Inspection on 14/02/07 for Ravenscroft

This inspection was carried out on 14th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Ravenscroft 27/09/05

Ravenscroft 03/05/05

Ravenscroft 25/01/05

Ravenscroft 26/07/04

Ravenscroft 17/03/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Ravenscroft Smelterwood Drive Stradbroke Sheffield S13 8RJ Lead Inspector Janice Griffin Key Unannounced Inspection 14th February 2007 9:55 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 Ravenscroft DS0000035763.V312587.R01.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. Ravenscroft DS0000035763.V312587.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ravenscroft Address Smelterwood Drive Stradbroke Sheffield S13 8RJ 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) 0114 265 3946 0114 203 7812 none None Sheffield City Council Mrs Jacqueline Lorraine Young Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Ravenscroft DS0000035763.V312587.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The 35 OP beds can be used as SI/E Sensory Impairment for people over 65 years. Minimum staffing levels providing direct care to service users must be maintained as described in the supplement to the Handbook of Guidance on Registration, Inspection and Management of Residential Care Homes in Yorkshire and Humberside dated 13.9.91. Where additional services are provided, eg day care, outreach, escort duty, staffing for this must be over and above that required by Condition 2 by 01/04/03. 27th September 2005 3. Date of last inspection Brief Description of the Service: Ravenscroft is a purpose built home in the Stradbrook area of Sheffield The home provides long term and short term care service for up to 35 older people over the age of 65, specialising in the care of the deaf and hard of hearing. It is a two-story building accessible by stairs or lift. The home also has a day care provision four days per week. The home has an enclosed patio area. Car parking is provided. Copies of the last Commission For Social care inspection report were kept in the entrance for service users and their families to read. The weekly fees are £371 per week. This information was provided on the 14th February 2007. The home charges extra for chiropody, toiletries, clothing, and hairdressing. Ravenscroft DS0000035763.V312587.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out from 9.55 am to 4.00 p.m. Twelve service users, five relatives and six staff, including two managers, were spoken to as part of the inspection process. A number of records were examined and several areas of the building were inspected. The inspector was pleased to note that throughout the inspection staff interacted positively and sensitively with each service user who were obviously comfortable and at ease in the company of staff. The inspector would like to thank service users, the relatives, the managers and staff for their commitment to the inspection process. What the service does well: What has improved since the last inspection? Ravenscroft DS0000035763.V312587.R01.S.doc Version 5.2 Page 6 The statement of purpose has been updated. Several areas have been redecorated; all bins were fitted with lids and the string light cords replaced. Hazardous substances and medication for external use were securely stored. 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. Ravenscroft DS0000035763.V312587.R01.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 Ravenscroft DS0000035763.V312587.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 3. Quality in this outcome area is: good. This judgement has been made using available written evidence, discussion with twelve service users, five relatives, four staff, the managers and a visit to the home. No service users have moved into the home without having his or her needs assessed, this ensures that care needs can be met. Service users were able to have informal introductory visits to the home at the time of their admission. Relatives confirmed that this helped service users to get to know everyone at the home, which made them feel less anxious. Intermediate care is not provided at this home. Ravenscroft DS0000035763.V312587.R01.S.doc Version 5.2 Page 9 EVIDENCE: Detailed full needs assessments had been completed by the referring social worker for all service users admitted to the home. Families had been involved in the assessment process as appropriate. Service users and the relatives spoken to said at the time of the service users admission they were able to have informal introductory visits to the home and they had been provided with a contract containing the relevant information. Records checked and discussion with twelve service users and five relatives confirmed that service users families had been involved in decisions regarding the arrangements. An up to date contract/statement of terms and conditions had been provided to service users and signed copies were retained on individual files. These clearly detailed the fees, including any extra charges, and the services and facilities provided by the home. Ravenscroft DS0000035763.V312587.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Quality in this outcome area is: good. This judgement has been made using available written evidence, discussion with twelve service users, five relatives, four staff and a visit to the home. Service users were encouraged and supported by staff to make decisions. This protects the rights and well being of service users. Information in care plans was good; it gave the staff full knowledge of the service users physical, social, health care, religious and cultural needs. Risk assessments had been reviewed on a regular basis. This protects the service users from harm. There was evidence in the care plans to show that the service users families are involved with the care planning production and the review. This allows the families to have a say in how their relatives care needs will be met. One care plan had not been reviewed monthly. The medication recording systems were up to date; but there were gaps in two recording sheets. This is unsafe practice. Ravenscroft DS0000035763.V312587.R01.S.doc Version 5.2 Page 11 EVIDENCE: The inspector observed staff interacting in a friendly and positive way towards service users. Four relatives spoken with said that staff were always welcoming whenever they visited the home. Bathroom, toilet and bedroom doors were noted to be closed if people were receiving personal care and staff knocked on doors before entering service users’ bedrooms or the bathrooms. Three service users plans of care were checked. Each set out individual service users needs and the action required and taken by staff to ensure those needs were met. Discussion with four staff identified that a range of health professionals visited the home to assist in maintaining health care needs. Service users weight was being checked on a regular basis. A range of aids to assist service users with mobility problems was provided; these included lifting hoists, assisted baths, walking frames and wheelchairs. The risk assessments in care plans had been reviewed on regular basis. Care plan detailed the gender of staff that the service users wished to support them with their personal care; they also contained details of the service users religious and cultural needs. Service users and their relatives have been involved with production of the care plans and the reviews. Medication was securely stored and there were systems in place for receiving the medication into the home. The containers were all clearly labelled, with prescription information fully legible. All items were for named individuals. There were medication administration (MAR) sheets for each service user; these recorded the type of medication, the dosage and how it was to be administered. Two medication administration sheets had not been signed on two occasions to show whether medication had been given or not. There were reasonable stock levels of medication kept in the home. Controlled drugs were safely stored and there were two signatories for the administration of controlled drugs. Ravenscroft DS0000035763.V312587.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in this outcome area is: good. This judgement has been made using available written evidence, discussion with twelve service users, five relatives, four staff and a visit to the home. Service users had access to a range of leisure activities based on their individual choices and preferences. Service users confirmed that the routines of daily living were flexible and suited their individual preferences. Service users were supported with maintaining and developing contact with their family and friends, and relatives said that they were always welcome at the home. Which creates a home that people want to visit. A good choice of food was offered to service users at lunchtime. Six service users were being offered special diets on a regular basis. This promotes the rights of service users. Ravenscroft DS0000035763.V312587.R01.S.doc Version 5.2 Page 13 EVIDENCE: The aims and objectives of this home reinforced the importance of treating service users with respect. Service users and relatives confirmed that staff were extremely supportive and always encouraged the service users to become integrated into the local community, when they felt able to do this and with the appropriate staff support provided. Staff confirmed that they were encouraged to support service users with discovering how to enjoy social situations and activities. All the service users spoken with said that they could have visitors whenever they wished and four visitors spoken with said they could come to the home at any time, although they were asked to avoid mealtimes if possible. The relatives also said that the home kept them informed of any problems. There are kitchenettes on each floor at the home visitors can also use the areas to make themselves a drink. There are a number of lounges and small quiet sitting areas if service users want to see their visitors outside of their rooms. Service users’ files contained information about any special dietary needs and service users had been weighed on a regular basis if this was felt to be necessary. The service users, who were able to say, said that the food was good; one commenting that she ‘had put weight on since I got here as it’s so good’. The cook was familiar with the dietary needs of service users. The inspector observed lunch offered to service users the food provided was of good quality, well presented and a good choice of food was offered. Six service users were receiving special diets. Special cutlery and crockery was provided for those service users who had difficulty using knives and forks. Ravenscroft DS0000035763.V312587.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available written evidence, discussion with twelve service users, five relatives, four staff and a visit to the home. The homes complaints procedure was clear, accessible and contained the necessary information. This protects the rights of service users. There was staff training on recognising and reporting abuse and checks were made on the staff prior to them starting work to reduce the risk of harm to vulnerable service users. EVIDENCE: The complaints procedure was available for service users, visitor, relatives and staff. The manager confirmed that this would be available in alternative formats and languages should this be requested. Service users and relatives spoken to said that they knew that they could complain if they were not happy about anything and that they felt able to discuss any issues or concerns that they may have with the manager and staff. They also said that staff were always available and that they were encouraged to talk about anything that troubled them or caused them anxiety. Since the last inspection no complaints have been made about this home. The staff had received training on recognising and dealing with abuse. Staff had been made aware of the action to take in dealing with third party information. Ravenscroft DS0000035763.V312587.