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Inspection on 05/01/06 for Ravendale Hall

Also see our care home review for Ravendale Hall for more information

This inspection was carried out on 5th January 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The service users stated to the inspector that they are very well cared for in the home. All of the service users have a copy of their terms and conditions of their residency at the home. Service users relatives stated to the inspector that they are always made to feel welcome at the home and that they can visit at any reasonable time. This standard was exceeded. The service users stated to the inspector that there are appropriate stimulating activities available to them at the home and in the community. The service users are protected from abusive situations and the staff receives appropriate protection training. All of the service users rooms are for single occupancy. The premise was kept exceptionally clean and tidy and was free of any offensive smells. This standard was exceeded. All new staff receive induction training to the National Training Organisations specifications. Staff do not have to financially contribute to the CRB`s or NVQ training. Service user, visitors to the home and staff all confirmed that the management of the home is open and approachable. The home has a clear business and financial plan that shows the financial viability of the home and identifies the training plan for the staff. All of the records required by regulation are maintained by the home and they were seen to be al up to date and were accurately recorded. The maintenance and service records for all of the equipment in the home were also observed to be up to date.

What has improved since the last inspection?

The exterior of the building has been completely redecorated since the last inspection. This makes the home look more appealing from the outside. The staff are closer to meeting their requirement of 50% of them having achieved NVQ 2 in care or equivalent. The homes quality assurance and monitoring system has improved and is close to being a complete and appropriate system for the home.

What the care home could do better:

All service users should have their nutritional needs assessed as part of their fuller assessment of needs. Medication procedures must be consistently followed and adhered to. Medication must not be left on tables with service users. All staff personnel files must include two written references. All care staff working in the home must receive a minimum of six formal recorded supervision periods per year (pro-rata).

