Inspection on 09/03/04 for Ravenhurst

Care Home For Older PeopleRavenhurst21 Lickhill Road North Stourport-on-Severn Worcestershire DY13 8RUAnnounced Inspection9th March 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Ravenhurst Address 21 Lickhill Road North, Stourport-on-Severn, Worcestershire, DY13 8RU Email Address jmccarthy@heart-of-england.co.uk Name of registered provider(s)/Company Heart of England Housing and Care Limited Name of registered manager Type of registration Care Home providing personal care No. of places registered 41 Tel No: 01299 825610 Fax No: 01299 879341Category(ies) of registration, with (number of places) Dementia - over 65 years of age (41), Old age, not falling within any other category (41), Physical disability over 65 years of age (41) Registration number E030000205 Date first registered Date of latest registration certificate 12th April 2001 Was the home registered under the Registered Homes Act 1984 Do additional conditions of registration apply ? Date of last inspection 12th November 2003 YES YES 2/09/03 If Yes Refer to Part CRavenhurstPage 1 Date of Inspection Visit Time of Inspection Visit Name of Inspector Name of Inspector Name of Inspector 1 2 39th March 2004 09:30 am C PresleyID Code111154Name of Inspector 4 Name of Lay Assessor (if applicable) Lay assessors are members of the public independent of the NCSC. They accompany inspectors on some inspections and bring a different perspective to the inspection process Name of Specialist (e.g. Interpreter/Signer) (if applicable) Name of Establishment Representative at Mrs D Fiddoe the time of inspectionRavenhurstPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspection Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: Part E: E.1. E.2. E.3. Compliance with additional conditions of registration (if applicable) Lay Assessors Summary (where applicable) Providers Response Providers comments Action Plan Providers AgreementRavenhurstPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the National Care Standards Commission (NCSC), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the NCSC in respect of Ravenhurst. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the NCSC regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Report of the Lay Assessor (where relevant) · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.RavenhurstPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. 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-on-Severn. A former coach house in the grounds is let to a tenant unconnected with the home. 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. Its chief executive is the designated representative for the purpose of the Care Standards Act 2000. The home does not have a registered manager, Mrs Fiddoe referred to in this report as the acting manager is in day-to-day charge of the running of the home. Mrs Poppitt who is manager of Areley House (another Heart of England Home) will be taking responsibility for the home once Areley House closes in April 2004.RavenhurstPage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.)RavenhurstPage 6 The focus of inspections by the National Care Standards Commission in 2003/4 is on: · Outcomes for service users · Progress in meeting National Minimum Standards where shortfalls were identified in 2002/3 and, in particular · On aspects of service provision that need further development in order to safeguard service users from potential risks This inspection, therefore, focuses on the areas that are most significant in the lives of service users and the areas that have been identified for action and development during the previous inspections. Some standards may not have been inspected on this occasion but will have been covered during the last inspection of this service. For a full overview of performance against standards, this report should be read in conjunction with the report of the last inspection. The inspection took place in March 2004 during a morning and early afternoon. This inspection focused on those standards not inspected at the announced inspection in September 2003. This inspection did not address the requirements and recommendations from the last report the inspector is therefore unable to comment if these have been met. As an overview many of the National Minimum Standards had been met or partially met and that the overall quality of care provided was good. Choice of Home Standards 1 ­ 6 0 of the 1 standard inspected was met. The home needed to develop the Service User Guide and Statement of Purpose further in order to meet the required standard. There was evidence staff received mandatory training and there was evidence of further training offered which met the specialised needs of the current service user group. Health and Personal Care Standards 7 - 11 None of the standards in this section of the report were inspected fully. The inspector noted care plan documentation had improved since the last inspection. There was a medication recording error regarding controlled drug medication, this was rectified by the home before the inspector left. Service users spoken to during the inspection said staff were respectful and ensured their privacy and dignity; this was borne out in comment card questionnaires received prior to inspection. Daily Life and Social Activities Standards 12- 15 0 of the 1 standard inspected was met. The home employed two staff who undertook activities in the home, over a twelve-hour period each week. Service users comments received via questionnaires sent out prior to the inspection evidenced service users felt there were enough activities offered in the home. Service users spoken to during the inspection were unhappy with the food; this was not borne out in service user questionnaires received prior to the inspection. Menus seen looked wholesome and nutritious and there was evidence of choice. The home had a residents bank account system; there was no evidence in the policies and procedures manual how this was dealt with including if interest was paid and gaining access to monies outside normal business hours. Ravenhurst Page 7 