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Inspection on 03/05/05 for Ravenscroft

Also see our care home review for Ravenscroft for more information

This inspection was carried out on 3rd May 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The service users said that the staff promoted their privacy and dignity and that their health care needs were met, they also said they received visits from health care professionals, including dental and optical treatment. Activities took place both inside and outside of the home. Many of the service users were able to go out unaccompanied to the local shops and to use the local facilities. Some had scooters, which allowed them to be independent. They had access at all times to their bedrooms where many of them choose to watch TV or enjoy their own company. Regular service user meetings were held, the subject of activities was always discussed said the service users. There was evidence to show that the home had responded to the request of the service users. Service users said that if they had any issues or complaints they were able to speak to the staff or manager and they would do their best to sort things out. All service users spoken to said they were happy with their rooms and they had their own personal possessions around them. All parts of the home were kept clean and tidy.

What has improved since the last inspection?

Since the last inspection redecoration of the communal areas and some bedrooms had taken place as well as replacement carpets, furniture and fittings. Service users were able to manage their own finances others choose to use the safety deposit facilities at the home. For those individuals account sheets were kept detailing income and expenditure. The service users spoken to said they were able to access their money at any time. The inspector checked two service users records. All the required information was recorded.

What the care home could do better:

The vacant staff post should be filled in order to promote a consistent staff group. Gaps in the staffs employment history must be explored. Further decoration is required to bring all the rooms up to standard. Bins used to house waste food must be fitted with lids to stop the spread of harmful bacteria.