CARE HOMES FOR OLDER PEOPLE Ravendale Hall Ravendale Hall East Ravendale Grimsby North East Lincs DN37 0RX Lead Inspector Stephen Robertshaw Unannounced Inspection 5th January 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.V272278.R01.S.doc Version 5.1 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.V272278.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ravendale Hall Address Ravendale Hall East Ravendale Grimsby North East Lincs DN37 0RX 01472 823291 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.V272278.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th August 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 include 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 DS0000035677.V272278.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on 5th January 2006. The inspection was over an eight-hour period. The service users, staff and management were all very open in their discussions with the inspector. The home was well maintained and the exterior of the home had been completely decorated since the last inspection. What the service does well: The service users stated to the inspector that they are very well cared for in the home. All of the service users have a copy of their terms and conditions of their residency at the home. Service users relatives stated to the inspector that they are always made to feel welcome at the home and that they can visit at any reasonable time. This standard was exceeded. The service users stated to the inspector that there are appropriate stimulating activities available to them at the home and in the community. The service users are protected from abusive situations and the staff receives appropriate protection training. All of the service users rooms are for single occupancy. The premise was kept exceptionally clean and tidy and was free of any offensive smells. This standard was exceeded. All new staff receive induction training to the National Training Organisations specifications. Staff do not have to financially contribute to the CRB’s or NVQ training. Service user, visitors to the home and staff all confirmed that the management of the home is open and approachable. The home has a clear business and financial plan that shows the financial viability of the home and identifies the training plan for the staff. Ravendale Hall DS0000035677.V272278.R01.S.doc Version 5.1 Page 6 All of the records required by regulation are maintained by the home and they were seen to be al up to date and were accurately recorded. The maintenance and service records for all of the equipment in the home were also observed to be up to date. 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.V272278.R01.S.doc Version 5.1 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.V272278.R01.S.doc Version 5.1 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): 2,3,4 and 5 The service users are provided with the opportunity to visit the home before making a decision to move in to the home on a more permanent basis. This means that they are provided with a personal choice in whether or not to move in to the home. EVIDENCE: There are currently thirty service users living at the home. The inspector observed the case files for three of the service users. All of the files observed by the inspector included terms and conditions of the service users residencies at the home. Two of the case files included assessments of the individual service users needs. The third file was for a respite service user that had progressed on to being in permanent care at the home. There had been no new assessment of their needs identifying what had changed to make the move to a permanent placement. Ravendale Hall DS0000035677.V272278.R01.S.doc Version 5.1 Page 9 The case files all included the individual service users care management assessment of needs and care plans. Service users spoken to by the inspector stated that ‘the staff were very caring’ and that all of their needs were ‘met in the home’. Observation of service users in the home showed that they appeared to be very happy in their environment. Visitors to the home on the day of the inspection stated that they are always made to feel welcome at the home and that the staff always kept them up to date on the care that their families were receiving and where appropriate they were invited to review of their care. One visitor to the home stated that he believed that younger service users with disabilities should not have to be placed at the home with older people as they had ‘completely different needs’. The home does not provide intermediate care to serviced users. Ravendale Hall DS0000035677.V272278.R01.S.doc Version 5.1 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 and 9 Service users are supported at the home to maintain their physical and personal health care needs. EVIDENCE: The individual care plans observed by the inspector had all been evaluated on a minimum of a monthly basis. All of the needs identified in individual service users assessments had been addressed in the homes care plans and were clearly linked to risk assessments where appropriate. The homes care plans would benefit from including greater detail of how individual needs must be met. Service users spoken to by the inspector said that they were aware of their care plans and they had been involved in the development of them. Individual case files showed that the service users health care needs are met through appropriate professionals based in the community. This included GP’s, Ravendale Hall DS0000035677.V272278.R01.S.doc Version 5.1 Page 11 occupational therapists, continence nurses, district nurses and hospital specialists. The service users told the inspector stated that they always see healthcare workers in private unless they request support from staff at the home to see them. The assessment of the service users includes a screening of their nutritional needs. These had not been included in some of the case files observed by the inspector. The majority of the homes policies and procedures for the administration of medication was followed buy the staff in the home. The staff administering medication to service users have all received accredited medication training. Observation of the administration of prescribed medication identified that one service users was left with medication on the dining table and was not observed taking the medication. The medication in the home is locked in a trolley and stored in a secure room when not in use. Ravendale Hall DS0000035677.V272278.R01.S.doc Version 5.1 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 service users are provided with choice in how they lead their daily lives and whether they engage in activities or not in the home and in the community. EVIDENCE: Service users stated to the inspector that they have ‘good choice’ of activities at the home. The home has an activities co-ordinator. Her role is to develop a wide range