Complaints and Protection Standards 16 ­ 18 1 of the 2 standards inspected was met The home took all complaints serious no matter how minor. The procedures and policies in place were user-friendly. There was evidence from service user questionnaires received prior to the inspection that some service users were unaware of the complaints procedure. There was evidence of criminal record checks being carried out on staff working in the home and evidence of protection of vulnerable adult training. Environment Standards 19 ­26 None of the standards were inspected in this section of the report. The fire logbooks were checked during the inspection and there was evidence of regular fire drills. The home had not re-instated the shower room for the sleep-in member of staff. Staff needed further training in infection control. Staffing Standards 27 ­ 30 1 of the 5 standards inspected was met Heart of England were planning to recruit a training manager who would undertake induction training and the purchase of foundation training from outside agencies as necessary plus NVQ training in the home. There were no domestic and laundry staff employed seven days per week, care staff undertook some of these duties at weekends. Staff files seen had shortfalls regarding documentation to meet the standard. Management and Administration Standards 31 ­ 38 4 of the 7 standards inspected were met The home did not have a manager in post on the day of inspection; the acting manager is covering the home with the support of two senior lead cares. The incoming manager works in another Heart of England home that is due to close in April 2004. There was evidence when staff and service users were questioned the acting manager had an open and inclusive approach to running the home. The home ensured the health and safety of service users and staff through policies, procedures and risk assessments. The inspector would like to thank Mrs Fiddoe for her hospitality and co-operation during the announced inspection. She would also like to thank service users and staff for answering her questions, and for those service users, relatives and professionals who completed the feedback forms.RavenhurstPage 8 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. No. Regulation Standard Required actions Timescale for action 1 23 OP21 The staff bathroom on the second floor must be re-instated or replaced by a similar facility approved by the Commission The registered provider must submit its proposals to the Commission for Bedroom 20 30/06/04223OP2330/06/04Action is being taken by the National Care Standards Commission to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard It is recommended that if a service user was unable to visit the home prior to admission reasons why were recorded in the care plan.1OP5CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). The home may accommodate one person over 65 years of age who has a past or present alcohol dependency,Met (Yes / No) NORavenhurstPage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements and recommendations are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action 1 4 OP1 The Statement of Purpose must be amended so that it includes all the information detailed in Regulation 4 and Schedule 1. Manual handling and risk assessments must be reviewed monthly on all service users. The staff bathroom on the second floor must be re-instated or replaced by a similar facility approved by the Commission The registered provider must submit its proposals to the Commission for Bedroom 20 30/06/04213, 15OP730/06/04323OP2130/06/04423OP2330/06/0455OP1A Service Users Guide, which includes all the information detailed in Regulation 5 and Standard 1, must be available in the home 30/06/04 and copies must be given to all current, and any prospective, service users The controlled drug medication book must be filled in correctly each time controlled medication is given to a service user. The home must ensure all staff adhere to the infection control policy and procedure with regards to the handling of foul laundry. The home must employ laundry staff and domestic staff in enough numbers to cover the home seven days per week immediate613OP9713OP26immediate818OP2730/06/04RavenhurstPage 10 912,18OP30OP2 8All members of staff must receive foundation training to National Training Organisation specification within 6 months of appointment to their posts. Recruitment procedures must be developed in accordance with the requirements of Regulation 19, Schedule 2 and Standard 29. The home ensure records kept in the home comply with Regulation17 Schedule 4 of the Care Home Regulations.30/06/041019OP29OP2 9 OP37OP3 730/06/04111730/06/04RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s) No. Refer to Good Practice Recommendations Standard * It is recommended that if a service user was unable to visit the home prior to admission reasons why were recorded in the care plan.1OP52OP19It is recommended the home develop a matrix as evidence all staff have been involved or talked through a fire drill at least once a year.* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.RavenhurstPage 11 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct Observation Indirect Observation Sampling · Pre-inspection Questionnaire · Records · Care Plans / Care Pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting Professionals survey / feedback Tour of Premises Formal Interviews Document reading Additional Inspection Information: Number of Service Users spoken to at time of inspection Number of Relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the Responsible Individual seen CRB check for the Acting Manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of Inspection Time of Inspection Duration Of Inspection (hrs) YES YES YES YES YES NO NO NO YES YES YES YES YES YES YES YES NO NO NO YES 5 0 49 YES NO YES NO 21 0 09/03/04 09.40 5.5RavenhurstPage 12 The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards for Care homes for older persons have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.RavenhurstPage 13 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide