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Inspection on 28/06/06 for Ravenscroft Nursing Home

Also see our care home review for Ravenscroft Nursing Home for more information

This inspection was carried out on 28th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Prospective service users have their needs assessed before admission to the home this allows the staff in the home to make a professional and informed judgement about if/how those needs are able to be met at Ravenscroft and ensures the process is safe. Staff in the home make referrals to specialist health care professionals when needed, this promotes and maintains the health of those living in the home. The homes policies and procedures for dealing with medicines are robust and protect people who use this service. Service users are treated with respect and their right to privacy is upheld. Social activities are organised and provide stimulation and interest for residents on some days and people living in the home are helped to exercise choice and control over their lives. Service users maintain contact with family/friends/representatives and the local community as they wish. Service users receive a wholesome appealing balanced diet, and are aware of options to the main menu. Most of the home is well decorated and furnished, clean, pleasant and hygienic. The numbers of and skill mix of the staff team meets Service users needs.

What has improved since the last inspection?

A new shower room has been installed suitable for use by both immobile and independent residents this enables people to chose their preferred method of Bathing. Well-appointed garden paths have been installed improving access to the grounds for those living in the home and general landscaping to the gardens continues to improve the external environment.

What the care home could do better:

Service users are not formerly assured that their assessed needs will be met at the time of their admission to this home which, may increase peoples anxiety when moving to the home. Each service user has a plan of care however these are not reviewed on a monthly basis or always updated when changes in needs are recognised. This poses a risk that peoples changing needs may not be met consistently. Not all residents and their relatives/friends know how to make a complaint this may affect peoples confidence in the service and mean that they remain dissatisfied if unable to voice their concerns. Lack of regular staff training/updates in adult protection and prevention of abuse has the potential to place those living at this home at risk. Staff are not consistently supervised or trained this may lead to lack of motivation and poor practises which may affect their ability to care for those living in the home. Service users are not protected by the homes recruitment policy and practices this poses the risk that inappropriate staff may be employed to care for this vulnerable resident group. The lack of clinical management of this home poses a risk that the health care needs of residents may not be identified or managed safely.

CARE HOMES FOR OLDER PEOPLE Ravenscroft Nursing Home Ravenscroft Nursing Home Old Crapstone Road Yelverton Devon PL20 6BT Lead Inspector Fiona Cartlidge Unannounced Inspection 28th June 2006 10:00 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 Nursing Home DS0000029227.V292747.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 Nursing Home DS0000029227.V292747.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ravenscroft Nursing Home Address Ravenscroft Nursing Home Old Crapstone Road Yelverton Devon PL20 6BT 01822 853491 01822 853444 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) Timothy O`Carroll Mrs Karen Louise O`Carroll Vacancy Care Home 54 Category(ies) of Old age, not falling within any other category registration, with number (12), Physical disability (12), Physical disability of places over 65 years of age (40), Terminally ill (4) Ravenscroft Nursing Home DS0000029227.V292747.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. Old age, not falling within any other category (12) Physical disability over 65 years of age (40) Terminally ill (4) 2 Service Users under the age of 65 years (named elsewhere) Physical disability (12) A maximum of 54 service users at any time Date of last inspection 30/11/05 Brief Description of the Service: Ravenscroft is a care home providing nursing and/or personal care for a maximum of 54 residents of either gender with physical frailty, illness or disability. It is situated near Yelverton, West Devon, on the edge of Dartmoor National Park. The home is arranged on 3 floors within an old ‘Edwardian house’ and more modern extensions. A new purpose built wing was registered and opened in September 2005; all rooms in this wing have en-suite toilets and are attractively decorated and furnished. Further improvements to the existing environment are on going. The home is well equipped to meet the needs of those residents identified with moving and handling risks and disabilities that affect their capability to bathe. Specialist mattresses were seen in place for those residents requiring them as were height adjustable beds. Level access is accomplished via 3 passenger lifts. There are 3 lounges and a dining room. There are large grounds, with grass and paved areas, with level access from the house. Ravenscroft Nursing Home DS0000029227.V292747.