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made after discussion with twelve service users, four relatives and using available evidence including a visit to the home. The home was clean, tidy and well maintained ensuring that the service users live in pleasant and comfortable surroundings with easy access to well maintained garden areas. One toilet had damaged decoration and the radiator guard in one kitchenette was dirty. This is not hygienic. EVIDENCE: All the service users interviewed said that the rooms were very clean and one service user said that her room ‘was always kept spotless’. At least four bedrooms were checked, all were very homely, highly personalised and contained a range of furniture, including chairs, bedside tables and suitable storage. Most had photos and ornaments. Ravenscroft DS0000035763.V312587.R01.S.doc Version 5.2 Page 16 The lounge areas were spacious and furniture was arranged in small groups. There was a quiet lounge for service users who preferred not to sit in the area with the TV on. There were other areas around the home where service users could sit or take visitors if they did not wish to use their rooms. The radiator guard in one kitchenette was dirty. Each floor had a number of toilets and bathrooms and assisted baths were provided for those service users with mobility problems. Toilets were easily accessible as they were close to lounge and dining areas. All the toilets had been adapted for service users with physical disabilities and a good supply of equipment was also available for those service users. One of the toilets had damaged decoration. The appropriate seating had been provided in the garden for those service users wishing to sit outdoors whenever the weather permitted. The home had a proactive infection control policy and they work closely with external specialists, e.g. the Health Authority, Environmental Health and their own staff to ensure infections are minimised. Clinical waste is properly managed and stored. Staff confirmed that they were provided with protective clothing if they needed it and that all the equipment was in good working order and that it had been serviced as required. The well-maintained gardens were easily accessible for people in wheelchairs and other service users and there was garden furniture for them to use. Ravenscroft DS0000035763.V312587.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is: good. This judgement has been made after discussion with twelve service users, five relatives, four staff and using available evidence including a visit to the home. The staff team was experienced with a good knowledge of the service users’ needs, enabling them to support the service users in maintaining their independence. Appropriate checks had not been made on all the staff; this does not ensure that vulnerable service users are protected. The home had a training and development plan and all staff had completed a range of training relevant to their role. This allows the staff to ensure they meet the individual assessed needs of service users. 64.7 of the staff is trained to NVQ level 2. This shows the providers commitment to staff development. EVIDENCE: All the service users who were able to clearly express themselves said that they felt that they were well looked after by the staff and that there were ‘usually’ enough people on duty. They said that the staff worked very hard and described them as “very caring, kind and understanding”. Ravenscroft DS0000035763.V312587.R01.S.doc Version 5.2 Page 18 Staff were approachable and sensitive to the needs of service users and were able to communicate effectively with each person. Three staff files were checked; the files demonstrated that the recruitment processes had not been followed as required by the Care Homes Regulations. Criminal record checks had been done for all three staff. Two references had been obtained. Gaps were noted in two staff’s employment history. Staff spoken to had an understanding of the home’s fire procedures; they had received training on moving and handling, fire, food safety and infection control. Staff files checked and discussions with four staff and the manager confirmed that all staff had completed detailed induction training. 64.7 of the staff team were qualified to NVQ level 2. Staff were being formally supervised at the frequency required to fully ensure individual staff development and the monitoring of care practices Ravenscroft DS0000035763.V312587.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38. Quality in these outcome areas is: good. This judgement has been made after discussion with the managers, twelve service users, five relatives and four staff and using available written evidence including a visit to the home. The service users, relatives and five staff spoken to said the managers were approachable and very professional. Service users and relative’s surveys are completed regularly, which ensures that the home is run in the best interest of service users. Records were in the main up to date and well ordered to ensure the best interests of service users. The homes policies and procedures met the required standards. A safe environment was provided in all parts of the home. This protects the health and welfare of the service users. Ravenscroft DS0000035763.V312587.R01.S.doc Version 5.2 Page 20 EVIDENCE: The manager had a job description that clearly defined her roles and responsibilities and staff were aware of her role. Staff said she was committed to ensuring that the home provides a high standards of care, she completes regular internal audits on all aspects of the service provided by the home. She has completed her NVQ level 4 equivalent training. Staff spoken to had an understanding of the home’s fire procedures; they had received training on moving and handling, fire, food safety and infection control. There was a quality assurance system, which sought the views of service users and relatives. The responsible individual visit the home on a regular basis a report is written following the visits. No fire exits were blocked and hazardous substances were securely stored. The staff handle money on behalf of some service users, account sheets were kept, receipts were available for all transactions and a second individual witnessed all transactions. All records were available for inspection up to date and securely stored. Ravenscroft DS0000035763.V312587.R01.S.doc Version 5.2 Page 21 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 3 Ravenscroft DS0000035763.V312587.R01.S.doc Version 5.2 Page 22 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 2. Standard OP7 OP9 Regulation 15 13 Requirement Care plans must be reviewed monthly. Medication administration charts must always be signed to show whether medication has been given or not. The areas with damaged decoration must be redecorated. The dirty radiator guards must be cleaned or replaced. Gaps in staff’s employment history must be explored. Timescale for action 01/04/07 14/02/07 3. 4. 5. OP19 OP19 OP29 23 23 19 01/07/07 01/06/07 01/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ravenscroft DS0000035763.V312587.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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. Extracts may not be used or reproduced without the express permission of CSCI Ravenscroft DS0000035763.V312587.R01.S.doc Version 5.2 Page 24 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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