Inspection on 08/12/06 for Ravenhurst

This inspection was carried out on 8th December 2006.

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 29/12/05

Ravenhurst 20/07/05

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 Y South Unannounced Inspection 8th December 2006 09:00 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.V318455.R02.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 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.V318455.R02.S.doc Version 5.2 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 ravenhurst@heart-of-england.co.uk www.heart-of-england.co.uk 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.V318455.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Non additional conditions of registration Date of last inspection 29.12.06 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. Appropriate mobility aids such as handrails, hoists and bathing aids are provided. 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. The pre inspection questionnaire completed and returned to the Commission for Social care Inspection by the registered manager on 26.10.06 states that the charges for accommodation and care at that time were between £1700 and £1920 per month. Additional charges were made for hairdressing, toiletries, newspapers, private chiropody, taxis, personal phone calls, holidays, trips, dry cleaning, medical requirements, clothing, satellite TV aerials. Ravenhurst DS0000018469.V318455.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection. The focus was on the key standards. As part of this unannounced inspection the quality of information given to people about the care home was looked at. People who use services were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service user’s guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that the Commission for Social Care Inspection (CSCI) are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk. Evidence was gathered from information provided to the CSCI since the previous inspection which took place on 29/12/05, questionnaires that the Commission for Social Care Inspection asked the home to distributed to residents, relatives and health care professionals and a site visit that took place on 08/12/06 which extended over 8 hours 45 minutes during which the inspector talked to three residents, two relatives and six staff, undertook a partial tour of the building and assessed a range of documents. The inspector was assisted principally by the Registered Manager of Breme, another Heart of England home, who was current overseeing the management of the home in the absence of Mrs Poppit, the Care Services Manager and the Hotel Services Manager. What the service does well: The service provides a warm welcome for everyone and tries to make sure it is the ‘right’ home for each individual. Residents describe the home as excellent and the staff as caring and committed. Individual social and health care is provided and a range of activities and events are available in which people can participate if they choose. Support and respect is provided for people to continue their religious and cultural commitments. A varied and quality menu is provided from which residents can make their daily selections and special diets can be provided when necessary. Ravenhurst DS0000018469.V318455.R02.S.doc Version 5.2 Page 6 Staff are well selected and there is a strong and successful commitment to training. The premises are homely and well located. Individual bedrooms are well decorated and furnished to personal preference and need. 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. Ravenhurst DS0000018469.V318455.R02.S.doc Version 5.2 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.V318455.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, (standard 6 is not relevant to this home as an intermediate care service is not provided) Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents receive all the information and support they need so that they can make a decision regarding their choice of home. The home only offers a service to people whose needs they can meet. EVIDENCE: The inspector focused on the care of three residents. One person, recently admitted to the home, was being visited by members of his family. They confirmed that the home was chosen after intensive research Ravenhurst DS0000018469.V318455.R02.S.doc Version 5.2 Page 9 that had included studies of Statements of Purpose, Service Users’ Guides and inspection reports. They had visited homes and had discussions before deciding that Ravenhurst was the best they had seen. They said that the people made the difference and the staff were dedicated. They had been impressed by the content and ‘good plain English’ of the information they had received which had included copies of the complaint procedure. The prospective resident had been visited and his needs had been assessed. This was confirmed by the pre-admission assessment on file. They confirmed that they had received a contract and clear information regarding the terms and conditions and costs. Copies of this information were seen in the records. All their questions had been welcomed and fully answered. The second resident was very frail and unable to respond to most of the inspector’ questions. However she did say that she was well looked after and had no complaints. The inspector spoke to her son who confirmed that several homes were considered before a choice was made. Full information and support was received from Ravenhurst. They had received a pack of documents that had included the brochure and a contract and a complaint procedure. Regular detailed accounts for accommodation and care continue to be received. The resident’s records contained copies with clear information regarding her financial situation, contract, charges and agreements. The third resident had looked at three other homes before deciding on Ravenhurst. She had received all written information to help her make her decision and this had included a copy of the complaints procedure. Two staff from the home had visited her ‘to see