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 6 hours and 30 minutes and was unannounced. A partial tour of the home took place when some bedrooms and all communal living rooms were viewed. Personal records of care of 4 residents and personnel records of 5 members of staff were inspected. The inspector spoke with 12 residents, 2 staff members one of the registered providers and administrator. Written feedback was received from 3 residents and 1 visiting health care professional. The homes senior staff had also submitted answers to a pre-inspection questionnaire supplied to them by the Commission. What the service does well: What has improved since the last inspection? A new shower room has been installed suitable for use by both immobile and independent residents this enables people to chose their preferred method of Bathing. Well-appointed garden paths have been installed improving access to the grounds for those living in the home and general landscaping to the gardens continues to improve the external environment. Ravenscroft Nursing Home DS0000029227.V292747.R01.S.doc Version 5.2 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 Nursing Home DS0000029227.V292747.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ravenscroft Nursing Home DS0000029227.V292747.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users have their needs assessed before admission to the home but there is no formal mechanism to assure them that these needs will be met. This home does not currently provide intermediate care. EVIDENCE: The inspector examined personal documentation held on behalf of 4 residents; all included pre-admission information supplied from care management or hospital settings about the residents assessed needs. In addition to this information the documents of 2 of the residents showed evidence that senior nursing staff employed by the home had visited them to perform a full assessment of their needs this information is used to determine how the needs of the individuals will be met at the home. The inspector spoke to a number of residents about how they had made the decision to be admitted to this home, those spoken to said their relatives had Ravenscroft Nursing Home DS0000029227.V292747.R01.S.doc Version 5.2 Page 9 been given the opportunity to visit before making a decision about their admission. Ravenscroft Nursing Home DS0000029227.V292747.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each service user has a plan of care however these are not reviewed on a monthly basis or always updated when changes in needs are recognised. This poses a risk that peoples changing needs may not be met consistently. Staff in the home make referrals to specialist health care professionals when needed. The homes medication policies and procedures for dealing with medicines protect people who use this service. Service users are treated with respect and their right to privacy is upheld. EVIDENCE: The inspector found that the records held on behalf of residents contained an assessment of their needs in relation to moving and handling, nutrition and skin integrity which had been performed soon after their admission; there was little documentary evidence that these had been reviewed or updated at regular intervals or monthly as recommended. In 2 of the 4 records seen evaluations had not been performed for over 3 months despite daily records indicating high levels of need such as falls and or swallowing difficulties and tissue damage or high risk of pressure ulcer development. Care plans indicated Ravenscroft Nursing Home DS0000029227.V292747.R01.S.doc Version 5.2 Page 11 that 1 resident was at high risk of falls and indicated that as part of their planned care regular checks should be made of the person at 30-minute intervals; the records did not indicate whether this was actually being performed. Records also suggested that a residents health was at risk because they were unable to be weighed the assessment indicated a need for immediate action but there was no record of any action taken. A record of weights is maintained in a separate book to the individuals care records; the information in this book was not consistent and although it indicated weights were to be recorded at monthly intervals for several residents this was not the case. In the case of one resident they had lost over 10kgs between February and April, the nursing staff told the inspector that this had been referred to the General practitioner but the records did not indicate any plan to meet this persons needs in relation to their nutrition although the nurses verbally confirmed it is challenging even to keep the individual sufficiently hydrated. The inspector found records of visiting health care professionals, which included General Practitioners, District Nurses, Physiotherapist, Dentist, Optician and Chiropodist. The commission supplied a number of questionnaires to visiting Health and social care professionals, only one of these had been returned at the time of reporting, this indicated that ‘the home does not communicate clearly and work in partnership, there is always a senior member of staff to confer with, they are able to see service users in private, staff in the home do not always demonstrate a clear understanding of service users care needs, specialist advice given is incorporated into the service users plan, they had received complaints about the home but were not specific about this. Letters regarding hospital appointments were seen providing evidence that residents are enabled to access specialist services according to need. 3 residents provided written feedback, 2 confirmed they always receive the medical support they need the other indicated they usually received the medical support they need. The inspector examined the system for storing. Administering and recording of medication held in the home. The records of medication entering and leaving the home were of a good standard. The storage of medication was found to be safe. The inspector randomly examined the actual balance of one controlled medication against records held and found it was accurate. Residents told the inspector that the staff respect their privacy and dignity, the inspector observed that when personal care was being provided this was done behind closed doors, the staff spoke to residents in a polite manner and were witnessed to knock on the doors to private accommodation before entering. Ravenscroft Nursing Home DS0000029227.V292747.