Inspection on 15/02/06 for Ravenhill Way, 240-242

This inspection was carried out on 15th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ravenhill Way, 240-242 06/01/09

Ravenhill Way, 240-242 01/03/07

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 LU3 1HE Lead Inspector Ansuya Chudasama Unannounced Inspection 15th February 2006 09:50 Ravenhill Way, 240-242 DS0000014950.V262653.R01.S.doc Version 5.1 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.V262653.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 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.V262653.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ravenhill Way, 240-242 Address Lewsey Park Luton LU3 1HE 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 www.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.V262653.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th June 2005 Brief Description of the Service: Ravenhill Way Care Home provides accommodation for ten adults with mental health problems. The property was owned by Aldwyck Housing Association but operated by Together Working for Wellbeing in partnership with the local community NHS Trust and Aldwyck. The building consisted of two houses linked together by a conservatory with five single rooms available in each house. Each house had separate facilities, lounge/diner, kitchen, bathrooms and toilets. There was a shared garden with patio area to the rear. The houses both had four floors with no lift so the home would not be suitable for those with mobility problems. The home was situated next to a small shop in a predominately residential area with local amenities and public transport routes near by. There was parking available to the side and front, shared by the shop. Ravenhill Way, 240-242 DS0000014950.V262653.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 6 hours. Veronica Hill the acting deputy manager assisted with the inspection. The inspection was comprised of talking to staff and service users. One service users case records were also case tracked in detail. The inspector would also like to thank the staff and service users who helped with the inspection. This report should be read in conjunction with the last inspection report undertaken on the 28th June 2005 What the service does well: What has improved since the last inspection? What they could do better: The care plans and risk assessments had been further developed. However more work was still required to make the risk assessments more clear to Ravenhill Way, 240-242 DS0000014950.V262653.R01.S.doc Version 5.1 Page 6 understand. The care plans also needed to have all the information that was assessed for meeting service users needs. The assessment forms needed to be dated and signed by the person completing. An annual development plan and a quality assurance system were required. 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. Ravenhill Way, 240-242 DS0000014950.V262653.R01.S.doc Version 5.1 Page 7 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.V262653.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 0 None of the standards were assessed on this occasion but these were all assessed at the last inspection EVIDENCE: Ravenhill Way, 240-242 DS0000014950.V262653.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,9,10 The care plans needed to be developed further to ensure that all information was available to meet the needs of the service users. Risk assessments needed to be recorded in a simple and easy to understand language to ensure that every one stood the risks to ensure service users were kept safe. EVIDENCE: The service users’ file inspected was well laid out. The file had two formal assessment questionnaires. One was dated and the other was not dated. There was no information to state how the information was obtained or who was involved. The home did not have an assessment form, which included having all the information stated in the standard. A form was seen that the service user completed. There was no information recorded from the people that looked after the service user. The service user had a care plan but it needed developing further to explain in more detail how the needs of the service users were being met. The inspector was aware by talking to staff that they understood the needs of the service users well. The risk assessments seen needed to be made simple and easy to Ravenhill Way, 240-242 DS0000014950.V262653.R01.S.doc Version 5.1 Page 10 understand. The information on hazards needed to be clearly recorded for individual risks that were identified. These should also be signed by the service user to state that they understood the risks. There were risk assessments, which also needed undertaking due to the vulnerability of the service user. The staff spoken to was aware of the service users risks. Information recorded in some of the risk assessment was not available in the care plan. The home had a policy on confidentiality. The staff also discussed this information with the service users on a one to one basis. The Service users files were kept secured in the office. Ravenhill Way, 240-242 DS0000014950.V262653.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,14,17, The home provides good activities to meet service users social and independent needs. EVIDENCE: The service users spoken to stated that they had a very nice Christmas. It was stated that they helped with food shopping and they had regular house meetings. They choose the meals and the food at the home was said to be very nice. The staff were described as being helpful and they gave them their medication. The service users helped with recycling, hovering, polishing, and with washing up. They informed the inspector that they were going on holiday next month to Devon and they were looking forward to this. It was stated that they choose the holiday from the brochures that the staff brought to the home. Ravenhill Way, 240-242 DS0000014950.V262653.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 0 None of the standards were assessed on this occasion but these were all assessed at the last inspection EVIDENCE: Ravenhill Way, 240-242 DS0000014950.V262653.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Staff listen to Service users views and this therefore ensures that they are protected from any abuse. EVIDENCE: The home had a complaints policy and procedures. The address and telephone number of the commission for social care inspections was required in complaints procedure. The service users spoken to stated that they would tell staff if any one was “horrible” to them or if they were unhappy at the home. They also appeared very assertive and evidence showed that they said what they felt. The inspector was informed that they had not received any complaint. The staff at the home had received training on protecting vulnerable adults. Ravenhill Way, 240-242 DS0000014950.V262653.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 0 None of the standards were assessed on this occasion but these were all assessed at the last inspection EVIDENCE: Ravenhill Way, 240-242 DS0000014950.V262653.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 Service users are supported by an experienced staff team. EVIDENCE: The inspector was informed that the home had a few changes in staffing at the home. One of the staff in the home was acting up as the deputy manager. This was because the deputy manager was off sick and the home was not sure when the staff was returning back to work. The home had three new staff employed since the last inspection. It was stated that the home had a very good staff team and they enjoyed working with the service users. The staff were observed talking to service users in a positive manner. Ravenhill Way, 240-242 DS0000014950.V262653.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 The home did not have an annual development plan in place to review aspects of its performance. EVIDENCE: It was stated that the management approach was not as open as it should have been. A proper direction from management was needed. A team building away day and more staff meetings were requested to be undertaken on a regular basis to discuss what was happening in the home. At present staff meetings were held on a monthly basis. The staff on duty was unable to find the annual development plan. The responsible individual was undertaking regulation 26 visits on a monthly basis. A survey was undertaken in September 2005. However the analysis from this Ravenhill Way, 240-242 DS0000014950.V262653.R01.S.doc Version 5.1 Page 17 was not available in the home and there was no information to state what action had been undertaken from the information. The registered person must ensure that there are arrangements in place to monitor and review the quality of care in the home. Also a written development plan, which is renewed annually, is required. Ravenhill Way, 240-242 DS0000014950.V262653.R01.S.doc Version 5.1 Page 18 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 X 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 X 25 X 26 X 27 X 28 X 29 X 30 x STAFFING Standard No Score 31 X 32 X 33 3 34 X 35 X 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 2 3 LIFESTYLES Standard No Score 11 3 12 X 13 X 14 3 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X X 3 2 X X X x Ravenhill Way, 240-242 DS0000014950.V262653.R01.S.doc Version 5.1 Page 19 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA40 Regulation 17 Requirement The registered person must provide a policy/procedures on continence promotion, Time scale of 31/9/2004 and 31/1/3/2005 and 31/08/05 not met. The registered person must develop a quality assurance system based on the views of the service users and produce an annual development plan for the home The registered person must ensure that all service users risk assessments undertaken are made clear and easy for service users to understand. Timescale for action 30/03/06 2 YA39 24 30/06/06 3 YA9 13 30/04/06 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 YA6 Good Practice Recommendations Ensure that the care plans are expanded and include all DS0000014950.V262653.R01.S.doc Version 5.1 Page 20 Ravenhill Way, 240-242 2 3 4 YA37 YA37 YA37 the information in the standard. Ensure that the home is provided with a team away day training. Provide more staff meetings. Management needs to ensure that an open door policy is created in the home. Ravenhill Way, 240-242 DS0000014950.V262653.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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