of activities for the whole of the service user group as individuals, and alternatively small and larger groups. Service users said that they enjoyed the two weekly visits to ‘the luncheon club’ and trips to ‘local pubs’. Other service users also stated that they enjoyed ’reading’ and ‘doing jigsaws’. The service users spoken to by the inspector stated that the activities in the home are stimulating and are on a frequent basis. They also stated that there is no pressure placed on them to become involved in activities if they choose not to be part of them. Ravendale Hall DS0000035677.V272278.R01.S.doc Version 5.1 Page 13 The standard for visitors access to the home was exceeded, Visitors to the home stated to the inspector that there was ‘nothing else’ the staff and manager of the home ‘could do to improve’ their visits. The visitors stated that they are always made to feel welcome at the home and that they could visit at any reasonable time. They also said that they could join in the activities with the service users if they wanted to. Service users confirmed to the inspector That they are able to make choices in the home throughout their daily lives. This included times to get up from and retire to bed, what and where to eat it, and activities. Observations by the inspector supported the evidence that the service users are provided with personal autonomy and choice. The inspector ate lunch with the service users. There was a clear choice of meal and the quality of the meals was very good. The service users were observed being offered appropriate support to complete their meals where appropriate. Service users stated that they have regular drinks provided throughout the day but if they required drinks at any other time then they would be given them. A tour of the homes kitchen by the inspector found it to be very clean and there were plentiful supplies of food stocks in the home. At the time of the inspection there were no special diets required by service users at the home except low fat and low sugar diets. Ravendale Hall DS0000035677.V272278.R01.S.doc Version 5.1 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): 1617 and 18 The home has a clear complaints procedure that is easily accessible to the service users and the serviced users are protected from abusive situations at the home. EVIDENCE: The homes complaints procedure had recently been updated and meets the needs of the service users and the home itself. Since the last inspection there have been no complaints recorded at the home. One complaint was made directly to the local authority and was investigated by them. The complaint was not upheld. The complainant stated that they were not satisfied with the local authority’s response and requested a further investigation. The local authority has moved the complaint to stage 2 in their process and this investigation was still ongoing at the time of the inspection. The manager of the home was able to provide information that evidenced that the service users at the home are supported and encouraged to vote at local and national elections. The service users were also included on the electoral register. The management of the home do not hold responsibility of any service user through the Court of Protection, or Power of Attorney. Ravendale Hall DS0000035677.V272278.R01.S.doc Version 5.1 Page 15 Staff working at the home receive training for the protection of vulnerable adults. This training is provided through the local authority and also through staff NVQ training. Staff interviewed by the inspector were aware of protection issues for service users in their care. They were also aware of how to report suspected abuse. When staff are appointed to the home they do not commence work with the service users until after they have received appropriate safety clearances. The homes policies and procedures preclude staff from benefiting from service users wills. The inspector observed a sample of service users pocket money accounts and these were all up to date and were accurately recorded. Ravendale Hall DS0000035677.V272278.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20,21,23,24,25 and 26 The environment of the home is very well maintained and meets the needs of the service user group. EVIDENCE: The service users are provided with good choice in relation to the communal areas that are available to them in the home. The lighting and furnishings in the communal areas were domestic in character and the service users stated that they felt ‘comfortable’ in their environment and that it was ‘well decorated’. The bathrooms and toilets in the home were very clean and tidy and were well spaced throughout the building. One of the bathrooms had a selection of linen towels on a trolley in it. The inspector stated that this practice must be stopped, as this practice did not uphold the homes control of infection and personal hygiene policies and procedures. Ravendale Hall DS0000035677.V272278.R01.S.doc Version 5.1 Page 17 All of the service users are provided with single occupation bedrooms. Only one bedroom in the home includes en-suite facilities. Service users individual case files identified the furniture and fittings that are included in their rooms and if any of the required items were not included a reason was included for their omission. The service users stated that they were ‘very happy’ with their bedrooms and several invited the inspector to look at their rooms. These had all been personalised to their own tastes and preferences. The hot water temperatures at the outlets are regularly maintained and monitored at the home and all of the radiators (with the exception of one in the library) were provided with low temperature surfaces. All of the required maintenance and service records were observed by the inspector for the heating, lighting and water supply to the home. These were all up to date and were accurately recorded. The staff at the home exceeded the standard for keeping the home clean, tidy and free of any offensive smells. The domestic staff are employed to work at the home over the seven-day period. Therefore the home is cleaned on a daily basis including weekends. The home has a programme for all of the carpets to be cleaned on a routine basis. The washing machines in the home are programmable to disinfection and sluicing standards. The service users stated to the inspector that they always get their own clothes back from the laundry. Ravendale Hall DS0000035677.V272278.