Range of fees charged From (£) 315.00 To (£) 357.00Any charges for extras If yes, please state what the extras are:YES · · · · · · · Hairdressing Chiropody Newspapers/magazines Private dentist Private physiotherapist Private telephone Taxis 2Key findings/EvidenceStandard met?RavenhurstPage 14 The home had a Statement of Purpose and Service User Guide. The Statement of Purpose had the following shortfalls;· There was reference to care being provided in single en-suite rooms this is not the case in the home as there are some shared rooms. · The charges in the Statement of Purpose did not correspond to the information given by the acting manager to the inspector on the day of inspection. · The home did not have an outgoing switchboard for telephone calls. · It was unclear how often service users would be involved in their review of care. · The document listed extras charged to service users but there were no prices attached. · The page called social activities was not filled in, therefore the inspector was unsure when Church Services took place. · The full complaints procedure was not evident. The Service User Guide had page numbers that were not in sequential order; this was very confusing. Some of the shortfalls outlined in the Statement of Purpose were also evident in the Service User Guide. Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 0 Key findings/Evidence Standard met? This standard was not inspected at this inspection, for further information refer to previous report. This standard was met at the last inspection.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 0 Key findings/Evidence Standard met? This standard was not inspected at this inspection, for further information refer to previous report. This standard was met at the last inspection.RavenhurstPage 15 Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? This standard was not inspected at this inspection, for further information refer to previous report. This standard was met at the last inspection. Staff interviewed by the inspector during the inspection evidenced staff they had received mandatory training and specialised training to deal with the specific needs of the current service user group in the home. The acting manager told the inspector Heart of England were planning to recruit a training manager who would undertake induction and N.V.Q. training in the home. One of the Senior Lead Cares was awaiting confirmation her portfolio on manual handling submitted to an outside agency met the required standard to enable her to become the manual handling trainer in the home. Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 0 Key findings/Evidence Standard met? This standard was not inspected at this inspection, for further information refer to previous report. This standard was met at the last inspection. The acting manager told the inspector service users were encouraged to visit the home prior to admission, preferably for a day where further assessment of need if any could be identified.Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff to deliver short-term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? The home did not offer intermediate care.RavenhurstPage 16 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 0 Key findings/Evidence Standard met? This standard was not inspected at this inspection, for further information refer to previous report. Documentation seen since the last inspection had improved. Care plans were reviewed monthly and there was evidence of service user involvement in the care plans. All care plans had a photograph of service users in place. Manual handling assessments and risk assessments were not reviewed monthly.RavenhurstPage 17 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. Number of incidents where service users have been taken to Accident and Emergency since the last inspection. Number of service users with pressure sores at time of inspection (from information taken from care notes)8 00 Key findings/Evidence Standard met? This standard was not inspected at this inspection, for further information refer to previous report. This standard was met at the last inspection. A number of service users had been admitted to accident and emergency since the last inspection, the acting manager said these were mainly falls in the home. The inspector saw the accident book the acting manager told the inspector the accident book was audited monthly and quarterly returns were sent to Heart of England. Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 0 Key findings/Evidence Standard Met? This standard was not inspected at this inspection, for further information refer to previous report. On checking the controlled drug medication the inspector noted an error written in the controlled drug medication book. The acting manager and lead carer rectified this before the inspector left the home.RavenhurstPage 18 Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with and examination by health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 0 Key findings/Evidence Standard met? This standard was not inspected at this inspection, for further information refer to previous report. This standard was met at the last inspection. Twenty-one service user comment cards were received prior to the inspection all said their privacy and dignity was respected in the home. Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 0 Key findings/Evidence Standard met? This standard was not inspected at this inspection, for further information refer to previous report. This standard was met at the last inspection.RavenhurstPage 19 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 0 Key findings/Evidence Standard met? This standard was not inspected at this inspection, for further information refer to previous report. This standard was met at the last inspection. The home employed two activities co-ordinators who worked a total of twelve hours in the home. Service users comment cards-received evidenced most service users were happy with the activities offered in the home. The home was planning for Mothering Sunday and entertainment and a buffet tea for service users families and friends was being arranged. The home had a minibus; the acting manager was hoping they would be able to use this facility more this summer. The home was planning to enter the Garden in Bloom competition and was involving service users in planning the garden this was commendable. Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences 0 Key findings/Evidence Standard met? This standard was not inspected at this inspection, for further information refer to previous report. This standard was met at the last inspection.RavenhurstPage 20 Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 2 Key findings/Evidence Standard met? The acting manager confirmed some service users were able to take care of their own finances. The acting manager told the inspector service users could access advocacy services locally if they chose. The home had a facility whereby service users could deposit money with the home, this money was kept in a `pooled bank account called Residents Property Account, and the account was non-interest bearing. There were no policies or procedures regarding this facility or how service users could access their monies out of hours in the homes policies and procedures or Service User Guide or Statement of Purpose. Service users were able to personalise their bedrooms and a list of furniture brought in by service users was kept in the home. Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet which is suited to individual, assessed and recorded requirements and that meals are taken in a congenial setting and at flexible times. 0 Key findings/Evidence Standard met? This standard was not inspected at this inspection, for further information refer to previous report. This standard was met at the last inspection. Comment cards received back from service users indicated food offered in the home was acceptable. Two service users spoken to during the inspection complained the food was not good, they complained about the quality of the food and choice. This was discussed with the acting manager who was trying to resolve the situation. Menus were submitted to the Commission prior to the inspection and there was evidence choice was offered, the menu content looked nutritionally wholesome.RavenhurstPage 21 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple clear and accessible complaints procedure which includes the stages and time-scales for the process and that complaints are dealt with promptly and effectively. No. of complaints made to the home since the last inspection No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to NCSC Percentage of complaints responded to within 28 days Key findings/Evidence 6 1 1 4 0 0 100 3Standard met?The home took all complaints no matter how minor seriously these were recorded and audited quarterly. The inspector saw the complaints book. There had been no complaints to the National Care Standards Commission since the last inspection. The complaints policies and procedures were clear and user friendly, comment cards received from service users evidenced service users knew how to complain and to whom if they chose. Feedback cards received from relatives and friends showed seven out of twenty seven were unaware of the complaints procedure.RavenhurstPage 22 Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 0 Key findings/Evidence Standard met? This standard was not inspected at this inspection, for further information refer to previous report. This standard was met at the last inspection.Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial, or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES X2 Key findings/Evidence Standard met? The acting manager showed the inspector the homes policies and procedures regarding the protection of vulnerable adults. Training was offered to staff in this field and was on-going. The acting manager confirmed all new staffs were subject to a criminal record bureau check before commencing work in the home. The acting manager said most staff had now been checked; she was still awaiting the return of her own criminal record check.RavenhurstPage 23 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 0 Key findings/Evidence Standard met? This standard was not inspected at this inspection, for further information refer to previous report. This standard was met at the last inspection. The fire logbook was checked and there was evidence of ongoing maintenance checks; the last fire drill from information taken from the pre-inspection questionnaire was on the 04/02/04. The acting manager confirmed fire training was ongoing and staff received fire training from an accredited fire trainer within three months of commencing employment in the home. There was no quick reference to make sure all staff had been involved in a fire drill at least once a year. The inspector recommended a matrix be set up to evidence this for future inspections.Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 0 Key findings/Evidence Standard met? This standard was not inspected at this inspection, for further information refer to previous report. This standard was met at the last inspection.RavenhurstPage 24 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 0 Key findings/Evidence Standard met? This standard was not inspected at this inspection, for further information refer to previous report. The acting manager told the inspector the home was fitting new boilers the day after inspection. The home had not re-instated the shower room for the sleep-in member of staff since the last inspection. The acting manager told the inspector there were plans to re-instate this facility within the next two months.Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons including a qualified occupational therapist, with specialist knowledge of the client groups catered for and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 0 Key findings/Evidence Standard met? This standard was not inspected at this inspection, for further information refer to previous report. This standard was met at the last inspection.RavenhurstPage 25 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite NO YES NO 26 9 2 1 35 00 0 2 10 Key findings/Evidence Standard met? This standard was not inspected at this inspection, for further information refer to previous report. This standard was met at the last inspection.RavenhurstPage 26 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user, which is furnished and equipped to assure comfort and privacy and meets the assessed needs of the service user. 0 Key findings/Evidence Standard met? This standard was not inspected at this inspection, for further information refer to previous report.Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 0 Key findings/Evidence Standard met? This standard was not inspected at this inspection, for further information refer to previous report. This standard was met at the last inspection.Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection in accordance with relevant legislation and published professional guidance. 0 Key findings/Evidence Standard met? This standard was not inspected fully at this inspection, for further information refer to previous report. The home was clean and odour free on the day of inspection. Carpet in the bedroom highlighted in the last report had been replaced. The home had an infection control policy and procedure however when staff were questioned by the inspector it was clear this was not being adhered to with regard to dealing with foul laundry. The acting manager and hotel services manager said they would obtain some `red bags and retrain all staff. The home had a new washing machine with a sluice facility.RavenhurstPage 27 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff Key findings/Evidence X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X XX X X Standard met? 3RavenhurstPage 28 The Commissions guidance on using the Residential Forum Staffing tool to calculate the minimum staff number exists for new homes registered after April 2000 only and does not apply to homes registered prior to this date. The home had four care staff and one lead care staff on duty each morning and three care staff and one lead care staff on duty during the afternoon and evening. There were two waking night staff and one sleep in member of staff overnight. Service users and relatives comment cards received prior to inspection felt at times staff were stretched. The Commission was in receipt of duty rotas and there appeared to be adequate cover to meet the assessed needs of the current service user group. The home did not employ laundry staff and cleaning staff over the weekend, this needed to be addressed as care staff were undertaking these duties. The home employed cooks and kitchen assistants in enough numbers to cover all aspects of the catering requirements of service users seven days per week.Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 7 33 2 Key findings/Evidence Standard met? The home had seven staff who had completed NVQ level 2 training in care. Four staff were working towards attaining their NVQ 2 in care. The home was on target to achieve 50 of care staff attaining an NVQ qualification by 2005. The home had a comprehensive induction programme for all new care staff. There was no evidence of a foundation training that was TOPSS certified.RavenhurstPage 29 Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 2 Key findings/Evidence Standard met? The home operated an equal opportunities recruitment procedure. A random selection of staff files were seen by the inspector, files seen lacked the following information;· Copies of birth certificates · Copy of current passport if one available · Written references Discussion took place with the acting manager regarding meeting the requirements of Regulation 19 Schedule 2 of the Care Homes Regulations 2001. The home did not employ volunteers.Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme, which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 2 Key findings/Evidence Standard met? There was evidence of an induction programme for all new care staff, which met the requirements of this element of the standard. However the home did not have a foundation-training programme in place, which met the requirements and was TOPSS specific. The Director of Care for Heart of England told the inspector Heart of England were planning to recruit a training manager who would be undertaking NVQ training and would be responsible for purchasing foundation training from outside agencies as necessary. It was hoped care staff would finish their induction programme and commence NVQ training immediately. Staff received mandatory training in;· Food hygiene · First aid · Fire safety · Manual handling · Protection of vulnerable adults · Infection control regularly. The training matrix evidenced staff were receiving at least three paid training days per year.RavenhurstPage 30 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 2 Key findings/Evidence Standard met? The home did not have a manager in post at the time of the inspection. Two senior lead carers supported the acting manager; the acting manager was competent and had the experience to run the home in the short term. The proposed manager for the home works in another Heart of England home that is due to close in April 2004. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This standard could not be inspected at this inspection as the home has an acting manager in post. The proposed manager was hoping to take up her post in April 2004. The acting manager had control of a financial budget for the home and staff and service users spoken to during the inspection felt she was open and approachable.RavenhurstPage 31 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 3 Key findings/Evidence Standard met? The home had developed a quality assurance monitoring tool and was working towards collating the information gained into an annual report.Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure that there is effective and efficient management of the business. 