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Social activities are organised and provide stimulation and interest for residents on some days. 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, and are aware of options to the main menu. EVIDENCE: Resident’s spoken to by the inspector said that the activities arranged and offered in the home suited their needs and preferences. On the day of the inspection a musical entertainer provided a sing along session in one of the lounges. Some residents were seen enjoying the sun sitting in the garden; others were spending time in their own rooms, which they confirmed was at their request. Residents were seen to be encouraged to maintain hobbies; one was busy painting and several of their works were seen exhibited in the home. Another resident showed the inspector their vast collection of CD’s and videos. Of the 3 residents who completed written surveys when asked ‘Are there Ravenscroft Nursing Home DS0000029227.V292747.R01.S.doc Version 5.2 Page 13 activities arranged by the home that you can take part in? 1 indicated ‘usually’, 1 ‘sometimes’ and 1 ‘never’. Service users records did not include a social history or refer to past interests such as hobbies, one record seen indicated that the person was very religious and that contact would be made with a local minister to arrange visits, but there was no documentation to confirm they had actually been contacted or had visited. The inspector found some information in an ‘activities’ book on how service users social needs are met, for the month of June it was recorded that 7 residents had been on a trip to the moors, 2 had been assisted to have a stroll in the gardens, 7 had enjoyed keyboard entertainment and 1 had been encouraged to assist with laying up the dinning tables. No other records were available of any activities the service users may have participated in or how activities were structured around individual needs for example memory games for service users with poor memory recall. The home does not employ any one specific person to organise and access social care but relies on the care assistants to provide it, the nurses said the carers were often too busy attending to peoples physical needs to be able to provide social activities. The feedback about food was positive most of the residents spoken to said how good it was; Lunch was served at the time of the inspection which was sausages and mash or fish. Residents were aware of the options. The 4 weekly rotating menus advertise an option and this is displayed in the home on a daily basis. Of the 3 surveys completed and returned 1 indicated they ‘always’ 1 ‘usually’ and 1 ‘never’ like the meals at the home. Throughout the inspection service users were observed receiving visits from family and friends and relatives spoken too said that they felt welcomed into the home at any time one resident was being visited by their 2 dogs at the time of the inspection. Service users also said that they regularly received visits from family and friends and that they could receive visitors privately in their own accommodation or socially in the communal areas of the home. Most residents said they could rise and retire at times that suited them. The Care plan and assessment information seen during the inspection did not include information on service users personal preferences and choices about such things as preferred gender carer, daily routines etc. Ravenscroft Nursing Home DS0000029227.V292747.R01.S.doc Version 5.2 Page 14 Ravenscroft Nursing Home DS0000029227.V292747.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Most residents and their relatives/friends know how to make a complaint. Lack of staff training/updates in adult protection and prevention of abuse has the potential to place those living at this home at risk. EVIDENCE: Ravenscroft Nursing Home DS0000029227.V292747.R01.S.doc Version 5.2 Page 16 The inspector examined the homes complaints procedure this was found displayed in a notice in the entrance hall. The inspector also found forms available at the homes reception for people to document their concerns/complaints. The inspector was unable to find a record of complaints but information seen in the minutes of a management meeting indicated that a complaint had been received but neither the provider, nurses or administrator were aware of what action the manager had taken in relation to the complaint and the manager was on leave at the time of the inspection. Of the 3 people who returned surveys when asked - do you know who to speak to if you are unhappy? 1 said ‘no’ 1 said ‘always’ and one ‘sometimes’ When asked - do you know how to make a complaint? 