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Staff receive all of the mandatory training that is required and can meet the needs of the service users. EVIDENCE: The service users stated to the inspector that there are always appropriate numbers of staff available at the home to meet their needs. The manager of the home must ensure that at all times the staffing numbers represent the recommendations of the residential forum. With the current needs and numbers of service users in the home this would equal 600.14 hours per week. There were no staff working in the home that were under eighteen and no staff under twenty one are ever left responsible for the running of the home. The home is close to meeting its requirement for a minimum of 50 of the care staff to have achieved NVQ 2 or equivalent. The staff and management at the home have a strong commitment to NVQ training. Staff undertaking NVQ training have all of the costs for the course paid by the management and on achieving a full NVQ award an increment is included to their salary. This policy also ensures a greater staff commitment to the home. The inspector observed the personal and training files for three of the staff members. The records indicated that good practices and equal opportunities were followed in the employment of staff at the home. All staff receive a minimum of Pova first clearances before beginning work at the home. Ravendale Hall DS0000035677.V272278.R01.S.doc Version 5.1 Page 19 Two of the three files observed included two written references for the staff however the third only included one reference. The training records in the home evidenced that ten of the staff have completed an induction to the National Training organisations specifications and standards. Staff spoken to by the inspector confirmed that they had received induction training when they began working in the home and that they receive over the requirement of three days paid training per year. The manager has a training plan and maintains up to date records of individual staff members involvement in training. Ravendale Hall DS0000035677.V272278.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37 and 38 The management of the home ensure that the health and safety of the service users is maintained. EVIDENCE: The manager of the home is working towards the Registered Managers Award. She has only one unit outstanding before the award is complete. The manager has NVQ 2 and 3 in care and is an NVW work base assessor. There are clear lines of responsibility and accountability in the home. And interviews with the management and staff confirmed that they were all aware of each other’s roles. The service users, visitors and staff all confirmed that the management approach of the home is very open and positive. Ravendale Hall DS0000035677.V272278.R01.S.doc Version 5.1 Page 21 Views of service users and visitors would be identified more clearly through more regular service user meetings. The quality assurance and monitoring system has improved since the last inspection. Since October 2005 three different surveys have been sent out by the management to the service users in relation to meals, laundry and chiropody services. The replies have been evaluated and summarised and the manager of the home was preparing an action plan that is soon to be published. The manager of the home had a business and development plan for the home that planned the homes finances up to April of 2006. This included provision for staff training and development of the environment of the home. The management of the home pay for the CRB checks for prospective staff. No charge is made to the individual for their CRB. Staff are also provided with paid study time for courses that they are on and they are paid to attend training when it is their off duty. No top-up fees are charged to service users. The inspector sampled the records of the pocket money accounts for the service users. They were all up to date and had been accurately recorded. The staff supervision records showed that the frequency of supervision for individual staff members is improving the staff still do not receive the minimum of six formal recorded supervision periods per year. Staff that were interviewed by the inspector stated that although they do not meet the standards for formal supervision the management offer constant supervision and support on an informal basis. All of the confidential records required by the home were up to date and were stored in accordance with the Data Protection Act 1998. The only records that could be improved were the daily diary recordings made by the care staff. Currently they are very brief and do not clearly identify the feelings of the service users when they are involved in different activities. The manager was able to produce up to date documentation that the electrical systems for the home are safe and the homes oil tank has been updated to a bonded tank in line with new regulations. New boilers have also been included in the home to control the central heating system. Ravendale Hall DS0000035677.V272278.R01.S.doc Version 5.1 Page 22 There was an up to date fire risk assessment for the building and all of the appropriate fire safety maintenance checks were carried out including regular checks of the emergency lighting system and the fire extinguishers were maintained and refilled in July 2005. Ravendale Hall DS0000035677.V272278.R01.S.doc Version 5.1 Page 23 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 X 3 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 2 X 3 3 3 4 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 2 3 2 4 3 1 3 3 Ravendale Hall DS0000035677.V272278.R01.S.doc Version 5.1 Page 24 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 Requirement The registered person must ensure that all service users have their needs fully assessed before they are admitted in to the home The registered person must ensure that appropriate legislation and guidelines are followed for the administration of medication in the home. The registered person must ensure that all staff working in the home including the manager receive the minimum of six formal recorded supervision periods per year (pre-rata). Timescale for action 30/01/06 2 OP9 12 06/01/06 3 OP36 19 30/03/06 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 OP8 Good Practice Recommendations The registered person must ensure that all service users living in the home have their nutritional needs assessed. DS0000035677.V272278.R01.S.doc Version 5.1 Page 25 Ravendale Hall 2 3 4 5 6 OP21 OP28 OP29 OP31 OP33 The registered person must ensure that no linen towels are openly stored in bathrooms to minimise the risk of infection to service users. 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 all new staff to the home have received two written references before they begin work with the service users. 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 ensure that the home has an effective quality assurance and monitoring system. Ravendale Hall DS0000035677.V272278.R01.S.doc Version 5.1 Page 26 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. Extracts may not be used or reproduced without the express permission of CSCI Ravendale Hall DS0000035677.V272278.R01.S.doc Version 5.1 Page 27 - 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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