Inspection on 30/10/07 for Ravenscroft

This inspection was carried out on 30th October 2007.

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

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

Other inspections for this house

Ravenscroft 15/05/07

Ravenscroft 15/06/06

Ravenscroft 28/10/05

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 Steve Cousins Key Unannounced Inspection 09:00 30 – 31st October 2007 th 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.V349501.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 DS0000065178.V349501.R01.S.doc Version 5.2 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) www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited Mrs Katherine Pearson 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.V349501.R01.S.doc Version 5.2 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 male service user under the age of 65 years can be accommodated. 10th August 2007 Date of last inspection Brief Description of the Service: Ravenscroft Nursing Home is registered to provide nursing care for forty older people and personal care for six older people. The home is an older building, which has been extended over the years, offering a range of single rooms and shared rooms over four floors. Two communal rooms are situated on the ground floor linked by a conservatory, which is also combined as part of the dining room. There are expansive gardens to the rear of the building. Ravenscroft is situated on the outskirts of Trowbridge with good access to the town centre and its amenities. Southern Cross Healthcare owns the home and Mrs Katherine Pearson is the homes registered manager. The fees range from £455 to £700 per week. Ravenscroft DS0000065178.V349501.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 30th and 31st October 2007 in order to inspect all of the key minimum standards relating to care homes for elderly people. We visited the home between 9.00am and 4.00pm on the first day and 9.00am and 2.15pm on the second day, making a total of 12.25 inspection hours. We then met with Mrs Pearson, the registered manager, at the end of the second day in order to discuss the outcome of the visit. The findings from this inspection are based on a tour of the premises, speaking to people who live in the home, their relatives, the manager and staff, and visiting frail residents. A number of records were inspected, including care plans, medication records and staff records. We reviewed the care of four people in detail, male and female. They had varying physical, social and mental health needs. Some were new to the home and others had been at Ravenscroft for some years. The care of other people was reviewed in less detail. Consideration was given to issues of ethnicity and diversity. During September, comment cards were received from thirteen people who live at Ravenscroft and from twelve relatives, carers or advocates. Their views were used to inform the inspection process and some are incorporated into this report. We had carried out a random inspection of the home on 10th August 2007 in response to a complaint and the findings of that inspection have been reviewed and are incorporated in this report. The judgements contained in this report have been made from evidence gathered during the inspection and take into account the views and experiences of people using the service. What the service does well: The service provided by the home appears to have has improved since the manager was appointed in June 2007. Complaints are taken seriously and there is a determination to address any poor practice in the home. People living in the home appear to receive the personal support and health care that they require and they are able to maintain links with family and friends. The level of social activities is good, with opportunities to get out of the home. People were happy with the meals provided. Ravenscroft DS0000065178.V349501.R01.S.doc Version 5.2 Page 6 The home is being well managed; recruitment practices were good, as were quality-auditing systems. The home was clean and well maintained. What has improved since the last inspection? What they could do better: Where possible, staff need to make sure that people in the home (or their advocate) sign care plans in order to show that they agree with them. People told us there are occasions when reduced staff numbers and availability of lifting equipment makes delivery of care more difficult and slower; these issues should be addressed to improve the quality of life of the people living in the home. Some comments received would indicate that increased vigilance is required by care staff when using lifting equipment to ensure people’s safety. Although staff have received training in mandatory subjects, not all had received updates this year. Further improvement to the environment could be achieved by improving the flooring in bathrooms and toilets, and replacing older divan beds and mattresses. Access via the front door of the home needs to be reviewed as the wheelchair ramp is a possible risk to those not in wheelchairs. Ravenscroft DS0000065178.V349501.R01.S.doc Version 5.2 Page 7 The current system for sterilising commode pots needs to be reviewed and the provision of another sterilising washer would enhance current practice. 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. The summary of this inspection report can be made available in other formats on request. Ravenscroft DS0000065178.V349501.R01.S.doc Version 5.2 Page 8 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.V349501.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Standard 6 does not apply to this home. Information is available for people to make a choice about moving into the home and their needs are assessed prior to doing so. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A copy of the previous CSCI inspection report was available on display in the foyer. The home has a statement of purpose and service users guide, which were also available in the foyer. The information contained in the documents was clear and easily read. Some information relating to the contact address of CSCI and comments relating to previous inspections required updating. Ravenscroft DS0000065178.V349501.R01.S.doc Version 5.2 Page 10 Two peoples pre admission assessment documentation was reviewed. The registered manager, who is a registered nurse, had filled out assessment forms and these were included in peoples’ care plans. The information obtained related to the person’s current and long -term needs and was used to produce the care plans. Ravenscroft DS0000065178.V349501.