1 said ‘always’ and 2 said ‘no’. Training in adult protection was provided to all staff last year but according to information about training during the past 12 months has not been included in the training programme for this year or future planned training. A copy of the local authorities ‘alerters’ guidance was seen to be available at the time of the inspection. Although adult protection and prevention of abuse is mentioned in the ‘Induction training’ booklets seen in the home, those booklets found in the files of staff seen at the time of inspection had not been completed. Ravenscroft Nursing Home DS0000029227.V292747.R01.S.doc Version 5.2 Page 17 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): 19,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Most of the home is well decorated and furnished and clean, pleasant and hygienic. EVIDENCE: A tour of the home provided evidence that residents are able to personalise their rooms and those spoken to said they liked their private accommodation. One resident told the inspector that they thought the setting of the home and its situation was perfect, commenting that they enjoyed watching and listening to the sheep, ponies and children on the open moors. Of the 3 residents who provided feedback in surveys returned to the commission 2 state that the home is ‘always’ fresh and clean and the other states it is not always fresh and clean. The inspector noted that only one room had an odour and the provider confirmed that this room was now empty and was not going to be used again until it had been decorated and re-carpeted. Ravenscroft Nursing Home DS0000029227.V292747.R01.S.doc Version 5.2 Page 18 Since the last inspection a new shower room suitable for use by severely physical disabled as well as able-bodied persons has been installed. The kitchen has been redecorated, new laundry equipment has been supplied and landscaping to the garden continues. Residents in self- propelling and assisted wheelchairs were seen enjoying the grounds, which they access via well designed garden paths. A range of equipment is available to assist with safe moving and handling of residents. The inspector observed that hand washing facilities are available for staff and protective clothing including gloves are in ample supply. Ravenscroft Nursing Home DS0000029227.V292747.R01.S.doc Version 5.2 Page 19 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): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The skill mix of staff meets Service users needs. Staff are not consistently supervised or trained. Service users are not protected by the homes recruitment policy and practices. The home has enough staff to meet service users needs. EVIDENCE: The inspector examined the personnel records held on behalf of 5 members of staff the records were incomplete and did not all contain 2 written references, evidence that Criminal Record Checks had been obtained or POVA 1st checks had been performed before their employment commenced. There were no records of individual training needs analysis. Each file did contain a completed application form but references from the latest employers had not been recorded for 3 of the 5 records seen. 2 of the files contained induction training booklets but neither of these contained any entries or evidence that the units had been completed. There was indication that some members of staff had received some training in fire safety, moving and handling, continence, first aid and health and safety but the records lacked sufficient detail to provide evidence that staff receive the recommended minimum of 3 paid days training/year. 8 care staff have obtained a National Vocational Qualification in care. Ravenscroft Nursing Home DS0000029227.V292747.R01.S.doc Version 5.2 Page 20 Resident spoken to during the inspection said the staff were kind and able to meet their needs quotes received were ‘the staff will do anything, no trouble what so ever’, ‘all the staff are nice’ ‘the staff are good and very kind’ ‘all the staff are so helpful, nothing is too much trouble’. Of the 3 residents who returned surveys when asked are the staff available when you need them 2 indicated ‘always’ 1 and 1 ‘sometimes’. The staff spoken to on the day of the inspection said they sometimes felt there was insufficient staff available which impacted not only on the level of social care available to the residents but also on their responsibility for accurate record keeping. The staff said that they felt able to discuss these matters with the senior clinician and that they brought it to the attention of the homes manager and proprietors at weekly meetings. None of the staff returned surveys to the Commission. Of the 5 personnel records seen 2 indicated they receive 1:1 formal supervision although nursing staff spoken to at the time of the inspection said there was no clinical supervision. One commented that they do not feel they have enough support from the management staff in the care home to do their job well because they need more one to one clinical supervision. Ravenscroft Nursing Home DS0000029227.V292747.