Inspection on 28/06/05 for Ravenhill Way, 240-242

This inspection was carried out on 28th June 2005.

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

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

Other inspections for this house

Ravenhill Way, 240-242 06/01/09

Ravenhill Way, 240-242 01/03/07

Ravenhill Way, 240-242 15/02/06

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 Ravenhill Way Lewsey Park Luton, Bedfordshire LU3 1HE Lead Inspector Ansuya Chudasama Unannounced 28th June 2005 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 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 Stationary 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 I51 S14950 Ravenhill Way V232976 280605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Ravenhill Way Address 240 - 242 Ravenhill Way Lewsey Park Luton Bedfordshire LU3 1HE 01582 477145 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) MACA CRH Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Ravenhill Way I51 S14950 Ravenhill Way V232976 280605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28.6.05 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 MACA 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 I51 S14950 Ravenhill Way V232976 280605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken at 09.50, and it took place over 6 hours. The manager, Colin Edmunds was present at the inspection. The inspection was comprised of a tour of the communal areas, two service users’ bedrooms, talking to staff and service users. The community psychiatric nurse was also spoken to at the inspection. Three service users’ case records were case tracked and other documents were examined in detail. There were 10 service users living at the home at the time of the inspection. What the service does well: What has improved since the last inspection? Some of the requirements had been met. The office floor had been replaced. One of the lounges had the carpet replaced and another lounge had a wooden floor. Some of the service users bedroom Ravenhill Way I51 S14950 Ravenhill Way V232976 280605 Stage 4.doc Version 1.30 Page 6 carpet had also been replaced. The carpet on the stairways was replaced and looked very pleasant. 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. Ravenhill Way I51 S14950 Ravenhill Way V232976 280605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Ravenhill Way I51 S14950 Ravenhill Way V232976 280605 Stage 4.doc Version 1.30 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 standard(s) 1,2,3,4,5. The homes statement of purpose and service user’ guide provided prospective service users and their families information of the services the home provides enabling an informed decision about admission to the home. EVIDENCE: The homes statement of purpose and service user’ guide provided clear and detailed information about the services that were provided by the home. Service users’ files inspected had relevant information from appropriate professionals prior to the service users admission. The home also undertook assessments of service users to ensure that they were able to meet their needs. The service users spoken to confirmed that they had visited the home on several occasions and had overnight stays to find out if they liked the home, and wanted to stay. The home also encouraged service users’ families and friends to visit the staff and service users. A licence agreement was available in each service users’ file and the service user and the home signed this. Ravenhill Way I51 S14950 Ravenhill Way V232976 280605 Stage 4.doc Version 1.30 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 standard(s) 6,7,8,9. The home had care planning systems in place to adequately provide staff with the information they need to satisfactorily meet service users’ needs. EVIDENCE: The service users’ files inspected had care plans and contained information about the service users’ needs. However, they still needed to be further developed as discussed at the inspection to include all the information stated in standard 2. A lot of the information was available in the file but it needed to be included in the care plan. The plans also needed reviewing and expanding in certain areas to state how the staff were helping the service users achieve these goals. Discussion with staff showed that they were doing this in practice. The manager stated that they had started work on ensuring that all the relevant information was recorded in the care plan. The care plans were explained to service users and signed by them. The home had risk assessments for service users and these were good but information recorded in the risk section needed to be in the hazards section. Ravenhill Way I51 S14950 Ravenhill Way V232976 280605 Stage 4.doc Version 1.30 Page 10 The staff respected service users privacy and dignity by knocking on their doors. This was confirmed by talking to a service user who stated that the staff always knocked on her door before entering her room. The advocacy services were accessed from the Disability Resource Centre when required by service users. The information on how to access advocacy services was stated in the Service Users’ Guide. Information was also displayed on the notice board. Ravenhill Way I51 S14950 Ravenhill Way V232976 280605 Stage 4.doc Version 1.30 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 standard(s) 12,13,14,15,16,17. Meals provided are varied and nutritious with a menu that changes each week so that