CARE HOMES FOR OLDER PEOPLE
Ravenhurst 21 Lickhill Road North Stourport-on-Severn Worcestershire DY13 8RU Lead Inspector
Y South Unannounced Inspection 29th December 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ravenhurst DS0000018469.V269498.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ravenhurst DS0000018469.V269498.R01.S.doc Version 5.0 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 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) 01299 825610 01299 879341 www.heart-of-england.co.uk/care/ravenhurst Heart of England Housing and Care Limited Ms Jane Elizabeth Poppitt Care Home 41 Category(ies) of Dementia - over 65 years of age (41), Old age, registration, with number not falling within any other category (41), of places Physical disability over 65 years of age (41) Ravenhurst DS0000018469.V269498.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 20th July 2005 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 visitor’s 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, Mr John McCarthy, is the responsible individual and Ms Poppitt is the registered manager. She is supported by a hotel services manager and a care manager who deputise in her absence. Ravenhurst DS0000018469.V269498.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This routine unannounced inspection took place over approximately three and a quarter hours from 09:30am until 12:45pm. The focus was on the requirements and recommendation that had arisen out of the previous inspection and key standards that had not previously been assessed this year. Ms Poppitt the registered manager, Mrs Deborah Fidoe the care services manager and Mrs Shirley Preece the hotel services manager assisted the inspector. A tour of the home was undertaken and the inspector spoke to residents and staff. A range of records was assessed. A service questionnaire was sent to the manager prior to this inspection, which was completed and returned to the Commission for Social Care Inspection. The manager was also asked to distribute other questionnaires regarding the service to residents, relatives and health care professionals. The completion of these is voluntary but proves useful in assessing the various views that are held. Sixteen responses had been received prior to this inspection. What the service does well:
The service provides a warm welcome to everyone who calls. The premises are clean and comfortable and the bedrooms individual and pleasantly decorated. A good quality of care is provided by a cheerful, well-trained staff team. Positive comments received by the Commission for Social Care Inspection in the returned questionnaires were: “Very happy with the home.” “A tolerant and able staff group who are aware of their limitations as well as the limitations of the home’s registration.” “I feel this place is the best for my relative. Girls are fab and the food is good and she likes her food.” There is strong commitment to training and the staff have achieved a great deal. The home has also received a glowing letter of appreciation from a grateful relative who commends the professionalism and commitment of the staff. She
Ravenhurst DS0000018469.V269498.R01.S.doc Version 5.0 Page 6 states, “If only everyone in care of the elderly could mirror this outstanding approach.” 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. Ravenhurst DS0000018469.V269498.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ravenhurst DS0000018469.V269498.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Assessments are made to ensure the home is able to provide the service needed by prospective residents. EVIDENCE: This standard was assessed in full during the previous inspection following which a requirement was made that the assessments forms used prior to admission must be completed in detail. Two care records were assessed during this inspection and were acceptable. Ravenhurst DS0000018469.V269498.R01.S.doc Version 5.0 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 the following standard(s): 7, 8 The records provide information to inform and guide staff to care for the residents. EVIDENCE: These standards were assessed in full during the previous inspection following which four requirements were made. These were that care plans must be signed and dated, they must show details of all residents needs including their mental health needs and 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. Two sets of care records were assessed and it was considered that the requirements had been met. A new care record system was being piloted and evaluated. A valuable discussion took place.
Ravenhurst DS0000018469.V269498.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 Residents control their life choices and care. EVIDENCE: The residents who spoke to the inspector during this inspection confirmed that they were happy with their lives and the home. They were most complimentary regarding the staff and the standard of care they received. They felt in control of their life choices. One resident said that she liked living in the home, she always felt well cared for and that her privacy was respected. She felt included and able to be as involved as much as she wished. A good selection of food was usually offered and she liked it very much. Ravenhurst DS0000018469.V269498.R01.S.doc Version 5.0 Page 11 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 People have the information and support that enables them to raise any issues and concerns they have. EVIDENCE: These standards were assessed in full during the previous inspection. The home has an active policy to encourage people to raise concerns and issues and pay compliments as appropriate. This supported and encouraged a strong determination to develop and improve the service provided. The complaints procedure was available in the statement of purpose and service user’s guides. Copies of which were readily available at the entrance to the home. Two people responded in the questionnaires that they were unaware of the complaint procedure. The manager was asked to send them additional copies. Residents said that they knew who to speak to if they were troubled. Ravenhurst DS0000018469.V269498.R01.S.doc Version 5.0 Page 12 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26 The policies, procedures, systems and training enable the home to reduce the risks of cross infection as much as possible. EVIDENCE: The home was clean and tidy. The laundry was appropriately sited, well equipped and arranged. Personal protective equipment was readily available to staff and it was confirmed that all staff had received training in infection control. Areas of the décor were damaged and some of the communal areas of the home needed to be redecorated and re-carpeted. The shower room upstairs needed at lot of minor repairs and should not be used until they have been addressed. Ravenhurst DS0000018469.V269498.R01.S.doc Version 5.0 Page 13 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were assessed in full during the previous inspection. This time the inspector met two staff that, with the hotel service manager, had qualified to levels 1 and 2 in NVQ Interior and Support Services. They were justifiably proud their hard work and achievements. Five of the domestics now had qualifications. The questionnaire responses complimented the staff of the home and residents who spoke to the inspector endorsed this. When asked about staffing levels one relative commented that when the rooms were all full the staff “run around like mad”. During this inspection staff were working well with the residents. Two staff were sitting in the conservatory doing crosswords with them and there was a delightful amount of ‘audience participation’. Ravenhurst DS0000018469.V269498.R01.S.doc Version 5.0 Page 14 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38 The policies, procedures, training and systems ensure health and safety matters are addressed in the home. EVIDENCE: Staff receive training in health and safety matters. Systems are in place to monitor the services that are provided to the premises. Following the previous inspection three requirements were made that fire doors must close onto their rebates, lighting in communal areas must be adequate and window restrictors must be fitted to all upstairs windows. All these requirements had been met.
Ravenhurst DS0000018469.V269498.R01.S.doc Version 5.0 Page 15 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 3 X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 3 Ravenhurst DS0000018469.V269498.R01.S.doc Version 5.0 Page 16 Are there any outstanding requirements from the last inspection? NO 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 OP19 Regulation 13, 23 Requirement The communal areas in need of re-decoration and re-carpeting must be attended to and repairs must be made as necessary to the upstairs shower room. Timescale for action 01/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ravenhurst DS0000018469.V269498.R01.S.doc Version 5.0 Page 17 Commission for Social Care Inspection Worcester Local Office 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
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