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lack of clinical management of this home poses a risk that the health care needs of residents may not be identified or managed safely. The home lacks effective quality assurance and quality monitoring processes. EVIDENCE: The last registered manager left Ravenscroft in March 2006, since then a person who is not a qualified nurse has managed the home. The existing manager has submitted an application to be registered as manager of Ravenscroft under the Care Standards Act 2000 but because the applicant is Ravenscroft Nursing Home DS0000029227.V292747.R01.S.doc Version 5.2 Page 22 not a nurse the Commission has asked that a clinical lead be identified with their responsibilities and that of the manager clearly defined. These proposals have recently been received; however at the time of this inspection the inspector was informed that the clinical lead has given notice to resign their position at the home. Communication systems are regular through staff handovers, and formal meetings are held the inspector examined the recorded minutes of recently held meetings for both the homes management team and professional nursing staff team. There is no documentary evidence of quality assurance or quality monitoring systems. The systems for measuring customer satisfaction are informal, the inspector found a file containing letters of gratitude from relatives of residents which is held in the reception area, the provider confirmed these ‘thank you letters/cards’ are often displayed in the office to enable staff to recognise and reinforce the value of their work. The inspector found blank service user satisfaction questionnaires (dated June 2006) but the provider was unable to confirm if these had been circulated yet to the residents or their representatives. Pre inspection information provided to the Commission by the manager indicates that an annual development plan for quality assurance is due to be introduced. The inspector examined the records of money held on behalf of residents in the home; it was not possible to check the records against actual balances because the administrator confirmed the money is held in a bank account but the details of this account were not available in the home at the time of the inspection visit. The records were clear and displayed detail of all income and expenditure for each individual. The provider demonstrated a responsible attitude towards health and safety of the environment all fire doors that were open were being held by ‘safe’ hold open devices and notices were displayed throughout the home. The home employs its own maintenance person and records of checks and services by visiting professionals are maintained. Risks to residents safety and well being are individually assessed and documented but it is not always clear who has agreed the action plan or what action is to be taken. The inspector found the risk assessment for 1 resident indicated the need for bedrails however daily records indicated this person climbed over the top of the railings and was found on 2 occasions on the floor beside them as well as having caught their legs in the rails but there appeared to be no re-assessment of the high risk or plan to prevent reoccurrence of these incidence. In another risk assessment pertaining to nutrition and recording of weight the risk was documented as very high but there was no corresponding plan of how this risk is managed for the individual. Ravenscroft Nursing Home DS0000029227.V292747.R01.S.doc Version 5.2 Page 23 Ravenscroft Nursing Home DS0000029227.V292747.R01.S.doc Version 5.2 Page 24 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 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 X X 3 Ravenscroft Nursing Home DS0000029227.V292747.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15 Requirement Residents care plans must be regularly reviewed and updated when a change in need requiring a change in their care occurs. To ensure that all service users have opportunities for stimulation through leisure and recreational activities in and outside the home which suit their needs, preferences and capabilities their interests must be recorded and information about activities should be circulated to all service users in formats suited to their capacities. The registered person must ensure that any complaint made under the complaints procedure is fully investigated. The registered person must not employ a person to work at the care home unless the person is fit to work at the care home. All references and gaps in employment must be explored DS0000029227.V292747.R01.S.doc Timescale for action 01/08/06 2 OP12 12(2)(3) 01/09/06 3 OP16 22(3) 01/09/06 4 OP29 19 01/09/06 Ravenscroft Nursing Home Version 5.2 Page 26 5 OP30 18(1) c 6 OP31 8&9 7 OP33 24 and previous employers references must be taken up. The registered person must 01/10/06 ensure there is a staff training and development programme that ensures staff fulfil the aims of the home and meet the changing needs of service users. The registered person must 01/11/06 appoint a person to manage the care home and that person must be fit to do so – they must be of integrity and good character, have the qualifications and experience necessary for managing the care home and have full and satisfactory information available in relation to them in respect of the matters specified in paragraphs 1 to 5 and 7 of schedule 2. The registered person must 01/11/06 establish and maintain a system for reviewing at appropriate intervals and improving the quality of care including nursing at the home and make a report of the quality review available for service users and or their representatives and the Commission. 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 OP18 Good Practice Recommendations All staff should receive regular training and updates on how to safeguard residents from physical financial or material, psychological or sexual abuse, neglect, discrimination, self harm, inhuman or degrading treatment through deliberate intent, negligence or ignorance. DS0000029227.V292747.R01.S.doc Version 5.2 Page 27 Ravenscroft Nursing Home Ravenscroft Nursing Home DS0000029227.V292747.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Nursing Home DS0000029227.V292747.R01.S.doc Version 5.2 Page 29 - 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!