Inspection on 01/03/07 for Ravenhill Way, 240-242

This inspection was carried out on 1st March 2007.

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 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

Ravenhill Way, 240-242 06/01/09

Ravenhill Way, 240-242 15/02/06

Ravenhill Way, 240-242 28/06/05

Ravenhill Way, 240-242 23/12/04

Ravenhill Way, 240-242 28/06/04

Ravenhill Way, 240-242 08/03/04

Ravenhill Way, 240-242 12/12/03

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

CARE HOME ADULTS 18-65 Ravenhill Way, 240-242 Lewsey Park Luton LU4 0XZ Lead Inspector Mr Paul Worthy Unannounced Inspection 1st March 2007 1:00 Ravenhill Way, 240-242 DS0000014950.V331098.R01.S.doc Version 5.2 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 Ravenhill Way, 240-242 DS0000014950.V331098.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 Adults 18-65. 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. Ravenhill Way, 240-242 DS0000014950.V331098.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ravenhill Way, 240-242 Address Lewsey Park Luton LU4 0XZ 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) 01582 477145 ravenhillway@together-uk.org www.together-uk.org Together Working for Wellbeing Vacant Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Ravenhill Way, 240-242 DS0000014950.V331098.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th February 2006 Brief Description of the Service: Ravenhill Way Care Home provides accommodation for ten adults with mental health problems. The provider is Together Working for Wellbeing and the owner of the property Aldwyck Housing Association. The building consists of two houses linked together by a conservatory with five single rooms available in each house. Each house has separate facilities, lounge/diner, kitchen, bathrooms and toilets. There is a shared garden with patio area to the rear. The houses both have four floors with no lift. The home is situated next to a small shop in a predominately residential area with local amenities and public transport routes near by. There is parking available to the side and front, shared by the shop. Ravenhill Way, 240-242 DS0000014950.V331098.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and started at 1.00 p.m. It took place over 7 hours. The inspector met seven of the people living at the home, and talked privately to two of them. He spoke to three staff and the manager, and joined those living at the home and staff for the evening meal and sampled some of the main course. He looked over some of the public parts of the building and saw some records. The inspector is very grateful to everyone at the home for their help during this inspection. What the service does well: 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. The summary of this inspection report can be made available in other formats on request. Ravenhill Way, 240-242 DS0000014950.V331098.R01.S.doc Version 5.2 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ravenhill Way, 240-242 DS0000014950.V331098.R01.S.doc Version 5.2 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were good arrangements for assessing the needs of service users to ensure that they could be met. EVIDENCE: One person had moved recently to the home. Staff confirmed that the procedures for ensuring that the needs of the person could be met at the home had been followed. This included giving them the opportunity to visit on a number of occasions before committing themselves to the move. Good arrangements were seen to be in place for ensuring that there was up to date information about the changing needs of those living at the home, where this was being helped by the involvement of the appropriate professionals. Where needs were known to be changing excellent recording and monitoring arrangements were in place for ensuring that information about the changes could be passed to the other professionals involved to help them make their assessments. Ravenhill Way, 240-242 DS0000014950.V331098.R01.S.doc Version 5.2 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were good service users plans which ensured that the needs of those living at the home would be met in ways that took account of their wishes and encouraged as much independence as possible. EVIDENCE: Comprehensive and up to date planning information was seen on the personal files of those living at the home. There were very well structured service users plans. These were complemented by risk assessments. The staff talked to were all very aware of the service users plans and key workers were involved in constantly monitoring them. There were reviews of the service users plans every month by the key workers who produced excellent notes. Staff confirmed that staff meetings were used to provide Ravenhill Way, 240-242 DS0000014950.V331098.R01.S.doc Version 5.2 Page 9 updating information regarding the service users and that the handover meetings ensured the consistency and continuity of care and support. Risk assessments were seen to be in place to allow service users to undertake a range of activities that required special precautions to ensure their safety. Ravenhill Way, 240-242 DS0000014950.V331098.R01.S.doc Version 5.2 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those living at the home were provided with the appropriate support they needed to be able to lead fulfilling and enjoyable lives in and outside the home. EVIDENCE: Arrangements, including assessment and planning information, were seen to be in place to ensure that those living at the home were encouraged and supported to enjoy a full range of normal activities. The staff were seen to provide ongoing support to the service users in appropriately risk assessed contexts to develop the self-confidence, motivation and skill to be as independent as possible. This included encouraging the service users to have some participation in normal domestic activities to Ravenhill Way, 240-242 DS0000014950.V331098.R01.S.doc Version 5.2 Page 11 extend their independent living skills. The records showed ongoing assessment of the levels of independence that people had achieved with a view, where appropriate, to support them to move to a more independent living environment. Staff confirmed that those living at the home were supported to return to work if they wished to do this and an example was given. Staff confirmed that most of the service users could and did go out as they chose without staff accompanying them and were able to organise their own activities in the community such as going to restaurants. Service users were seen going off and returning from such outings. The independent activities of the service users were complemented by activities organised by staff both within the home and involving trips out. Annual holidays were also organised. The activities within the home were intended to provide opportunities for those living there to build their self-confidence while also enjoying themselves and each others company. Talking to staff and service users provided evidence of the support that service users had in maintaining their relationships with their relatives and friends. Good arrangements were seen to be in place for ensuring that the service users had nutritional and healthy food. Those living at the home were involved in choosing the meals and in helping with the cooking. Normally those living in the two houses eat in their own dining room and use their own kitchen. On the day of the