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. The standard and clarity of care plans is good and peoples health care needs appear to be addressed. They are supported to access health care professionals as required. People are protected by the homes procedures relating to medication. People were generally happy with the support they receive and their privacy and dignity appears to be respected. Manual handling practice needed to be reviewed and improved and action has been taken to address this. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A random inspection of the home on the 10th August 2007 found that there were concerns regarding care planning and the ability of the home to meet people’s needs. The findings of this inspection indicate and improvement in both areas. Ravenscroft DS0000065178.V349501.R01.S.doc Version 5.2 Page 12 The care plans we reviewed were of a good standard. Plans appeared to be an accurate reflection of the person’s needs and were based on appropriate assessment. They were reviewed monthly or more often if required and contained relevant individualised information. Newly admitted people had been assessed promptly and care plans put in place, which was an improvement on findings of the previous inspection. Not all care plans had been signed by the person it related to (or their advocate if necessary) to confirm agreement with the plan and improvement is required in this area. We visited the people whose care plans were reviewed and found that interventions were in place to meet their assessed needs, such as pressure relief equipment, continence aids and manual handling equipment. Fluid and food intake and positional changes were being recorded where required. People who were sitting in the lounge were sat on pressure relief cushions and drinks were available. Those who were assessed as nutritionally at risk had been regularly weighed in order to ascertain if there had been any weight loss. Plans were in place to direct care in relation to nutritional needs. All people living in the home are registered with a local General Practitioner (GP). Records indicated that staff are prompt in referring people to their GP when required and to other health care professionals, such as the tissue viability nurse. One person living in the home told us, “They are very nice to me here, they look after me, I get plenty to eat and drink”. Anther person said, “I’m happy, looked after well. They come quickly when I ring my bell”. Other people spoken to confirm that they received the support they needed, although one person told the inspector of a delay in receiving attention on the second day of the inspection, which the manager was made aware of and would investigate. The majority of comment cards received from people living in the home, and their relatives, were positive about the care and support given. One person had indicated dissatisfaction and the manager was aware of this and reported that a review of the person’s care was being undertaken by the funding authority to ensure that their present placement was appropriate. One relative stated on a comment card, ‘The care that I see whenever I visit Ravenscroft shows no discrimination whatsoever. Each person is treated with respect’ and another relative put ‘good overall care provided’ and another ‘My wife’s needs always seem to be met’. One relative met during the inspection told us that staff members are “very good and kind. Mum is always clean and they keep in touch with me”. Comments received from some people on comment cards indicated that staff needed to be more careful when carrying out manual handling procedures. Ravenscroft DS0000065178.V349501.R01.S.doc Version 5.2 Page 13 One stated that ‘the handling of the hoist could be better, have sustained bumps in various places’ and ‘some staff may be a bit negligent moving **** about, her legs are usually bruised’. The manager was aware of this problem and confirmed that action had been taken with regard to reviewing manual handling practice in the home. There was evidence to suggest that people’s privacy and dignity was respected. It was observed that personal care was being given behind closed doors and staff knocked on doors before entering a room. People appeared to be having their personal hygiene needs met and those who were unable to dress themselves were dressed in clothing that maintained their dignity. The arrangements for the handling of medicines were reviewed. Medicines are stored securely and indirect observation indicated that staff administered medicines safely. A written policy was available along with a list of homely remedies agreed by GP’s. Controlled drugs and refrigerated items are suitably stored and recorded. There was one person living in the home that self medicated. A risk assessment had been carried out regarding fitness to self medicate and records indicated that this was reviewed monthly. The medication administration record did not indicate whether the person had taken their medication and it is recommended that this be recorded to ensure a clear audit trail of all medicines kept in the home. Some medication administration records contained hand written amendments and in one case the record had not been signed by the person making the amendment or signed and witnessed by another member of staff, which is considered best practice. Ravenscroft DS0000065178.V349501.