what help she needed’ before she had moved in and had ‘explained everything to her’. She thought that her son had the copy of her contract. It was observed that copies were on file and acceptable. The manager said that all prospective residents and their families were sent a copy of the contract and terms and conditions of residence to consider prior to admission. If time were short the document would be provided on admission. Documentation was always supported by a verbal explanation. People were invited to the home and could visit and discuss their situation as often as they wished to help them make a decision. As the three residents were relatively new to the home a four set of care records were assessed. These contained acceptable copies of a contract and letters from the home and the Worcestershire County Council explaining the charges and how they had been calculated. There were also copies of letters that explained why rises in charges were necessary and how much they were to be. Ravenhurst DS0000018469.V318455.R02.S.doc Version 5.2 Page 10 Three staff were interviewed by the inspector. They were all aware of the action they would take if inquiries were received about the home. They knew where the Statement of Purpose and Service Users’ Guide were and their purpose. Their roles did not require knowledge of financial details. However they rightly presumed that the managers and administrative staff dealt with such matters, and letters were sent to appropriate people when changes occurred. Three files that were assessed held acceptable pre-admission assessments and care plans. Minor suggestions for improvements were made. A copy of acceptable up to date Statement of Purpose, Service Users’ Guide and Inspection Reports were available in the reception area. Information was available that documents could be provided in other formats and languages if required. A health care professional commented in the questionnaire response; Generally clients I have worked with, who have chosen Ravenhurst as a placement, are very pleased with the service they receive. Ravenhurst DS0000018469.V318455.R02.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Information and training is provided so that staff provide the personal and health care that the residents need with due regard for their wishes and dignity. EVIDENCE: The records indicated that initial care plans had been set up based on the preadmission assessment. This provided first information for staff on how the individuals’ needs should be met. They were acceptable but would have benefited from the inclusion of more details. Subsequent care plans were available and more detailed as they reflected the growing knowledge of the residents’ needs and how they should be met. Ravenhurst DS0000018469.V318455.R02.S.doc Version 5.2 Page 12 It was suggested that one person should have a nutritional care plan and another person should have a night care plan. Residents had signed the facing page to their care records but there was no other evidence of their involvement in their care planning. The residents had access to doctors, district nurses, chiropodist, opticians, dentist and other health care professionals. Records were well maintained of all visits and contacts. One doctor commented in the questionnaire; The home provides appropriate care and is aware of its limitations in relation to its registration. Good community resource with high standards. The notification made to the Commission for Social care Inspection demonstrated that appropriate action was taken when people became ill or had accidents. The daily records demonstrated that advice was being sought and appropriate care was provided. All relatives who completed and returned questionnaires to the Commission for Social Care Inspection, and the relatives who spoke to the inspector confirmed that communication between them and home was good and they were kept well informed. Comments included; I have improved since admission. My health has improved. A high standard of practical care and attention was observed. Medication storage was maintained in two wooden wall cupboards and a walk in cupboard, a medication trolley, a controlled drugs cupboard, a secure carry case and a refrigerator. Key security was good and there was a specific handover between shifts. Records were well maintained. It was recommended that the pharmacist be asked to apply labels to tubes rather that the boxes in case they became separated, and the quantity of medication stock given to residents who managed their own medication should be recorded on their administration sheet to assist in auditing purposes. Staff demonstrated that they knew how to respect residents’ privacy and dignity and it was observed that their relationship with residents was pleasant and courteous. Training had commenced when they had been appointed to their posts. (Induction training) Staff gave examples and it was observed that privacy and dignity was respected. It was observed that bedroom doors, ensuites, toilets and bathrooms were all fitted with approved locks so that privacy could be obtained when wanted without compromising safety. Ravenhurst DS0000018469.V318455.R02.S.doc Version 5.2 Page 13 Residents were able to make and receive phone calls in private. Those who chose had private phones fitted in their rooms. Mail was delivered unopened and staff assisted if required. Residents’ End of Life Care wishes had been ascertained and documented. Ravenhurst DS0000018469.V318455.R02.