CARE HOMES FOR OLDER PEOPLE
Ravenscroft Smelterwood Drive Stradbroke Sheffield S13 8RJ Lead Inspector
Janice Griffin Unannounced Inspection 27th September 2005 07:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ravenscroft DS0000035763.V252234.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ravenscroft DS0000035763.V252234.R01.S.doc Version 5.0 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 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.V252234.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 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. The 35 OP beds can be used as SI/E Sensory Impairment for people over 65 years. 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. 3rd May 2005 2. 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. Ravenscroft DS0000035763.V252234.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place from 7:00 am to 13:45 pm. As part of the inspection process twelve-service users, four relatives, the district nurse and five staff, including the manager on duty, were spoken to. 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, relatives, the district nurse, the manager on duty and staff for their commitment to the inspection process. What the service does well: What has improved since the last inspection?
Ravenscroft DS0000035763.V252234.R01.S.doc Version 5.0 Page 6 The homes still as a large number of staff vacancies but regular agency staff are used to cover posts and they are well known to the home and service users. Some areas around the home have been redecorated. Fifty of the care staff has completed their NVQ training at level 2. 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.V252234.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ravenscroft DS0000035763.V252234.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,and 5. A detailed service user guide and statement of purpose have been produced but the statement of purpose was out of date. Service users individual needs had been fully assessed prior to their admission, and they had moved into the home once it had been agreed that the home could meet their needs. Service users were able to have informal introductory visits to the home and at the time of their admission had been provided with a contract containing the relevant information EVIDENCE: The statement of purpose and service user guide contained all of the required information but the manager’s name and qualifications referred to the previous manager who left the home some eighteen months ago. Copies were available and the manager on duty confirmed that they would be available in alternative formats should the service users request this. Both documents were explained and read out to service users on a regular basis. Ravenscroft DS0000035763.V252234.R01.S.doc Version 5.0 Page 9 Detailed full needs assessments had been completed by the referring social worker for service users admitted to the home. Their families had been involved in the assessment process as appropriate. The manager confirmed that service users were only admitted to the home once they were sure that they could meet their needs. This is good management practice. Service users were able to visit the home for informal visits prior to their admission if they wished. Service users confirmed that this helped them to get to know everyone at the home and made them feel less anxious. Records checked confirmed that service users families had been very 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.V252234.R01.S.doc Version 5.0 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): 11. The staff interviewed said they would make every effort to ensure that service users are treated with respect at the time of death. Families are supported and treated sensitively. EVIDENCE: Staff interviewed said that they would always sit with service users at the time of death if family were not available and if necessary extra staff would be made available if required. They also said that every effort would be made to ensure that the service users receive appropriate medical attention and pain relieve. Staff would attend the funeral of service users. This allowed the staff to pay their respect to the service user and family and friends. Ravenscroft DS0000035763.V252234.R01.S.doc Version 5.0 Page 11 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 and 15. Service users were able to maintain and develop their social, emotional, communication and independent living skills. Service users were provided with regular opportunities to engage in appropriate activities, based on their personal preferences. Service users had varied weekly activity programmes and some service users had developed and maintained links with their local community. The home had a new mini bus but the service users said that they could not go in it as often as they would like, as the staff did not have the time to take them out in the bus on a regular basis. The daily routines were flexible and promoted individual choice and independence. The service users said the meals provided were in the main wholesome, appealing and well balanced. EVIDENCE: Service users said that staff encouraged and supported them with their chosen activities in the home and in the local community. All spoken to confirmed that staff encouraged them to be independent. Service users said they liked how they spent their time and if they wanted to do anything different they would discuss this with the manager or at their review meetings. All service users said they could choose what they wanted to do and who they wished to spend time with whilst they were at the home. Ravenscroft DS0000035763.V252234.R01.S.doc Version 5.0 Page 12 They did say that the home had a new mini bus which was stood in the car park for most of the time as the current staffing levels meant that staff did not have much time to take them out on regular trips. Staff observed were respectful and attentive to the needs of each individual with whom they had obviously developed positive relationships. Service users confirmed that they had a key for their own room and that they could entertain their visitors in their room if they wished. They also said they were able to see visitors in private and that visitors were made welcome, encouraging the maintenance of contact with family and friend, which creates a home that people want to visit. The service users said the food was “good and there was always plenty of it”. Three meals were offered each day and snacks and drinks were provided inbetween meals. Ravenscroft DS0000035763.V252234.R01.S.doc Version 5.0 Page 13 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): 18. The homes policies and procedures protected service users from abuse. Staff had a good understanding of the procedure and some had attended training on recognising and dealing with abuse. EVIDENCE: The home had robust procedures for responding to suspicions or evidence