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 14 and 15 Quality in this outcome area is good. Social activities are available that people appear to enjoy and there are opportunities for people to get out of the home. Contact with friends and relatives is maintained and as far as possible, people are supported to live their lives as they wish, although this is sometimes hampered by delays due to availability of hoists. The standard of meals appears good and people were complimentary about the food. This judgement has been made using available evidence including a visit to this service. EVIDENCE: An activity person is employed and there is a range of in-house and external social activity available that includes group and one to one activity. Positive comments were received from people living in the home and their relatives about the activities and the activity person. Comments received included: ‘Entertainment is good – especially the musical session’ – ‘Organised trips out are very popular’ and ‘Great effort goes into stimulation for those able to participate’. Ravenscroft DS0000065178.V349501.R01.S.doc Version 5.2 Page 15 Relatives were around the home at different times during the day and there were no restrictions on visiting. One relative confirmed that they were able to visit the home when they wanted to and a record of family liaison is kept in care plans. People were able to receive visitors in their rooms or in the communal sitting area. The relatives who returned comment cards all felt that the person in the home was supported to keep in touch with them where this was applicable. Comments received were: ‘Very good at notifying me of any concerns regarding my mother. Flexible about visiting times’ and ‘Staff are always very friendly and helpful. They are always willing to discuss issues with you, and they always act upon requests made’. Many of the people living at Ravenscroft were very dependant on staff to meet their needs however some of their comments during the inspection indicated that they had some control over how they lived their lives. Three people were able to confirm that they were assisted to go to bed and get up at times convenient to them, although two did report that they sometimes had to wait for a while. One more able person was enjoying having a lie in during the late morning and reported that she was able to “do as I please”. Staff reported that they tried to be flexible and respect people’s choices about getting up and going to bed, but said that this was sometimes difficult due to having to find or wait for manual handling equipment to become available. People are able to bring in personal items and furniture if required and one person said that staff respected their wishes not to join in with the social activities organised. People spoken to were complimentary about the meals available and comments included: ‘they serve very good meals’ and one relative commented ‘I often have lunch and it is always freshly cooked and appetising’. People were observed eating in their own rooms or in the dining room if preferred and staff were observed supporting people to eat and giving them sufficient time. Discussion with the catering manager indicated that a choice of two main meals is available at lunchtime and that people were asked the day before which meal they would like. Records seen confirmed this Tea and cakes are served during the afternoon and a light meal or sandwiches are served at around 5.50pm. The catering manager reported that the kitchen was left open after the evening meals to allow staff access should someone require food during the period prior to breakfast. Ravenscroft DS0000065178.V349501.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Complaints are taken seriously and investigated. As far as possible people living in the home are protected from abuse. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A complaints policy and procedure is available and on view and also contained in the homes service users guide. The complaints record was reviewed, there were five complaints logged since 30 July 2007. Records indicated that these had been dealt with within the time scale stated in the complaint procedure and written replies had been sent to the complainants where necessary. We had carried out a random inspection of the home on 10th August 2007 in response to a complaint and the findings of this inspection would indicate that the home has taken action in response to our findings. Conversation with the manager indicated that she had a good awareness of complaint handling and a determination to resolve problems and tackle bad practice. The manager had referred two complaints to the local Vulnerable Adults Unit in order for the issues to be properly considered. One issue was referred back to the manager and Southern Cross Healthcare to investigate, which they did to the satisfaction of the vulnerable adults forum. The other issue was under review at the time of this report. Ravenscroft DS0000065178.V349501.R01.S.doc Version 5.2 Page 17 We spoke to four care staff members, all of who were able to state the correct procedure for reporting suspected abuse and who confirmed that they had either received or were due to receive abuse awareness training. Records of staff meetings indicated that the subject had been discussed as an agenda item. A review of staff employment documentation indicated that procedures for the protection of people living in the home had been carried out, including Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks. Ravenscroft DS0000065178.V349501.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24, 26. The home is clean and well maintained. Changing some communal and bedroom furniture would enhance the environment further for the benefit of those living in the home. Arrangements and facilities for the sterilisation of commodes need to improve and the access via the front door made safer. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the building was made and all bedrooms and communal living areas were seen. Two lifts enable access to areas throughout the home. Records indicated that the building was being adequately maintained and two maintenance staff are employed. The decoration was generally in good order throughout. Ravenscroft DS0000065178.V349501.R01.S.doc Version 5.2 Page 19 There is a ramp to enable wheelchair access to the front of the home that is not entirely satisfactory as there is a risk to those accessing the door that are not in wheelchairs of banging into, or slipping off the side of the ramp. One relative stated ’the ramp arrangement is a potential hazard’. Adapting the ramp so that it covers the entire door entrance may remove the risk. There are two separate communal lounges on the ground floor where comfortable seating is provided. There is a dining area in between the two lounges. Some of the furniture in the lounges was functional and comfortable but old and