Inspection on 28/10/05 for Ravenscroft

This inspection was carried out on 28th October 2005.

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 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 30/10/07

Ravenscroft 15/05/07

Ravenscroft 15/06/06

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Ravenscroft Ravenscroft Hilperton Road Trowbridge Wiltshire BA14 7JQ Lead Inspector Karen Mandle Unannounced Inspection 28th October 2005 9.30am 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 DS0000065178.V255070.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 DS0000065178.V255070.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ravenscroft Address Ravenscroft Hilperton Road Trowbridge Wiltshire BA14 7JQ 01225 752087 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) Ashbourne (Eton) Limited Mrs Susan Mary Davina Robins Care Home 46 Category(ies) of Old age, not falling within any other category registration, with number (45), Physical disability (1), Terminally ill (3) of places Ravenscroft DS0000065178.V255070.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Room 27 is not registered for nursing care as overall ceiling height is too low. No more than 40 persons in receipt of nursing care at any one time. One named female service user under the age of 65 in the category (PD) Physical Disability 17th May 2005 Date of last inspection Brief Description of the Service: Ravenscroft Nursing Home is registered to provide nursing care for 40 older people and personal care for 6 older people. The home is an older building, which has been extended over the years offering a range of single rooms and shared rooms. Two communal rooms are situated on the ground floor linked by a conservatory, which is the dining room. The gardens are to the rear of the building, which are well maintained. Ravenscroft is situated on the outskirts of Trowbridge. The home is owned by, Ashbourne Healthcare. The registered manager is Mrs Sue Robins. Ravenscroft DS0000065178.V255070.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place 28th October 2005. Prior to this inspection, the CSCI have made two follow up visits to the home, one in July and another in August since the announced inspection took place in May 2005. This inspection commenced at 9.30am and was completed at 3.45pm. The registered manager was available to assist the inspector. The inspection included a tour of the building, observation of leadership within the home, review of care records, medication records and staff training records. What the service does well: What has improved since the last inspection? Since May the home has worked hard to improve environmental standards, and care standards, which had been identified through the inspection process and a complaint investigation. Generally the staff are now providing a more individualised approach to care which the care plans also reflect. The care plans have been recently thoroughly reviewed and are now more comprehensive. The activities programme has improved and service users choice more respected. A review had taken place of all night medication, which has since reduced. The standard of hygiene has improved throughout the home and was generally cleaner. The quality of food has also improved and service users were more positive about the food provided. Ravenscroft DS0000065178.V255070.R01.S.doc Version 5.0 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. Ravenscroft DS0000065178.V255070.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 DS0000065178.V255070.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): 3 A clear admission procedure is in place with a pre admission assessment taking place for all prospective service users. EVIDENCE: All service users are fully assessed by the registered manager prior to admission to Ravenscroft to ensure that through the assessment process the home is able to meet the nursing and social needs of the service user. The most recent assessment completed was reviewed which provided information relating to current health care needs and social needs. A record of the assessment is kept on the service users file. Ravenscroft DS0000065178.V255070.R01.S.doc Version 5.0 Page 9 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, and 10 The care records apart from the wound care documentation have improved to provide a more individual approach to care apart from the wound care documentation. Health care needs are more closely monitored and personal care needs are being met. The privacy and dignity of service users is supported by the care team. EVIDENCE: Each service user is provided with a care plan. The format of the care plan is detailed which provides opportunity for all aspects of care to be assessed and fully addressed. The care staff had recently worked hard to improve the information recorded and to personalise the care plans to ensure a more individual approach to care is provided for service users through this process. However wound care information was not fully up to date in the care plan records and evidence was not in place to ensure that service user are fully supported with appropriate wound care. The care plans were being reviewed monthly and care charts/fluid charts were up to date. Ravenscroft DS0000065178.V255070.R01.S.doc Version 5.0 Page 10 The care records did indicate that health care needs were assessed. The Head of Care who is a qualified nurse was observed providing leadership and supervision to care staff during the inspection ensuring service users care needs were being met. All service users are registered with a GP with evidence available in the care records of when the GP visited. Two care reviews were taking place during the morning of the inspection providing evidence that other health and social care professionals are involved with the care of the service users. The medications were not fully assessed as the procedure of administration of medications was assessed as safe at the previous inspection. However the use of night time medication for service users was assessed which has decreased and a night care plan is now in place for any service user who is prescribed night sedation ensuring the use of this mediation is reviewed monthly. Handwritten orders on the medication sheets were not signed by two members of staff ensuring accuracy of the medication order. During the tour of the home care staff were observed providing care behind closed doors and knocking on doors before entering. Service users confirmed that their care was always provided in privacy. Ravenscroft DS0000065178.V255070.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 The current activities programme provided meets the needs of the social needs of the service users. The quality and presentation of the food has improved and service users are supported throughout the meal time period. EVIDENCE: A full time activities person has now been employed who provides a range of activities, which are clearly displayed on several notice boards. Service users are provided with a choice to participate with the group activities or if preferred have one to one sessions with the activities person which was observed taking place. A record of activities is maintained in the care records. The inspector was invited to have lunch, which was well cooked and nicely presented. Service users also confirmed that the food had recently improved and meals were generally more enjoyable. A 4-week menu system is in place with special diets being catered for. Nutritional risk assessments are in place for each service user ensuring that nutritional needs are identified and addressed. It has been observed previously that several of the service users’ were eating in the lounge area rather than being supported to use the dining room. However the inspector observed all service users apart from one service Ravenscroft DS0000065178.V255070.R01.S.doc Version 5.0 Page 12 user whose choice it was to stay in the lounge area, having their lunch in the dining room. Service users were fully supported by the staff during the meal. Ravenscroft DS0000065178.V255070.