Inspection on 28/01/06 for Ravenscourt

This inspection was carried out on 28th January 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ravenscourt 26/08/08

Ravenscourt 22/08/06

Ravenscourt 08/08/05

Ravenscourt 12/11/04

Ravenscourt 06/05/04

Similar services:

Prinsted

Elizabeth House

Kenward House

Boons Park

Winthrop Hall

Life Works Community Ltd

Turning Point

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

CARE HOME ADULTS 18-65 Ravenscourt 15 Ellasdale Road Bognor Regis West Sussex PO21 2SG Lead Inspector Ms B Tye Unannounced Inspection 28th January 2006 10:00 Ravenscourt DS0000014677.V276273.R01.S.doc Version 5.1 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 Ravenscourt DS0000014677.V276273.R01.S.doc Version 5.1 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 Adults 18-65. 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. Ravenscourt DS0000014677.V276273.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ravenscourt Address 15 Ellasdale Road Bognor Regis West Sussex PO21 2SG 01243 862157 01243 867126 robin@ravenscourt.org.uk 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) Ravenscourt Trust Mr Robin John Woznicki Care Home 17 Category(ies) of Past or present alcohol dependence (17), Past or registration, with number present drug dependence (17) of places Ravenscourt DS0000014677.V276273.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th August 2005 Brief Description of the Service: Ravenscourt is a care home registered to provide personal care (PC) for up to seventeen service users in the categories A (Past or present Alcohol Dependency) and D (Past or present Drug dependency). The property is a converted and extended premises located on the outskirts of Bognor Regis. Accommodation is provided over three floors. The home offers both single and double rooms. The service is a voluntary organisation named Ravenscourt Trust and the registered manager is Mr R Wozniciki. The responsible person on behalf of the company is Mr J Harman. Ravenscourt DS0000014677.V276273.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the unannounced inspection of Ravenscourt information held on file was examined, including the last two inspection reports and any official documentation relating to the home. During the inspection a tour of the home was undertaken and records relating to the residents care and health needs was examined. The inspector spoke to the Senior on duty and spent some time with the homes housekeeper. Where assessed standards continue to be met, the text of the inspection report will remain unchanged from the last report. What the service does well: What has improved since the last inspection? Since the last inspection a new mini bus has been purchased to take the residents out as a group. The kitchen storage area has been reorganised and improved. The house has undergone a general spring clean, curtains and carpets have been cleaned and some redecoration has been undertaken. The programme of redecoration is on going in the home. New furniture for some of the residents rooms has been ordered to update existing furnishings. Ravenscourt DS0000014677.V276273.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ravenscourt DS0000014677.V276273.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ravenscourt DS0000014677.V276273.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 5 Pre-admission assessments are completed prior to admission to the home and held on residents files. Prospective residents are provided with relevant information prior to admission. All residents are provided with a contract of Terms and Conditions, which they are required to sign before undertaking the programme. EVIDENCE: The inspector viewed an up to date Statement of Purpose and Service Users Guide, which are given to all prospective residents prior to admission. This provides detailed information about the services available to them and helps them to decide whether the home can appropriately meet their needs. Individual care files contained pre-admission information, which was relevant and detailed. Records showed prospective residents had contributed to the assessment process. Providing the opportunity for them to identify their perceived needs and aspirations prior to admission. Terms and Conditions are provided and signed by each resident on arrival, copies of which was seen on file. This ensures residents are fully aware of their rights and exactly what the home has to offer them. Ravenscourt DS0000014677.V276273.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 10 Residents have the opportunity to contribute to and review the care planning process through one to one and group sessions. Documentation that was examined confirmed that the home meets their changing needs and personal goals appropriately. The service promotes independence as part of a structured programme and in line with assessed risk and agreed limitations. All information is stored securely. EVIDENCE: The inspector examined care records. These are generated from the initial assessment information. Each plan relates to all aspects of the residents assessed care needs including health, personal and social care. The plans are easy to follow which means staff can transfer the information into daily practice. Risk assessments are undertaken as part of the pre-admission assessment. This includes detailed information relating to personal history, mental health and behaviours. Assessment of risk ensures the manager and staff can provide care within safe boundaries. Ravenscourt DS0000014677.V276273.R01.S.doc Version 5.1 Page 10 Records include evidence of regular reviews by the therapeutic team. Through this process, objectives and progress are identified and discussed with individual residents. This was evidenced by the residents completion of written assignments and signed documentation held on file. Each review provides an opportunity for the resident to be consulted and participate in the care planning process. Residents meet on a daily basis for group-work. This forum enables residents to discuss and resolve issues relating to their recovery. Through these and weekly community meetings, the residents have the opportunity to discuss and contribute to the way the programme is run. Ravenscourt DS0000014677.V276273.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 & 17 The residents at Ravenscourt are required to participate in a structured programme, which includes group and individual activities both in the home and wider community. These are appropriate to their personal development and encourage individuals to take responsibility in their daily lives. The menu at Ravenscourt offers a range of healthy balanced meals. EVIDENCE: The home has a 7- seater vehicle to transport residents as needed. Residents go on weekly outings as a group and attend leisure activities as individuals. It is clear each resident has the opportunity to develop their personal goals and is encouraged to do so through group work and individual sessions. Goals have been set out in individual care plans to support this and there is evidence these are reviewed regularly according to the individuals changing needs. Ravenscourt DS0000014677.V276273.R01.S.doc Version 5.1 Page 12 The inspector noted there was a good balance achieved between supporting residents to participate in structured activities and encouraging independence where appropriate. Information seen on care plans confirmed family contact is promoted. The programme at Ravenscourt includes work with family members to resolve on going issues and provide support where needed. The inspector spent time with the house keeper and examined menus for the home. Meals provided are varied and balanced in nutritional content. The house keeper confirmed residents are consulted about what they liked to eat prior to menus being drawn up. Residents are required to assist the house keeper in preparing ingredients and cooking group meals on a daily basis, in order to promote independent living skills. Hot and cold drinks facilities are available for residents to make their own drinks when they choose. Ravenscourt DS0000014677.V276273.