service users receive a balanced diet to met their needs Service users are provided with a variety of activities so that they are able to develop, and maintain their independent skills EVIDENCE: The service users spoken to stated that they had menu planning on a weekly basis. All the service chose a meal once a week that they wanted to prepare with staff. The service users stated that if they did not like what was on the menu, they were able to have a different option. This was observed on the day of the inspection. It was stated that they liked the food. Service users also helped with laying the tables, hovering, cleaning, and doing their laundry with support from staff. Service users meetings were held once a month to discuss their views and what was happening in the home. Service users spoken to stated that they attended day care and went shopping with staff to buy their clothes. They also had social evenings at weekends and some of the activities included playing music, bingo, karaoke, watching films and doing quizzes. The manager was developing this activity further to meet service Ravenhill Way I51 S14950 Ravenhill Way V232976 280605 Stage 4.doc Version 1.30 Page 12 users needs. Some service users stated that they went to the pub, swimming, to shows, and on outings with their key workers. One service user was not happy, as he did not attend any day care facilities. He stated that he spend all his time at the home. He felt discriminated because he was 65 years old and the day care centres would not accept him. Prior to coming to the home, he stated that he attended day care that was run by the home he previously lived at. However the home closed down and he was not able to attend the centre any more. This issue was discussed with the manager and it was stated that he was going to discuss this with the service users social worker. The home also needs to explore this further with the service user to find out how his needs can be met. The service users spoken to liked the staff and found them very helpful. Ravenhill Way I51 S14950 Ravenhill Way V232976 280605 Stage 4.doc Version 1.30 Page 13 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 standard(s) 18,19,20,21. The health care needs of service users are well met with evidence of good working relationships with health professionals take place on a regular basis. The systems for the administration of medication are good with clear guidance in place to ensure service users needs are met. EVIDENCE: Two service users’ care plan needed to explain how staff managed service users verbal threatening behaviour. Discussion with staff stated that they were aware of how to deal with this situation. A risk assessment was undertaken on this for one service user but it was not discussed in the care plan. One service users review undertaken by the consultant stated that the service users was settled at the home and was doing well. It was also stated that she was about the best that the consultant had seen her in seven years. The inspector had also noticed a big change in how well the service user looked and communicated since the last inspection. One service user stated that she was helped by staff to reduce the number of cigarettes that she smoked and she was supported to lose weight. She was very happy because she had managed to lose weight and reduced her smoking. Good records were kept on service users health care appointments Ravenhill Way I51 S14950 Ravenhill Way V232976 280605 Stage 4.doc Version 1.30 Page 14 and evidence showed that the home was monitoring the needs of service users well. Service users’ medication record sheets were being signed by staff at all times. The service users were observed being given their medication and this was carried out well. Records showed that two staff signed the records when medication was given out to service users. Information on service users burial arrangements was completed. Ravenhill Way I51 S14950 Ravenhill Way V232976 280605 Stage 4.doc Version 1.30 Page 15 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 standard(s) Standards not inspected on this occasion. EVIDENCE: Ravenhill Way I51 S14950 Ravenhill Way V232976 280605 Stage 4.doc Version 1.30 Page 16 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 standard(s) 24,25,26,27,28,30. The home did not have a lift and so there fore did not meet the needs of service users who were frail and had mobility problems. The standard of décor within the home was good and so there fore provided service users with a homely place to live. EVIDENCE: The home was clean and had a homely atmosphere. As stated in the previous inspection reports, the design of the houses with the accommodation over three floors was potentially a problem for service users with mobility problems. Given the current age range of service users with several over 65 years. The building was also not suitable for having a lift”. The manager stated that the issues have been discussed with Aldwyck Housing Association and the funding authority. The Fire Officers visit on the 15th March 04 and had agreed to have the kitchen and lounge and dinning room doors open during meal times. This was because some service users found the doors heavy and difficult to open. The doors were closed at nighttime by staff. The home had undertaken risk assessments on this area. Ravenhill Way I51 S14950 Ravenhill Way V232976 280605 Stage 4.doc Version 1.30 Page 17 This standard remained the same since the last inspection. The two