Inspection on 20/07/05 for Ravenhurst

This inspection was carried out on 20th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Ravenhurst 25/02/10

Ravenhurst 17/11/09

Ravenhurst 08/12/06

Ravenhurst 29/12/05

Ravenhurst 23/11/04

Ravenhurst 06/09/04

Ravenhurst 09/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Bank House

Inspirations

Westmead

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Ravenhurst 21 Lickhill Road North Stourport-on-Severn Worcestershire DY13 8RU Lead Inspector Yvonne South Unannounced 20 July 2005 9:30 am 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 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. Ravenhurst E52 S18469 Ravenhurst V237136 200705.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Ravenhurst Address 21 Lickhill Road North, Stourport-on-Severn, Worcestershire DY13 8RU 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) 01299 825610 Heart of England Housing and Care Limited Ms Jane Elizabeth Poppitt Care Home 41 Category(ies) of OP Old age both genders (41) registration, with number PD(E) Physical disability over 65 both genders of places (41) DE(E) Dementia over 65 both genders (41) Ravenhurst E52 S18469 Ravenhurst V237136 200705.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: There are no additional conditions of registration to those recorded on the previous page. Date of last inspection 23 November 2004 Brief Description of the Service: Ravenhurst is a Victorian house, which has been adapted and extended for its present purpose. It is situated on a level site on the outskirts of Stourport-onSevern. (A former coach house in the grounds is used for a day care service). The home has 36 single bedrooms, 26 of which have en-suite facilities. There are 3 double rooms, 2 of which have en-suite facilities. Four communal lounge areas, dining areas, a visitors room and communal toilets and bathrooms are also provided. There is good parking in front of the building and sheltered garden areas. The home provides residential care for older people, some of whom may have a physical disability and/or dementia. Heart of England Housing Group owns the premises and the home is run by one of its companies Heart of England Housing and Care Ltd referred to in this report as the registered provider. The director of care is the responsible individual. Ms Poppitt is the registered manager. She is supported by a hotel services manager and the care manager who deputises in her absence. Ravenhurst E52 S18469 Ravenhurst V237136 200705.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced inspection took place during the morning and extended over four and a half hours. It was undertaken by two inspectors who were assisted by the managers, senior staff, staff and people who lived in the home. Eleven residents were spoken to during the inspection and three care records were inspected. What the service does well: What has improved since the last inspection? Since the last inspection work has begun on improvement to the building, decoration and lighting and this will be continuing. Ravenhurst E52 S18469 Ravenhurst V237136 200705.doc Version 1.40 Page 6 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. Ravenhurst E52 S18469 Ravenhurst V237136 200705.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Ravenhurst E52 S18469 Ravenhurst V237136 200705.doc Version 1.40 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 standard(s) 1, 3, 4, 5 Information was available for prospective residents and their families to help them make an informed decision about moving into the home. Assessment processes were in place although more attention needs to be paid to filling them in fully to ensure that residents’ needs are understood at the point of admission. EVIDENCE: Information about the services provided by the home was freely available and residents were able to confirm that they had been given their own copies. Residents were assessed by staff prior to being admitted to the home. The assessment format used by the home covered all areas of care needs, but there were some omissions on the form, which was inspected. These included details about mental health needs, details of food likes and dislikes, and whether or not a skin care risk assessment was needed. Residents confirmed that they had visited the home prior to admission. Ravenhurst E52 S18469 Ravenhurst V237136 200705.doc Version 1.40 Page 9 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 standard(s) 7, 8, 9, 10. The recording systems in place for meeting residents’ needs are comprehensive, but they are not consistently filled in by staff. This could put residents’ health and welfare at risk. The staff have a very good understanding of the residents’ needs and this is evident from the relationships between them and the comments made by the residents. Personal support is offered in a way, which promotes the privacy and dignity of the residents. EVIDENCE: The care file of a recently admitted resident was not completed. It had not been dated or signed by the staff member completing it nor the resident or their representative. There was no photograph of the resident on file. One assessment had indicated that a resident was depressed but this had not been carried over to the care plan. There was no indication that the community psychiatric nurse involved with the resident had visited. It was said that this had been discontinued but this had not been recorded. Ravenhurst E52 S18469 Ravenhurst V237136 200705.doc Version 1.40 Page 10 Deterioration in a residents’ condition had not been recorded on the care plan to show their changing needs. Changes in mobility needs’ were not shown on a risk assessment. The care records did not show a complete record of when the General Practitioner had been called in. A sore noted on a resident, had not been recorded as being referred to the District Nurse, nor was there a risk assessment in place. Nutritional risk assessments were not in place. Some of the residents, who were spoken to, were aware of their care plans, and without exception all said that they were well looked after by the staff. Comments about health care were “very good”. The member of staff who was giving out medication was very confident in her knowledge of the management and administration of drugs. The medication administration charts were up to date and storage was appropriate. Staff were observed to be respectful and promote the residents dignity and privacy. Relationships between staff and residents were seen to be warm and mutual. Residents confirmed that staff always knocked on doors and were “very respectful” to them and that they “listened”. Ravenhurst E52 S18469 Ravenhurst V237136 200705.doc Version 1.40 Page 11 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 standard(s) 12, 13, 15. Routines in the home are flexible and allow for individual residents to live their lives as they wish. A strong emphasis is placed on the importance of activities that allow residents to have meaningful occupations and actively promote independence. The choices for meals and standard of food meets the residents’ dietary needs. EVIDENCE: There was an activities program on display in the home. Residents were organising their own transport to visit a community based day care centre in the town. There were varied resources available in the home for residents to choose from to occupy themselves as they wished. Residents were consulted about their preferences. A resident said that “the freedom is tremendous” in the home. Also “we all have our own opinions and we use them”. All residents spoken to felt that they had enough to do with their time. Quotes about food from residents were as follows, “oodles of food” “very good” “always three choices at lunchtime and an alternative if you don’t like any” “extremely good”. Food seen during the inspection was appetizing and served attractively. Residents were regularly consulted about the food and menus. Ravenhurst E52 S18469 Ravenhurst V237136 200705.doc Version 1.40 Page 12 Ravenhurst E52 S18469 Ravenhurst V237136 200705.doc Version 1.40 Page 13 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 standard(s) 16,17,18 People are confident and assertive in raising their concerns, secure in the knowledge that they will be listened to and an appropriate response will be received. The policies, procedures and training ensure that vulnerable people are protected from abuse. EVIDENCE: The home had a corporate complaints procedure. Every prospective resident received a copy with the brochure of the home. People were actively encouraged to raise their concerns and the records indicated that they were responded to in an acceptable manner. People’s rights of citizenship were acknowledged, respected and actively promoted. Advocates were readily available for consultation and they had undertaken training with staff and sessions with service users to explain their role. Vulnerable people were protected through the implementation of robust policies and procedures relating to abuse and good practice. All staff had received training relating to the Protection of Vulnerable Adults. Ravenhurst E52 S18469 Ravenhurst V237136 200705.doc Version 1.40 Page 14 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 standard(s) These standards were not assessed during this inspection. EVIDENCE: The manager showed the inspectors round the home. The environment was tired and in need of repair and refurbishment. However the registered persons had acknowledged this and plans were already in hand to address the matter. There were plans to install a new staff call system and fire alarm system and then the refurbishment would follow. Eleven requirements had been made in the previous report relating to the environment. Eight of these had been met. Work to address the remaining three was in hand. It was noted that windows on the first floor were not restricted. Ravenhurst E52 S18469 Ravenhurst V237136 200705.doc Version 1.40 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28, 29, 30 The number of qualified staff ensures that competent people are available to assist those who live in the home. A thorough recruitment process protects people who live in the home. The strong commitment to training ensures staff develop their skills and are able to provide a high quality service. EVIDENCE: Duty rosters were available that demonstrated that the home was acceptably staffed. The service users endorsed this view. Records indicated that more than 50 of the staff team were trained to NVQ level 2 or above. This is an excellent achievement. Three staff had almost completed their courses and twelve people had been nominated for future courses. During the inspection bouquets of flowers were delivered for presentation to staff that had just successfully qualified. The manager was asked to pass on congratulations to all concerned. The home used a strong corporate recruitment procedure. Records indicated that application forms, references, CRB and POVA checks and interviews were undertaken in order to select suitable people to work in the home. Ravenhurst E52 S18469 Ravenhurst V237136 200705.doc Version 1.40 Page 16 Training records were maintained for each individual member of staff. In addition a training analysis a plan to meet training needs was available. The manager was enthusiastically committed to training and others endorsed this. Ravenhurst E52 S18469 Ravenhurst V237136 200705.