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 None of the residents require personal care however all have complex emotional and health needs. Care records were examined and showed evidence that needs of residents are assessed and reviewed on a regular basis. Medication is stored and labelled appropriately. The inspector found that all MAR sheets and information relating to medication was in good order and signed by staff. EVIDENCE: Care plan information is formed from the initial assessment and weekly reviews. All aspects of care provided by the home and community health professionals are recorded. Residents are registered with a local GP and Dentist. Residents are supported to attend appointments as required. Each resident is assigned a counsellor who provides a therapeutic one to one session on a weekly basis. These meetings provide residents with the opportunity to talk through all aspects of their care needs and make supported changes where needed. All information from these sessions is recorded and collated to the care plan. Ravenscourt DS0000014677.V276273.R01.S.doc Version 5.1 Page 14 The programme provides a rigid daily structure to the residents which is relevant to their on going treatment and complex needs. However individuals have the opportunity to make choices and demonstrate independence within this. Policies and procedures relating to all aspects of healthcare and medication are in place and up to date. Due to the nature of the service no resident self-administers medication. All staff have received relevant training to dispense medication safely. Medication at the home was inspected and found to be stored appropriately. All medication charts are up to date, completed in full and in good order. Ravenscourt DS0000014677.V276273.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 The inspector concluded that the home has satisfactory systems in place to protect the residents from abuse, neglect and self-harm. EVIDENCE: The home has a detailed Complaints policy and procedure, which is included in the Service Users Guide. Adult Protection Training is undertaken twice a year and staff are clear about their responsibilities should an incident occur. County Procedures and an updated Policy and Procedure for the protection of vulnerable adults are available at the home. Regular residents meetings provide individuals with peer support and the opportunity to discuss any issues of concern. Ravenscourt DS0000014677.V276273.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 - 30 The home’s premises are suitable for its stated purpose. The home was very clean and tidy and furnishings are homely and comfortable. Residents rooms suit their needs and all those observed by the Inspector were clean, tidy and of a reasonable standard of décor. EVIDENCE: The lounge and dining area were of a suitable size to meet residents needs. A conservatory area and relaxation room provide the residents with a space to smoke and socialize. Bedrooms are a reasonable size and some have been recently re-decorated. The occupants have personalised their rooms with pictures and possessions. None of the residents bedroom doors had locks as this was considered a risk in relation to their assessed needs. Each room contains a lockable space for residents to store valued possessions if they wish. En-suite facilities are available in some of the bedrooms and there is adequate bathroom and toilet facilities in the home to meet residents needs. Ravenscourt DS0000014677.V276273.R01.S.doc Version 5.1 Page 17 A large garden at the rear of the premises is accessible to all residents and has ramped access to the home. The domestic duties at Ravenscourt are completed by residents, as part of their programme. This is overseen by the homes Housekeeper and staff who support individuals to undertake various duties such as washing, cooking and cleaning. Involvement in these duties promotes the residents independent living skills and their investment in their living environment. Training records showed the housekeeper has completed a Health and Hygiene course. This promotes good health and safety practices and minimises the risk of infection within the home. Ravenscourt DS0000014677.V276273.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 35 & 36 The staff at Ravenscourt have all been trained and recruited to meet the assessed needs of the residents. Recruitment procedures are in place and records reflected these are adhered to. All staff are supervised and supported to fulfil their roles and responsibilities effectively. EVIDENCE: All care staff at the home have obtained a counselling qualification prior to being employed. The home also runs a training programme, which includes first aid, fire training, adult protection, confidentiality and health and safety courses. None of the staff have started the National Vocational Qualification; Level 2. This is due to the fact that the current training modules are geared more towards nursing and care homes. The director stated he is currently awaiting some planned national changes to the existing modules. This will make the qualification more relevant to the staff group at Ravenscourt and better serve the residents. This will be monitored at future inspections. The home currently has a staff vacancy for one part time care staff but does not use agency workers. This provides consistency of care to residents. Ravenscourt DS0000014677.V276273.R01.S.doc Version 5.1 Page 19 Discussion with the senior confirmed the care team have regular supervision sessions with a therapeutic counsellor contracted by the service. This gives staff members the opportunity to reflect on their practice and identify areas of personal development. In addition the staff group meet weekly as a team. This provides a forum for staff to contribute to the running of the home gain peer support in relation to practice issues. Ravenscourt DS0000014677.V276273.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 40 & 41 Residents rights and best interests are safeguarded through policies, procedures and detailed record keeping. EVIDENCE: The home has up to date policies and procedures in line with current legislation. This gives staff consistent guidance in working effectively with residents at the home. The inspector was unable to examine all safety records, as these were locked in the directors office in his absence. It was advised that senior staff have access to these in the event of an unannounced inspection during unsocial hours. Discussions with the staff confirmed they receive support and direction in their roles from management. Good working practices are promoted through training and regular staff support. Ravenscourt DS0000014677.V276273.R01.S.doc Version 5.1 Page 21 The inspector noted efficient administration and recording systems are in place, which support staff in their practice and ensure accountability in their day to day roles. Following examination of the available records and evidence collated during the inspection, the inspector concluded the conduct and management of the home served the best interests of the residents and continued to provide a good standard of overall care. Ravenscourt DS0000014677.V276273.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 X 3 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 3 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X X 3 3 X X Ravenscourt DS0000014677.V276273.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ravenscourt DS0000014677.V276273.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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