houses had adequate provision of communal facilities with a lounge/diner and a separate smoking area in the link between the two properties. The home also had a kitchen in each house and a shared utility room with a washing machine and tumble dryer and all were domestic in character. There was a good sized fenced garden to the rear with a patio area The staff sleeping in area was in one of the houses with cover provided to both properties. One service users bedroom seen was individualised but his carpet needed replacing. One of the lounges had new carpet and another lounge had a wooden floor and this looked very attractive. The carpet on the steps was also replaced and most of the service users rooms were carpeted. Ravenhill Way I51 S14950 Ravenhill Way V232976 280605 Stage 4.doc Version 1.30 Page 18 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35,36. After a period of staffing shortage, there is now a full complementary of staff offering consistency of care within the home. The arrangements for the induction of staff are good with the staff demonstrating a clear understanding of their role. EVIDENCE: The staff spoken to had received an induction with the home. She had also completed the TOPPS induction training. She had completed the health and safety, food hygiene, POVA, in house medication, mental health, fire awareness and infection control training. It was stated that the organisation provided good training. A training list for staff was displayed in the office and this was good and showed what training the staff had undertaken. Two staff had NVQ level 3 and the deputy manager was undertaking the NVQ level 4. Another member of staff spoken to had been at the home for eight weeks. She too had completed a two week induction at the home and stated that this was good and she was still completing the induction form. The staff also stated that she was still learning and building up relationships with the service users. All the staff stated that they enjoyed working at the home and they worked well together. The new staff worked on shifts with agency staff, Ravenhill Way I51 S14950 Ravenhill Way V232976 280605 Stage 4.doc Version 1.30 Page 19 as they were short staffed. The agency staff on duty were said to be skilled and good. The staff stated that they received supervision on a monthly basis. One of the staff files inspected had two references missing however the rest of the information was available but needed to be better filed. Ravenhill Way I51 S14950 Ravenhill Way V232976 280605 Stage 4.doc Version 1.30 Page 20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 The health and safety of service users and staff are promoted so there fore to ensure that they live and work in a comfortable and safe environment. EVIDENCE: The inspector was informed that the previous manager of the home had made the decision to step down and undertake the deputy manager’s position. The deputy manager was now the manager of the home. This change took place in May 2005. The manager needs to apply for registration to the CSCI. The manager has two years experience of working with people with mental health needs in a senior position. He has worked in the position of deputy manager since last year at the home. Prior to this experience, he was a Baptist minister for 20years. The manager has completed all the statutory training and has also completed counselling and mental health training. The manager was not aware when he was going to undertake his qualifications at Level 4 in both management and care. He stated that he had started his A1 assessors award six weeks ago and he was not sure when this was to be completed. The manager stated that they had been short staffed, however they had recruited Ravenhill Way I51 S14950 Ravenhill Way V232976 280605 Stage 4.doc Version 1.30 Page 21 two full time and three relief social care workers. The home was waiting for references and CRB checks before they could start. At present relief and agency staff were covering two full time and one waking night staff positions. The staff spoken to stated that they had fire drills and the service users were involved. The service users spoken to were aware of what to do if there was a fire. Information on this was discussed with them and a copy of the instructions was displayed in their rooms. The accident and incident report sheets inspected were well recorded and signed by staff. Ravenhill Way I51 S14950 Ravenhill Way V232976 280605 Stage 4.doc Version 1.30 Page 22 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ravenhill Way Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 x x x x 3 x I51 S14950 Ravenhill Way V232976 280605 Stage 4.doc Version 1.30 Page 23 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 40 Regulation 17 Requirement The registered person must provide a policy/procedures on continence promotion, service users’ finances. Time scale of 31/9/2004 and 31/1/3/2005not met. Timescale for action 31/8/2005 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 Good Practice Recommendations Ravenhill Way I51 S14950 Ravenhill Way V232976 280605 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Clifton House 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. Extracts may not be used or reproduced without the express permission of CSCI Ravenhill Way I51 S14950 Ravenhill Way V232976 280605 Stage 4.doc Version 1.30 Page 25 - 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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