 ensure that two written references are obtained prior to the employment of staff. Where Criminal Record Bureau checks have cautions or offences recorded there must be evidence that the management has sought to explore this with the employee and records of the decision making/risk assessment process for employment of staff in these cases must be maintained. This is to ensure that staff are fit to work in the home and to protect the welfare, health and safety of the service users. The registered person must 01/09/07 provide evidence to the Commission that all staff have received training in moving and handling. 01/08/07 The registered person must ensure risk assessments accurately determine whether a service user initially requires bed rail provision and evaluations must determine the continued need for them. Bed rails and protectors must be fitted and checked in line with manufacturers instructions and Medical and Healthcare products Regulatory Agency (MHRA) guidelines. Specialist mattresses must be fitted in line with manufacturers instructions on the correct beds with the correct height of bed rail when the latter is required. This is to minimise the risk of injury to service users. Ravendale Hall DS0000035677.V341587.R02.S.doc Version 5.2 Page 30 14 OP38 23(4) 15 OP38 17(1) The registered person must ensure that the fire alarm is tested weekly to ensure service users health and safety. The registered person must ensure that all accidents, treatment and outcomes are fully recorded and that these records are regularly audited to protect the service users health and safety and minimise risk for those at risk of falls. 01/08/07 01/08/07 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 OP1 Good Practice Recommendations The registered person should further develop the statement of purpose and service users guide to give information about the life style service users could expect if they lived in 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. 2. OP20 Ravendale Hall DS0000035677.V341587.R02.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000035677.V341587.R02.S.doc Version 5.2 Page 32 - 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. 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