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 to 37 The home is managed by someone who is capable and committed to guiding the staff team to provide a good quality service. Both staff and residents benefit from the strong leadership that promotes the individual’s rights and views. Residents’ financial interests are safeguarded by good management and sound procedures. EVIDENCE: It was observed that the manager was respected and managed the home well. There was a good understanding of what was happening in all areas. Administration was well organised and maintained. Both staff and residents found her approachable, supportive and helpful. Ravenhurst E52 S18469 Ravenhurst V237136 200705.doc Version 1.40 Page 18 With the guidance and support of the manager the residents had formed a committee and were active and articulate in their discussions and suggestions. Ideas were raised and discussed during residents’ meetings and proposals were taken to the manager for action. Minutes were maintained of all meetings. The home had been awarded the ‘User Involvement’ kite mark of which it was justifiably proud. The quality assurance file demonstrated that a system was in use that monitored all aspects of the service in a thorough manner through monthly audits. Where necessary action had been taken to develop and improve the service further. The views of residents were actively sought and there was some discussion as to how views of other stakeholders could be obtained regarding the service. Resident’s surveys were undertaken and the results were published and displayed in the reception area. Records indicated that issues identified through this work had been appropriately responded to. The staff and residents were empowered and encouraged to be open and articulate in their opinions. The policies and procedures in the home were readily available. These were currently in the process of review. Accounting and financial procedures were in use that ensured the interests of the residents were safeguarded. Good records were maintained, both on computer and on hard copy. Recently the manager had been given control of the home’s budget. Plans were now made in house and actioned for continued improvement and development in the home. In addition there was a separate budget for major expenditure that was controlled by the registered provider. Residents’ monies held in safekeeping were banked in a non-interest service users’ account. It was well managed and records were well maintained. However there was some concern as people who have money in this account are in effect being deprived any interest that may accrue on their funds in a different type of account. Further discussion will take place regarding this. Residents could access their personal monies every day. Records demonstrated that staff received regular developmental supervision from seniors who had received appropriate training. Records required by legislation were being maintained. The statement of purpose and service user guide were being reviewed at the time of this inspection. Ravenhurst E52 S18469 Ravenhurst V237136 200705.doc Version 1.40 Page 19 The fire log was assessed. Fire safety checks were being undertaken at an acceptable frequency and staff were receiving training that was well recorded. The Fire Risk Assessment for the home had been drawn up in December 2004 and was acceptable. The rebate on a fire door was observed to be in need of repair. This had already been urgently requested. It was observed that some windows on the first floor were wide open without restriction. The manager undertook to attend to this immediately. Ravenhurst E52 S18469 Ravenhurst V237136 200705.doc Version 1.40 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 2 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 4 4 3 4 3 3 3 3 3 x Ravenhurst E52 S18469 Ravenhurst V237136 200705.doc Version 1.40 Page 21 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. 2. 3. 4. 5. 6. 7. 8. Standard 3 7 7 8 8 19 20 38 Regulation 14 15 15 17(1)(a) Schedule 3 13(4) 23 23 13 Requirement The assessments forms used must be completed in detail. Care plans must be signed and dated. Care plans must show details of all residents needs including their mental health needs. A record of visits by the primary health care team must be kept. Risk assessments must be in place for mobility, skin care and nutritional needs. Fire doors must close onto their rebates Lighting in communal areas must be adequate. Window restrictors must be fitted to all upstairs windows. Timescale for action 31/8/05 31/8/05 31/8/05 31/8/05 31/8/05 31/8/05 31/8/05 31/8/05 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 33 Good Practice Recommendations A method of seeking the views of stakeholders should be introduced into the quality assurance program. E52 S18469 Ravenhurst V237136 200705.doc Version 1.40 Page 22 Ravenhurst Ravenhurst E52 S18469 Ravenhurst V237136 200705.doc Version 1.40 Page 23 Commission for Social Care Inspection The Coach House, John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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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