worn. Toilet and bathing facilities are situated on all floors of the home and close to communal living areas. Sluice areas were clean. It was noted that there was only one automatic sterilising washer located on the first floor, which is inadequate for the size and layout of the home. Staff reported that this machine was not working efficiently and also described the current procedures for sterilising commode pots, which is time consuming and not seen as best practice. A requirement of the inspection held on 15th May 2007 was that an audit of the flooring in communal toilets and bathrooms is carried out and flooring replaced where necessary. The manager reported that the audit had been carried out and replacement identified, but the work had yet to be completed. Another requirement was that the kitchenette on the ground floor be refurbished and this has been achieved. The majority of the bedrooms offer single occupancy and some en suite facilities. Bedrooms are situated over four floors of the home and vary in size and accessibility. Some beds are of the divan type, which are immobile and non-height adjustable. The use of these should be reviewed to ensure that they suitable for the needs of the resident, and do not pose a health and safety risk to staff if they have to deliver care to a person in bed. The manager reported that she was aware of this issue and had ordered more profiling beds for the home. The mattresses in rooms 9, 21, 22, 46 and 49 were hard and plastic coated. These should be replaced, or an overlay mattress supplied, for the protection of the person using it. Findings of the random inspection carried out in August were that some of the rooms on the top floor were very hot during the summer months. Only one room was occupied during this visit and the person in the room stated that the temperature was comfortable. Thermometers have been made available to monitor the temperature in theses rooms. Ravenscroft DS0000065178.V349501.R01.S.doc Version 5.2 Page 20 The home was generally clean and free from unpleasant odour. The housekeeper stated that they were normally two cleaners on duty between 8.00 am and 23.00pm throughout the week and that a further person was currently being recruited. All of the comment cards received from people living at Ravenscroft were positive about the cleanliness of the home. The laundry room is situated on the ground floor well away from any food preparation or food storage areas. The walls and floors are readily cleanable. Appropriate infection control procedures were in place in relation to the handling of soiled linen. The kitchen was clean and food safety checks are carried out and recorded. An inspection by an environmental health officer had been carried out on the 27th September to review food hygiene procedures and the home had been rated 4 stars, out of a maximum of 5. Ravenscroft DS0000065178.V349501.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. Staff numbers and skill mix appear to meet the needs of the people living at Ravenscroft, but there are times when reduced numbers of staff compromise this. The level of care assistants with or undertaking an NVQ is satisfactory, although some improvement is required to ensure mandatory training updates are delivered. Staff recruitment practice protect the people living in the home This judgement has been made using available evidence including a visit to this service. EVIDENCE: The number and skill mix of staff available in the home was reviewed. There were 30 people living in the home at the time of this inspection. The manager stated that care-staffing levels normally comprised of two nurses and four care assistants between 8.00am and 2.00pm. At 2.00pm the level of care assistants dropped to three. The number rose again to four between 5.00pm and 8.00pm. There were two nurses and two care assistants on night duty. The number of care staff over the two days of this unannounced inspection appeared enough to meet peoples’ needs and call bells were answered without any delay. Ravenscroft DS0000065178.V349501.R01.S.doc Version 5.2 Page 22 The manager and staff stated that there were times when four care assistants had not been available and indicated that when this occurs, it is more difficult meeting the needs of people in the home with just three. One person living in the home told us “The staff are good, but sometimes there are not enough, meaning you have to wait” Three relatives wrote on comment cards ‘Not enough staff to meet all requirements’; ‘employ more staff to answer call bells more promptly’ and ‘They sometimes seem to be short staffed, meaning that responses are not as quick as they might be’. Another felt that the situation was improving stating ‘There are fewer times when it is difficult to locate a member of staff; sometimes relatives had to wait 10 –15 minutes after ringing for help but this is improving’. The findings of this inspection would indicate that the current level of domestic, maintenance and catering staff is appropriate. The recruitment records of three staff members were reviewed. Criminal Record Bureau (CRB) checks had been obtained or applied for and references and Protection of Vulnerable Adults (POVA) checks had been obtained prior to the person starting employment in all cases. Other documentation required was in place. We reviewed the arrangements relating to staff induction training. Induction training relating to Skills for Care standards had commenced. Records indicated that newly appointed staff had received induction training along with mandatory training. One new staff member confirmed the training she had received and stated that the induction training was “O.K” and indicated that they had received good support from other staff members. With regard to mandatory training, the manager stated that Southern Cross employs a regional training manager and that the home also had an in-house training person. Records indicated that there was a need for some staff to receive training updates, particularly in regard to health and safety, infection control and COSHH. The manager was aware of this and had completed an audit of training needs along with a plan of action regarding any deficits. Staff spoken to confirmed the training they had received. The manager stated that four of the fourteen care staff had achieved an NVQ level 2 and two had achieved level3. She stated that two more were about to commence NVQ 2 and a further two would start following their induction training. The housekeeper stated that she and another domestic had obtained an NVQ. Ravenscroft DS0000065178.V349501.