3 Key findings/Evidence Standard met? The acting manager showed the inspector the financial plan for the forthcoming year. The home had adequate insurance in place. Financial records were kept and appeared in order.RavenhurstPage 32 Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders X X X2 Key findings/Evidence Standard met? The acting manager said a number of service users were able to control their own finances and were enabled to do so for as long as they were able. Written records of financial transactions were seen. The home had a facility whereby service users could deposit money with the home, this money was kept in a `pooled bank account called Residents Property Account, and the account was non-interest bearing. There were no policies or procedures regarding this facility or how service users could access their monies out of hours in the homes policies and procedures or Service User Guide or Statement of Purpose. The acting manager confirmed she did not act as appointee for any service user. Monies were kept secure in the home. Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 3 Key findings/Evidence Standard met? The acting manager said supervision was undertaken regularly with staff. Supervision covered all aspects of care practice and the homes aim and objectives. Records were kept in staff files and staff when questioned evidenced supervisory sessions took place regularly and were helpful. The home did not employ any volunteers.RavenhurstPage 33 Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 2 Key findings/Evidence Standard met? The home did not meet the required standard regarding records kept in accordance with Regulation 17 and Schedule 4 of the Care Homes Regulations 2001. The home had monthly visits from the registered provider and these were submitted to the Commission as required by Regulation 26 of the Care Homes Regulations 2001.Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable, the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? The acting manager ensured the health and safety of service users and staff through policies and procedures and risk assessments. Staff had received mandatory training and there was evidence of a training matrix in place in the home to ensure staff training was updated and on going. The home had evidence of;· Hazard warning sheets, first aid measures in the event of an accident · Boilers were being replaced the day after inspection · A legionella risk assessment had been carried out in February 04 and there was evidence water temperatures were checked, · Electrical testing was on-going for equipment · The home had window restrictors in place · The home employed contract gardeners who brought their equipment with them · The home was secure and had installed further door release catches to ensure safety The acting manager confirmed she complied with the legislation as set out in Standard 38.4 of the National Minimum Standards. The home had an environmental risk assessment in place. The acting manager understood the requirements under Regulation 37 regarding notification to the Commission of any events. The health and safety poster was posted in the care staff office in the home.RavenhurstPage 34 PART C(where applicable)COMPLIANCE WITH CONDITIONSNO Condition Compliance The home may accommodate one person over 65 years of age who has a past or present alcohol dependency. Comments As the named person no longer resides at Ravenhurst this condition is no longer appropriate.Condition Type of registration CommentsComplianceYESCondition Categories of registration CommentsComplianceYESCondition Maximum number of places registered CommentsComplianceYESLead Inspector Second Inspector Locality Manager Draft DateChrissy Presley Hilary Gaffey 24 March 2004Signature Signature SignatureRavenhurstPage 35 PART D(where applicable)LAY ASSESSORS SUMMARYLay Assessor Date Public reportsSignatureIt should be noted that all NCSC inspection reports are public documents.RavenhurstPage 36 PART EE.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.Please limit your comments to one side of A4 if possible Standard 18 ­ Protection. I do not agree with the inspectors scoring of 2 for this standard. In the name body of the report, on page 24, the inspector has recorded YES next to @The home has an Adult Protection Procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1988 and the Department of Health Guidance No Secrets. The acting homes manager showed the inspector the Heart of Englands policies and procedures regarding the protection of vulnerable adults. The inspector has commented and noted that training is not available to staff in this `field and is ongoing. The acting homes managers also confirmed that all new staff are subject to criminal record bureau checks before commencing work in the home I believe that this standard has been met and should be scored as 3. Below I have extracted from the action plan the following comments for inclusion in the final report: 8 18 OP27 Ravenhurst already employs two laundry staff. One works between Monday and Friday and the Other at weekends 30.6.04RavenhurstPage 37 Action taken by the NCSC in response to provider comments: Amendments to the report were necessary YESComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurate Note: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. Please provide the Commission with a written Action Plan by 21 April 2004 which indicates how requirements are to be addressed. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YES E.2YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESOther: enter details here RavenhurstPage 38 E.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.E.3.1 I John McCarthy of Heart of England Housing and Care Ltd (Ravenhurst) confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or E.3.2 I John McCarthy of Heart of England Housing and Care Ltd (Ravenhurst) am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons: See Providers response E1Print Name Signature Designation DateJOHN McCARTHY (John McCarthy) Director of Care 28 April 2004Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.RavenhurstPage 39 - 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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