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): A complaints policy and procedure is in place. The staff had recently received training in abuse awareness and employment procedures are safe with the aim of protecting service users from abuse. EVIDENCE: A complaints policy and procedure is in place a copy of which is available in the front entrance hall to home for service users and visitors. The CSCI has recently received a formal complaint about the home which was fully investigated leading to many changes taking place within the home. During the complaint investigation and process the registered manager and senior managers of Ashbourne Healthcare worked with the CSCI to improve practice within the home. A procedure is in place for dealing with any allegations of abuse. All staff had recently received in depth training of what is considered as abuse within a residential care setting and a “Residents Welfare” course. The registered manager is now fully aware of the local vulnerable adults procedure. Employment procedures as far as possible protected the welfare of service users by obtaining CRB disclosures and references prior to employment. Ravenscroft DS0000065178.V255070.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, 24 and 26 The corridors and communal areas in the newer part of the home are not well maintained and do not provide a homely environment for service users to live in. The bedrooms do provide comfortable and personalised accommodation. The standard of cleanliness in the home was satisfactory. EVIDENCE: The environmental standards of the home vary. The older part of the home is well maintained with freshly painted walls and good carpeting. However in the newer part of the building, the corridors and communal areas need to be refurbished and carpeting replaced to provide a homely and comfortable standard of accommodation for service users to live in. This has been raised previously with Ashbourne Healthcare. Many of the bedrooms were visited which were personalised and relatively homely. Unoccupied rooms were clean and tidy and ready for occupation. Call Ravenscroft DS0000065178.V255070.R01.S.doc Version 5.0 Page 15 bells were randomly tested all of which worked and service users were all seen to have a call bell available to them. The general hygiene of the home had improved since the previous inspection and the housekeeping department had been provided with better equipment to do the task with. No unpleasant odours were apparent and many carpets throughout the home had been recently cleaned. Working rotas of domestic staff had been altered to provide a better house keeping service. Infection control measures are in place and the staff was observed washing hands and wearing appropriate disposable gloves and aprons. Clinical waste is also managed appropriately. Ravenscroft DS0000065178.V255070.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, 29 and 30 The current staffing levels meet the needs of the current occupancy and care levels of the service users. Employment practices are satisfactory and aim to protect the service users. The training programme has improved and now provides staff with an opportunity to gain further competencies. EVIDENCE: The home was providing care to 34 service users at the time of the inspection out of a possible 46, which is full registered occupancy. The care staff available to support the nursing and personal care need’s of the service users’ was 2 Registered Nurses and 5 carers plus domestic staff. With the level of care service users required the staffing level was able to meet the care needs of the service users. The registered manager is working to the agreed staffing notice for the occupancy level. However when occupancy levels are high, the current staffing notice will be reviewed to ensure that the staffing level required fully meets and supports all care needs of the service users. This will also apply to the hours worked in the laundry and domestic, which again will be reviewed. Three employment files were reviewed all of which had a POVA 1st available with a CRB and two references. The employment procedures are satisfactory and as far as possible protect the service users. Ravenscroft DS0000065178.V255070.R01.S.doc Version 5.0 Page 17 The training procedure for all staff has been recently improved with a training person on site who is also a qualified nurse and each employer is now provided with a training file. All mandatory training was up to date with other training provided in line with changes taking place in the home. Ravenscroft DS0000065178.V255070.R01.S.doc Version 5.0 Page 18 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): 36 and 38 The staff are not appropriately supervised. Health and safety issues are addressed providing a safe environment for service users to live in. EVIDENCE: The registered manager has not yet fully commenced a one to one documented supervision programme. However several members of staff had attended a training session on how to provide supervision. The registered manager will be putting a supervision programme in place for all staff by the 1st December 2005. Fire records indicated that appropriate checks were being made to all fire equipment. All staff had just received more fire training. All accidents are recorded and audited regularly. Electrical equipment throughout the home had been tested in March 2005 and hoists were regularly serviced. Ravenscroft DS0000065178.V255070.R01.S.doc Version 5.0 Page 19 Ravenscroft DS0000065178.V255070.R01.S.doc Version 5.0 Page 20 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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X 2 X 3 Ravenscroft DS0000065178.V255070.R01.S.doc Version 5.0 Page 21 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 OP7 Regulation 15 Timescale for action The registered person will ensure 07/12/05 that the care plans provide detailed information relating to wound care and ongoing evaluation of treatment given. The corridors and communal 07/12/05 areas including both lounge areas and conservatory will be refurbished and new carpeting provided. Comment. This is outstanding from the previous inspection and is the responsibility of the providers Ashbourne Healthcare. The registered person will commence documented supervision for all staff. Requirement 2 OP19 23(2,d) 3 OP36 18(2) 01/12/05 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 DS0000065178.V255070.R01.S.doc Version 5.0 Page 22 1 OP27 The registered person will continue to closely monitor staffing levels in line with service users care needs. Ravenscroft DS0000065178.V255070.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 DS0000065178.V255070.R01.S.doc Version 5.0 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. 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