CARE HOMES FOR OLDER PEOPLE Ravenscroft Smelterwood Drive Stradbroke Sheffield S13 8RJ Lead Inspector Janice Griffin Unannounced 03 May 2005 9:00 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 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 J55 35763 Ravenscroft V218784 03.05.05 UI Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Ravenscroft Address Smelterwood Drive Stradbroke Sheffield S13 8RJ 0114 265 3946 0114 203 7812 None Sheffield City Council Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs J Young PC Care Home only 35 Category(ies) of OP Old Age (35) registration, with number of places Ravenscroft J55 35763 Ravenscroft V218784 03.05.05 UI Stage 4.doc Version 1.30 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. All areas of the care home used by Service Users must be in good repair internally and externally, furnished, decorated, heated and lit to the levels required by the Care Homes Regulations 2001 and stated in the National Minimum Standards for Older People by 01/10/03. 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 3 by 01/04/03. 3. 4. Date of last inspection 25 January 2005 Brief Description of the Service: Ravenscroft is a purpose built home In the Stradbroke 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 J55 35763 Ravenscroft V218784 03.05.05 UI Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over five hours from 9:00am to 14:15pm. Opportunity was taken to make a partial inspection of the home and examine a sample of records. The inspector spoke to ten service users, four relatives and three members of staff. Comments like ‘we couldn’t ask for better’ and ‘we’re well looked after’ were said. All the relatives said that they were “very satisfied” with the care delivered by staff, one relative said the service provided was” better than excellent”. Service users said that staff were “friendly”,“helpful” and ”kind”. What the service does well: What has improved since the last inspection? Since the last inspection redecoration of the communal areas and some bedrooms had taken place as well as replacement carpets, furniture and fittings. Service users were able to manage their own finances others choose to use the safety deposit facilities at the home. For those individuals account sheets were kept detailing income and expenditure. The service users spoken to said they were able to access their money at any time. The inspector checked two service users records. All the required information was recorded. Ravenscroft J55 35763 Ravenscroft V218784 03.05.05 UI Stage 4.doc Version 1.30 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 J55 35763 Ravenscroft V218784 03.05.05 UI Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Ravenscroft J55 35763 Ravenscroft V218784 03.05.05 UI Stage 4.doc Version 1.30 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 standard(s) These standards were not checked at this inspection they will be checked at a future one. EVIDENCE: N/A Ravenscroft J55 35763 Ravenscroft V218784 03.05.05 UI Stage 4.doc Version 1.30 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 standard(s) 7,8,9 and 10. The service users said that the staff promoted their privacy and dignity and that their health care needs were met, they also said they received visits from health care professionals, including dental and optical treatment. The home used the services of a continence advisor and service users were provided with appropriate supplies. Service user, where appropriate, can take responsibility for their own medication and are protected by the homes policies and procedures for dealing with medication. EVIDENCE: 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 service users identified that a range of health professionals visited the home to assist in maintaining health care needs. Service users who were able could retain control of their own medication, a lockable facility was provided to store such items. This allows service users to have control over their own medication. Records were kept of medication received, and disposed of. This ensures the safe storage and administration of medicines. A pharmacist had checked the home’s medication systems at regular intervals. Ravenscroft J55 35763 Ravenscroft V218784 03.05.05 UI Stage 4.doc Version 1.30 Page 10 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 standard(s) 13 and 14. Service users they were happy with their lifestyle within the home. Activities that matched preferences and capabilities were on offer. There were no restrictions on visiting times and service users were able to receive visitors in private. EVIDENCE: The home is situated within pleasant grounds and several service users said they would enjoy walking around the mature gardens. Throughout the day friends and family were seen visiting freely and being offered hospitality, which creates a home that people want to visit. Bedrooms seen were personalised and observation of the interaction between service users and staff confirmed that personal autonomy and choice were well considered. This supported service users to exercise control and choice over their daily routines. Ravenscroft J55 35763 Ravenscroft V218784 03.05.05 UI Stage 4.doc Version 1.30 Page 11 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 standard(s) 18. The homes arrangements for protecting service users and responding to their concerns were satisfactory. Complaints procedures and an ethos were in place to enable service users and relatives to feel confident that any concerns they voiced would be listened to. EVIDENCE: Relatives and service users said that if they had any concerns that they would feel comfortable in talking to the staff or the manager. Discussions with service users confirmed they had nothing to complain about, they were ‘happy’ and ‘well looked after’. This promoted the wellbeing of service users. Ravenscroft J55 35763 Ravenscroft V218784 03.05.05 UI Stage 4.doc Version 1.30 Page 12 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 standard(s) 19 and 26. The location and layout of the home is suitable for its stated purpose. Service users bedrooms met individual’s needs in a comfortable and homely way. The home was comfortable and had a homely atmosphere. More care needs to be taken to ensure that al areas at the home are hygienic. EVIDENCE: Since the last inspection redecoration of the communal areas and some bedrooms had taken place as well as replacement carpets, furniture and fittings making the home look attractive and homely. Some areas around the home still had damaged decoration, which made those areas look shabby. The service users said they were satisfied with their bedrooms, which they were able to personalise this they said made their rooms comfortable and homely. A bin used to house waste food had no lid, this was not a satisfactory standard of hygiene. Ravenscroft J55 35763 Ravenscroft V218784 03.05.05 UI Stage 4.doc Version 1.30 Page 13 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28 and 29. The home had 3 care staff and 1 domestic assistant vacancies, the posts were covered by agency staff. The staff said that the service users were often cared for by agency staff, creating confusion for some service users. The recruitment information obtained for staff was not sufficient to adequately protect the welfare of service users. EVIDENCE: The manager stated that although there were care staff and domestic vacancies agreed care staffing levels were being maintained, as agency staff would be used to cover some shifts. The staff said the vacant domestic post did not allow them to maintain good standards of hygiene at all times. Service users spoken to said that staff were kind, and helpful. Three staff files checked confirmed that, thorough recruitment procedures were not carried out as gaps were noted in one persons employment history, this did not adequately protect the welfare of service users. Staff training records identified an increase in training opportunities for the staff and all staff undertook an induction programme, this demonstrates the providers commitment to investing in the staff. Ravenscroft J55 35763 Ravenscroft V218784 03.05.05 UI Stage 4.doc Version 1.30 Page 14 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,35 and 38. There was a positive style of management in the home, which benefits the wellbeing of the service users. The service users and relatives spoken to said the manager was committed and very professional. EVIDENCE: Arrangements for all staff to undertake fire training and the regular servicing of the homes equipment and appliances were satisfactory which assisted the protection of service users and staff from a risk of harm. Records confirmed that weekly fire checks, alarm systems, extinguishers and emergency lighting had been completed as necessary. All staff had received fire practices and/or drills as required by the homes policy and procedures. Risk assessments were seen on individual service user files, these had been reviewed and updated as necessary, thereby promoting the safety of service users. Ravenscroft J55 35763 Ravenscroft V218784 03.05.05 UI Stage 4.doc Version 1.30 Page 15 Nurse call systems, the lift, gas and boilers had all been services as required. At the time of inspection no fire exits were blocked and window restraints were in situ at first floor windows checked to prevent falls. Hazardous products and records were safely stored in the home. This promoted the safety and welfare of the service users. Ravenscroft J55 35763 Ravenscroft V218784 03.05.05 UI Stage 4.doc Version 1.30 Page 16 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 x COMPLAINTS AND PROTECTION 2 x x x x x x 2 STAFFING Standard No Score 27 2 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 3 x x x 3 x x 3 Ravenscroft J55 35763 Ravenscroft V218784 03.05.05 UI Stage 4.doc Version 1.30 Page 17 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. 1. Standard 19 Regulation 23 Requirement The rooms with damaged decoration must be redecorated.This requirement has been oustanding since 2004. The vacant staffing posts must be filled. All bins used to house waste must be fitted with a lid. Gaps in staffs employment history must be explored. Timescale for action 1/9/05 2. 3. 4. 27 26 29 18 16 18 1/7/05 Immediate 1/7/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Ravenscroft J55 35763 Ravenscroft V218784 03.05.05 UI Stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection 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 J55 35763 Ravenscroft V218784 03.05.05 UI Stage 4.doc Version 1.30 Page 19 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!