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Facilities and events are organised so that residents have opportunities to participate in a choice of interesting social events in the home and in the community. Links are maintained with families, friends and faiths. A choice of good quality meals is provided from which residents can make a selection and enjoy nutritional food. EVIDENCE: Care records demonstrated that information was sought regarding culture and religion. Residents were of differing religions and commitments. One person was able to confirm that she and others attended their local church each week and services took place in the home. Ravenhurst DS0000018469.V318455.R02.S.doc Version 5.2 Page 15 More information could be included in residents’ records advising staff if support was needed. Documentation specifically sought information regarding ethnicity and cultural requirements. An audit was undertaken every three months. The pre-inspection questionnaire completed by the Care Services Manager indicated that a wide range of in-house and community activities were provided for residents. Records demonstrated their interests and participation. Residents confirmed that they were able to make choices in their daily lives. They were able to use their bedrooms and communal facilities as they wished and participate in events as they chose. An activities organiser was employed for 15 hours a week and staff confirmed that they participated and supported her and the residents. Recently the homes’ mini bus was stolen and a concerted effort by residents and staff has raised sufficient funds to replace it. Samples of menus were sent to the CSCI. They demonstrated that a choice of well-balanced meals was always provided. Staff were heard to support residents in making their selection. Residents told the inspector that; They ate well. Had lovely meals. They (meals) could not be better. They were well fed. Ravenhurst DS0000018469.V318455.R02.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People have access to the information they need so that they raise issues that concern them. Concerns are then investigated and responded to appropriately Staff are appropriately recruited and trained so that vulnerable people are not put at risk EVIDENCE: It was observed that the Statement of Purpose, Service Users’ Guide and Terms and Conditions of Residence contained copies of the complaints procedure. Relatives who spoke to the inspector confirmed that they had had copies and the relatives told her that they knew what to do if they had concerns. Nine of the eleven relatives who returned questionnaires confirmed that they were aware of the procedure. Comments made in questionnaire responses included; Any complaints have been dealt with immediately so they have never been made official. I am very happy with my mother’s overall care and the staff are wonderful and make her feel very ‘at home’. Ravenhurst DS0000018469.V318455.R02.S.doc Version 5.2 Page 17 The CSCI had received no concerns, complaints or allegations since the last inspection. The pre-inspection questionnaire stated that the home had received 13 complaints, 8 of which were substantiated. The inspector assessed the records held in the home. The complaints had concerned noise, meals, odour and slow response when assistance was requested. They had all been investigated and responded to appropriately. Between April and June it was recorded that two compliments had been received concerning catering and six general compliments had been made. The staff who spoke to the inspector confirmed that they were aware of their role should they receive a complaint. The pre-inspection questionnaire and staff records indicated that an acceptable recruitment process was pursued and the Criminal Records Bureau undertook checks before appointments were made. Training was provided during induction training to ensure staff could recognise abuse and would be able to respond correctly. They demonstrated this knowledge correctly when talking to the inspector. Ravenhurst DS0000018469.V318455.R02.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, well furnished and equipped so that the environment meets the residents’ needs. Equipment, systems, policies and procedures are in place so that the risks of cross infection are managed and the risk to residents is reduced. EVIDENCE: A partial tour of the home was conducted. It was observed that everywhere was clean and odour free. Ravenhurst DS0000018469.V318455.R02.S.doc Version 5.2 Page 19 The decoration shows signs of wear and tear in some places. Limited action had been taken to meet the requirement made following the last inspection that; 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. It was observed that the shower room was useable but some furnishings and fittings were pulling loose from the wall. The inspector was aware that progress to meet this requirement in full had been temporarily suspended as discussions were in progress for major work to be undertaken which would include a new fire alarm system, call bell system and shaft lift. This would inevitably damage the décor so therefore it is accepted that the work to redecorate to home had been postponed. One comment from a relative was; The only minor problems I have noticed concerns poor hot water supply to the west wing where my father lives (Room 11) and occasionally long intervals between cleaning his room. This was discussed with the manager who explained that for health and safety reasons the water temperature was maintained within safe limits to prevent the risk of scalds. This resident particularly liked water very hot. Bedrooms were usually cleaned daily. None the less it was observed that the residents’ bedrooms were attractive, well furnished and maintained. They had been personalised according to the wishes of the occupant with personal possessions and treasures. Communal lounges were well furnished, pleasant and comfortable. The laundry was well equipped. However there was only one tumble dryer, which could cause difficulty if it broke down. The room was well organised, clean and tidy. Attention had been paid to the risks of cross infection and liquid soap, disposable towels and personal protective equipment were appropriately placed around the home. The staff confirmed that there was no shortage of supplies and they had the equipment they needed to manage the risks and meet the needs of the residents. Staff said that they had received training in infection control and their records confirmed this. Ravenhurst DS0000018469.V318455.R02.