inspection there was a themed meal appropriate to St Davids Day. All those at home came together in one of the two dining rooms as was the normal practice when it was a celebratory day. Ravenhill Way, 240-242 DS0000014950.V331098.R01.S.doc Version 5.2 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were good arrangements for providing personal support and obtaining medical care to ensure that those living at the home were cared for in ways that respected their dignity and ensured that they enjoyed as much good health as possible. EVIDENCE: Staff spoken to were aware of the needs of those living at the home relating both their personal care and support, and their health needs. Details of these needs were seen to be given in the service users plans. The assessment and planning information about the medical needs was seen to be up to date and to cover routine, emergency and ongoing medical care. There were effective arrangements to ensure that regular checks were maintained. There was seen to be good links with other professionals and a Ravenhill Way, 240-242 DS0000014950.V331098.R01.S.doc Version 5.2 Page 13 willingness on the part of staff to instigate the involvement of other professionals where this was thought necessary if appropriate assessments were to be carried out. The mental health needs were complex but staff spoken to were very aware of the conditions and how to work in sympathetic and supportive ways. The availability of staff to talk to those living at the home was stressed so that concerns could always be talked about. Appropriate arrangements for managing medication were seen to be in place. The service user plans were complemented by a file containing source material relating to medical needs. The health component of the service users plans included information relating to the medication being taken by the service user. Details of all the medication being taken was given in the medicine file. Ravenhill Way, 240-242 DS0000014950.V331098.R01.S.doc Version 5.2 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were effective arrangements for identifying and addressing the concerns those at the home might have and for ensuring they were protected so that they would feel in control and safe. EVIDENCE: A recent report following the monthly visit on behalf of the provider had noted that an update with those living at the home on making complaints would was due. Staff and service users confirmed that this had been done at a service users meeting the previous week. The service users were confident they knew what to do if they had a concern and were also confident that the staff and manager would take their concerns seriously. Staff were aware of the local protection of vulnerable adults procedures and through the risk assessments aware of areas where they needed to be vigilant. The staff training matrices that were seen showed that this was an area in which staff had had training. Ravenhill Way, 240-242 DS0000014950.V331098.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The accommodation was well maintained and furnished so that it provided those living there with a homely and comfortable environment EVIDENCE: The accommodation consisted of two self-contained houses that had been connected. Both sides were visited and the public areas seen were well maintained and provided a homely environment. The home was observed to be being kept clean and fresh. Ravenhill Way, 240-242 DS0000014950.V331098.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient staff were appropriately trained and organised to ensure that all the needs of those living at the home would be met. EVIDENCE: The evidence on the day was that appropriate staffing was being maintained to ensure that those living at the home would be appropriately supported. The use of bank staff was seen to allow flexible staffing so that short periods with more staff allowed service users to have the support they need when they need it. An example of this working was seen on the evening of the inspection. Staff felt that there were enough staff normally on duty to ensure that those living at the home could be supported to undertake their normal range of activities. Ravenhill Way, 240-242 DS0000014950.V331098.R01.S.doc Version 5.2 Page 17 Staff confirmed that there were good arrangements for induction and that there was a robust training programme with ongoing updating. Examples of the training matrices for staff were seen and were clearly an effective way of keeping track of staff training. Speaking to staff and observing them interacting with those living at the home showed that they had a good knowledge of the service users and their needs. The staff were seen to have positive, caring and supportive relationships with the service users during the inspection. The staff confirmed that there were regular supervision and team meetings. Well maintained staff records were seen. These contained all the required recruitment material to ensure that only appropriate staff were appointed. Ravenhill Way, 240-242 DS0000014950.V331098.R01.S.doc Version 5.2 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those living at the home benefited from it being well managed so that they could live as independently and fully as possible. EVIDENCE: The appointed manager has been in post since May 2005. He confirmed that an application for him to be registered had been returned to CSCI. Staff confirmed that he was supportive and provided positive leadership. Talking to the manager provided evidence that he had a very positive vision of what he wanted to achieve along with his staff by way of creating an environment where those living at the home felt enabled and self-confident. Examples of this being achieved were seen during the day of the inspection. The manager stressed that he was s supported by an excellent staff and management team, Ravenhill Way, 240-242 DS0000014950.V331098.R01.S.doc Version 5.2 Page 19 which was confirmed by what was observed on the day of the inspection. Observing the running of the home provided evidence of excellent systems, including administrative ones, being in place to ensure that the needs of the service users were met. The manager outlined the various components of a very good quality assurance system, which was aimed at ongoing improvement. It included the required monthly visits on behalf of the provider and monthly reports produced by the manager. The latter were themed and looked in depth at different topics, for example social inclusion and health. These reports then provided the basis for drawing up the annual review, which was done by the manager and his line manager. An example of a monthly report for the provider was seen and a copy of the last annual review was provided. It was seen that there were good monitoring arrangements in the home relating to health and safety issues. There was seen to be an appropriate emphasis on a risk assessment approach in respect both of the environment generally and the specific service users. Ravenhill Way, 240-242 DS0000014950.V331098.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 3 x x 3 x Ravenhill Way, 240-242 DS0000014950.V331098.R01.S.doc Version 5.2 Page 21 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ravenhill Way, 240-242 DS0000014950.V331098.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Ravenhill Way, 240-242 DS0000014950.V331098.R01.S.doc Version 5.2 Page 23 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!