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. The home is well managed. Quality assurance systems are in place and the procedures for handling people’s money are satisfactory. As far as possible, the management of health and safety in the home protects the people living there, and it’s staff. This judgement has been made using available evidence including a visit to this service. Ravenscroft DS0000065178.V349501.R01.S.doc Version 5.2 Page 24 EVIDENCE: Mrs Pearson became the homes manager in June 2007 and has now been registered with CSCI following our ‘fit person’ process. Mrs Pearson is registered nurse who has extensive experience in caring for older people in nursing environment and nursing home setting. She has obtained the Registered Managers Award, Level 4 NVQ in Management and has a Bachelor of Science Degree. Positive comments were received about the manager from people living in the home, their relatives and the staff. These included, ‘The recent change over has improved the atmosphere and care considerably’ and ‘There have been many improvements since the new matron Kate came. It’s easy to see staff morale has improved and there is more contact between staff and residents than previously’. Mrs Pearson is supported in her role by a deputy and is line managed by a senior manager from Southern Cross Healthcare. The quality assurance arrangements were reviewed. ‘Residents’ meetings are held and the manager holds a regular ‘surgery’ for relatives. Staff meetings are held and staff reported that they were able to bring up any concerns they had within the meetings or individually with the manager or her deputy. Surveys are available to send out to people living in the home and their relatives, although the manager was unsure when this had last been done. The manager and a representative of Southern Cross Healthcare carry out comprehensive monthly environmental and practice audits. The arrangements for handling any personal money on behalf of people living there were reviewed and found to be satisfactory and regularly audited. The management of health and safety was reviewed. The company produce a comprehensive heath and safety manual and staff receive mandatory training in health and safety subjects, although as reported in the staffing section of this report, some require training updates. General risk assessments were in place and the manager was arranging these to be updated. Accidents and incidents are recorded and audited by the manager and the company. Records indicated that equipment and essential services were being a maintained and that fire safety checks and procedures were carried out. Hot water temperatures are being checked and showerheads are routinely cleaned and disinfected. Routine checks are carried out on call bells, window restrictors, fire door closures and wheelchairs. Radiators are covered. Ravenscroft DS0000065178.V349501.R01.S.doc Version 5.2 Page 25 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 2 3 X X 2 X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Ravenscroft DS0000065178.V349501.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? 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(1) 5(1) Requirement The registered person must ensure that the homes statement of purpose and service user guide be updated in relation to: • CSCI contact details • Information regarding previous inspections. There must be evidence that all care plans, have been agreed with and consented to by the service user. Requirement set at inspection 10/08/07 (Met in part) The flooring in the communal toilets and bathrooms will be audited and replaced where necessary. Requirement set at inspection 10/08/07 (Met in part) The registered person must ensure he mattresses in rooms 9, 21, 22, 46 and 49 are replaced, or an overlay mattress supplied, for the protection of the person using it. Timescale for action 01/12/07 2 OP7 15(2)(a) 01/12/07 3 OP19 23(2b) 01/01/08 4 OP24 16 (2,c) 01/12/07 Ravenscroft DS0000065178.V349501.R01.S.doc Version 5.2 Page 27 5 OP26 13 (3) 6 OP27 18 (1,a) 7 OP30 18 (1,c,i) 8 OP38 13(4c) 9 OP38 13 (4a) The registered person must ensure that the current practice relating to the sterilisation of commode pots is reviewed to ensure it meets the recommendations of the relevant agencies. The registered manager is required to ensure that the number staff on duty is sufficient to meet the needs of the people living at the home at all times. The registered manager is required to ensure that staff receive training updates appropriate to their role in regard to: • Infection control • Health and safety • COSHH The registered manager will ensure that the beds provided meet the care needs of the service users. Requirement set at inspection 10/08/07 (Met in part) The manager should ensure that access to the home via the front door is free of hazards to service users, staff or visitors, in regard to the wheelchair ramp 01/11/07 01/11/07 01/02/08 01/02/08 01/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations The registered manager should ensure that when people are responsible for taking their own medication, administration is recorded on the Medication Administration Record. DS0000065178.V349501.R01.S.doc Version 5.2 Page 28 Ravenscroft 2 OP9 3 OP14 4 OP26 The registered manager should ensure that any handwritten amendments/additions to medicine administration records are signed be the person making the amendment/addition and witnessed and signed by another person. In order to avoid delays and ensure that people have more choice with regard to getting up or going to bed, the registered manager should ensure that sufficient manual handling equipment is made available. The registered person should consider the purchase of another automatic sterilising washer to ensure best practice with regard to the sterilisation of commode pots. Ravenscroft DS0000065178.V349501.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V349501.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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