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Sufficient suitable staff are recruited and employed to provide the skilled care that residents need. Training is ongoing to ensure staff have the knowledge and skills to provide the care residents need. EVIDENCE: The pre-inspection questionnaire and samples of duty rosters indicated that sufficient staff were available to care for the residents. The home had based these calculations on dependency levels that were regularly re assessed. However eight of the eleven relatives’ questionnaires expressed an opinion that there were not always sufficient staff on duty The staff who were interviewed said that they considered the staffing levels to be acceptable. Ravenhurst DS0000018469.V318455.R02.S.doc Version 5.2 Page 21 Since the last inspection six staff had left the home. Two of these had retired, one had left for family reasons and the remainder had pursued their careers elsewhere. The pre inspection questionnaire stated that there were twenty-six care staff employed, nineteen of whom had National Vocational Qualifications to level two or above. This amounts to 73 and well exceeds the 50 National Minimum Requirement. The training matrix and records demonstrated that mandatory training was closely monitored and provided for all staff. Other opportunities were accessed and staff expressed their appreciation of the commitment to training. All staff said that they received 1:1 supervision with a senior, which they found useful and supportive. The staff who spoke to the inspector confirmed they had been correctly recruited. Their records indicated that they had completed application forms, references had been taken up, checks undertaken by the Criminal Records Bureau and they had been interviewed. There was currently one staff vacancy for a relief carer. Positive comments regarding the staff were received in the questionnaire responses from residents, staff, and health care professionals and from the residents and relatives who spoke to the inspector. These included; Some of the staff are fab. XXX in this home is great. I’ve seen her treating them as if it’s their own but not all are like that. I have been very satisfied with my aunt’s care and with the attitude of staff. I am always made welcome. I would recommend Ravenhurst to any one undertaking the task of looking for a care home for a relative or friend. Ravenhurst DS0000018469.V318455.R02.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home has an experienced and trained manager who ensures it is run in the best interests of the people who live and work there. The provider has taken action so that the home continues to be well managed in the absence of the registered manager. The home is managed with due regard for the health and welfare of everyone in it. Ravenhurst DS0000018469.V318455.R02.S.doc Version 5.2 Page 23 EVIDENCE: The registered manager is experienced and well qualified. She is currently unavoidably absent for an extended period of time and in her absence the home is being managed by the management team with support from another registered manager and a peripatetic manager. The staff expressed their appreciation for the quality of the registered manager of Ravenhurst and a relative stated; Overall I consider the home to be well run. The staff are friendly and caring. Another comment made was; Ravenhurst is a good home. It works from the top downwards. The manager has high standards and expects the same from everyone else. The home has a happy, homely atmosphere that is appreciated by everyone. Equality and diversity is respected and the Service Users’ Guide provides good information and contacts for people of different denominations. Pre-admission forms and recruitment forms seek information and monitor needs. Annual questionnaires are distributed by the home and completed by residents and it was seen that these had been analysed and the results were displayed in the home. Concerns that were expressed had been addressed and areas where development and the service could be improved were identified attention. The provider had employed the services of an independent company to also undertake a questionnaire survey regarding the quality of the service. A number of systems in the home were regularly monitored and audited, and inspections undertaken in accordance with regulation 26 provided more information on the quality of the service. These methods formed the quality assurance system for the home. Some residents held money in safe-keeping and monies were managed on their behalf by the home according to their wishes. Security and records were acceptable. The pre-inspection questionnaire indicated that the equipment and services in the home were regularly monitored, maintained and serviced. The documentation in the home supported this statement. Some records had been maintained in pencil. This is not acceptable. It was observed that the water temperature in the shower room was very hot. The manager undertook to check this. Ravenhurst DS0000018469.V318455.R02.S.doc Version 5.2 Page 24 Accident records were well maintained. The Fire Risk Assessment for the home was carried out in October 2004. Fire safety checks and training were being undertaken at an acceptable frequency and staff were receiving training in other health and safety topics. Ravenhurst DS0000018469.V318455.R02.S.doc Version 5.2 Page 25 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 4 4 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 3 X X X X X X 4 STAFFING Standard No Score 27 3 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 4 X X 4 Ravenhurst DS0000018469.V318455.R02.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 01/12/07 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 OP7 Good Practice Recommendations There should be more evidence of each residents’ involvement in their care planning. Ravenhurst DS0000018469.V318455.R02.S.doc Version 5.2 Page 27 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: 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 Ravenhurst DS0000018469.V318455.R02.S.doc Version 5.2 Page 28 - 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. 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