of abuse or neglect; this included a whistle blowing policy to ensure the protection of service users. The manager was aware that the CSCI must be informed of any allegations of abuse in accordance with the Public Interest Disclosure Act 1998 and the guidance ‘No Secrets’. Staff had received formal adult protection training. This helps to ensure that service users are protected from abuse. Ravenscroft DS0000035763.V252234.R01.S.doc Version 5.0 Page 14 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): 19,20,21,22,23,24,25 and 26. All areas of the home seen were clean, homely, comfortable and provided safe access for service users. Effective cleaning routines were in place and the home had the appropriate policies to ensure the control of infection, however the string light cords were dirty in some bathrooms and toilets. The home is welcoming but some areas had damaged decoration. Locks were provided to bedroom doors and lockable facilities were provided in each bedroom. Staff confirmed that all equipment was in good working order and that it had been serviced as required. Ravenscroft DS0000035763.V252234.R01.S.doc Version 5.0 Page 15 EVIDENCE: Service users said that the home was always clean; this they said made them feel safe because the home was well looked after by the staff group. The bedroom doors were fitted with suitable door locks and lockable facilities were provided in all the bedrooms. This respects the privacy of service users. Lounges and dining rooms were homely and attractively furnished. Service users could choose to meet with their visitors in these rooms or in the privacy of their own bedroom. Service users could smoke in a designated smoking area. The appropriate seating had been provided in the garden for those service users wishing to sit outdoors whenever the weather permitted. Each floor had a number of toilets and bathrooms provided as required. The string light cords in some bathrooms and toilets were dirty, this is unhygienic. Some waste bins housing soiled waste were not fitted with lids. Ravenscroft DS0000035763.V252234.R01.S.doc Version 5.0 Page 16 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. The number and skill mix of the staff employed at the home meets service users needs. Recruitment procedures did not fully protect service users. The home had a training and development plan and all staff had completed a range of training relevant to their role. EVIDENCE: Staff were aware of the needs of individual service users and they confirmed that the homes communication systems enabled them to support service users. Recruitment procedures did not fully protect service users as gaps were noted in staff’s employment history and the agency providing temporary staff were not informing the homes manager whether the staff members CRB check were clear or not. Staff files and discussions with the staff and the manager confirmed that all staff had completed detailed induction training. Staff were approachable and sensitive to the needs of service users and were able to communicate effectively with each person. Several staff had completed NVQ training in care and this had ensured that 50 of the staff team were qualified to level 2 or 3. Training records confirmed that staff had also completed training on fire safety, moving and handling and medication. Staff spoken to confirmed they receive much more than three days paid training, this demonstrates the provider’s commitment to investing in the staff. Ravenscroft DS0000035763.V252234.R01.S.doc Version 5.0 Page 17 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): 31,32,33,37 and 38. Service users benefited from a home that is well run by the registered manager. Service user surveys had been completed and service users had regular opportunities to discuss and feedback their views of the service provided by the home. A safe environment was not provided in all parts of the home. EVIDENCE: The registered manager has a wealth of experience of caring for the elderly in a residential care setting. She is a trained nurse and has successfully completed NVQ level 4 in management. Discussions confirmed that she is committed to further training for herself and all members of the staff team. Ravenscroft DS0000035763.V252234.R01.S.doc Version 5.0 Page 18 The manager had a job description that clearly defined her roles and responsibilities and staff were aware of her role. She is committed to ensuring that the home maintains and develops their high standards of care, she had completed regular internal audits on all aspects of the service provided by the home. Service users confirmed that they could see the manager when they wished and they said that she was very approachable and supportive. Feedback was being sought on a regular basis from service users, their families and social workers and other professionals involved with each individual. The manager on duty confirmed that their views via questionnaires would be available within the home. The responsible individual was visiting the home at least once a month and a report was written about the conduct of the home following the visit. Records were securely stored as required and those checked were accurate and up to date and in good order. Staff and service users confirmed that they had access to the appropriate records as required. Medication for external use and hazardous substances were noted to be insecurely stored. This does not maintain the service users safety. Ravenscroft DS0000035763.V252234.R01.S.doc Version 5.0 Page 19 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 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 2 3 3 3 3 3 3 1 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 4 X X X 3 1 Ravenscroft DS0000035763.V252234.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4 Requirement The statement of purpose must contain the name and qualifications of the current manager. The rooms with damaged decoration must be redecorated. The string light cords must be cleaned o repaced. All bins used to house waste must be fitted with a lid. Gaps in staffs employment history must be explored. The agency providing care staff at the home must inform the homes manager whether the individual staff members CRB check is clear or not. Medication for external use must be kept in a secure place at all times. Hazardous substances must be kept in a secure place at all times. Timescale for action 01/12/05 2 3 4 5 6 OP19 OP26 OP26 OP29 OP29 23 23 23 19 19 01/05/06 01/12/05 27/09/05 01/11/05 01/11/05 7 8 OP38 OP38 13 13 27/09/05 27/09/05 Ravenscroft DS0000035763.V252234.R01.S.doc Version 5.0 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP12 Good Practice Recommendations The organisation should try to deploy staff to take service users out more in the homes mini bus. Ravenscroft DS0000035763.V252234.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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