Inspection on 13/10/05 for Ravensknowle Road

This inspection was carried out on 13th October 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ravensknowle Road 01/10/07

Ravensknowle Road 21/11/06

Ravensknowle Road 25/01/06

Ravensknowle Road 08/03/05

Ravensknowle Road 17/05/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Ravensknowle Road 128 Ravensknowle Road Dalton Huddersfield West Yorkshire HD5 8DN Lead Inspector Alison McCabe Unannounced Inspection 13th October 2005 2.10 Ravensknowle Road DS0000026327.V258197.R01.S.doc Version 5.0 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 Ravensknowle Road DS0000026327.V258197.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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. Ravensknowle Road DS0000026327.V258197.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ravensknowle Road Address 128 Ravensknowle Road Dalton Huddersfield West Yorkshire HD5 8DN 01484 536080 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) Bridgewood Trust Limited Ms Mary Catherine Monaghan Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Ravensknowle Road DS0000026327.V258197.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th March 2005 Brief Description of the Service: Ravensknowle Road is a care home providing personal care and accommodation for eight adults with learning disabilities. It is operated by the Bridgewood Trust, a voluntary organisation that provides a range of services to adults with learning disabilities. The home is situated in the Dalton area of Huddersfield, adjacent to a park and a short distance from shops and community facilities. There is a bus route within close proximity and Huddersfield town centre is a ten-minute drive away. The home consists of an adapted detached property built over three floors with a stair lift between the ground and first floor and ramped access to the front door. All the bedrooms in the home are for single occupancy, one of which has ensuite facilities. The home has a garden and there is a car park to the front of the building. Ravensknowle Road DS0000026327.V258197.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place between 2.10pm and 6.20pm. One inspector conducted this inspection visit. The inspector had the opportunity to talk to six service users during the course of the inspection. The inspector also talked to the registered manager, service manager and two care staff. The inspector examined records and accessed all communal areas and four of the residents’ bedrooms. The last inspection was conducted on 8th March 2005. The findings of the inspection are positive. This is a well run home offering good quality care to the residents. Residents spoken to said that they were happy and liked living at Ravensknowle Road. The atmosphere at the home was relaxed and friendly. What the service does well: What has improved since the last inspection? A new kitchen has been fitted. Six monthly resident reviews have been introduced. Ravensknowle Road DS0000026327.V258197.R01.S.doc Version 5.0 Page 6 The home has a copy of the suggested guidance from the royal pharmaceutical society regarding the administration of medication. 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. Ravensknowle Road DS0000026327.V258197.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ravensknowle Road DS0000026327.V258197.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5 Clear contracts detailing terms and conditions are in place for residents. EVIDENCE: A contract setting out the terms and conditions of the placement was in place in those records that were examined and contained the required information. Ravensknowle Road DS0000026327.V258197.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Residents’ care plans fail to fully meet all their health and welfare needs. Identified risks to residents have not been assessed appropriately. Necessary steps to minimize risks need to be agreed, recorded and implemented. Staff are good at supporting residents to make choices about their lives. EVIDENCE: The inspector examined the care plans and risk assessments of three residents and found that these did not cover all aspects of service users’ personal, social and healthcare needs. Risk assessments did not contain sufficient detail about the identified risk or steps to be taken to minimize the risks. The system in place is a combined care plan/risk assessment. The organisation has identified that this does not adequately address all areas required and is in the process of introducing a revised system. The manager reported that she has attended training workshops regarding the new system and now has the appropriate paperwork. She stated that work to complete the new format would be commencing in the next week. There was evidence in the records that reviews are conducted on a six monthly basis. Daily records are not kept and it is Ravensknowle Road DS0000026327.V258197.R01.S.doc Version 5.0 Page 10 recommended that this be introduced to evidence whether or not residents’ identified needs have been met. Residents confirmed that they are supported to make choices about their lives. This was observed during the inspection, where residents made choices about how to spend their time and what they would like to eat/drink. Residents said that they had chosen where to go on holiday this year. Ravensknowle Road DS0000026327.V258197.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Residents are offered good opportunities to participate in leisure and educational activities both in the home and in the community. Staff are good at supporting residents to maintain relationships with friends and family. The food provided at this home is of good quality and is healthy; residents enjoy the meals provided. EVIDENCE: There was evidence in the records examined that residents attend a wide range of day placements or educational facilities. Residents confirmed this and all stated that they enjoyed the daytime activities. The manager explained to the inspector that if any resident decided not to attend day services, the home would be staffed during the day. Records showed that residents access community based activities on a regular basis. On the day of inspection, residents had arranged to go to Gateway Club in the evening. The residents said that they enjoyed meeting up with their Ravensknowle Road DS0000026327.V258197.R01.S.doc Version 5.0 Page 12 friends at the evening clubs and activities that they attend. A range of leisure activities is available to residents in the home and in the community. Through discussion with residents and examination of records, it was evident that residents are offered good support to maintain contact with their families and friends. Through observation of care practice and discussion with residents and the manager of the home, it was clear that residents are supported to be as independent as possible. Staff were observed to knock before entering bathrooms and bedrooms and to ask residents’ permission before going into their rooms. The manager reported that only one resident has asked for a key to their bedroom; all other residents have stated that they do not want a key to their room. The residents spoken to confirmed this. Residents were observed to choose whether to spend time alone or in the company of others. Residents have unrestricted access to all areas of the house with the exception of the laundry which is situated in the cellar. The manager stated that this was for health and safety reasons. Residents explained that they decide what the menu is each month. A choice of meal is offered and food provided is varied, nutritionally balanced and well presented. Residents said that they enjoyed the food provided. The manager reported that, as the residents have arrangements to go out most evenings in the week, staff tend to prepare the meals, as time is limited. Residents are supported to participate in meal preparation at weekends. Residents were observed to make themselves and visitors drinks independently. Ravensknowle Road DS0000026327.V258197.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 Good support is offered to residents to have their healthcare and personal care needs met. EVIDENCE: Most of the residents at this home require very little support with personal care. For any residents who cannot easily communicate their needs, there must be individual working records setting out residents’ preferred routines. This must be included as part of the individual care plan. Residents looked well cared for and said that they choose their own clothes and style. Support and guidance offered by staff was observed to be positive and respectful. Evidence that residents are supported to have their healthcare needs met was seen in the records. A resident had been supported to attend an appointment on the day of inspection. Medication was not checked as part of this inspection, however both the home manager and service manager confirmed that the recommendations made at the previous inspection in respect of the medication policy and procedure had been addressed. Ravensknowle Road DS0000026327.V258197.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Not assessed on this occasion. Ravensknowle Road DS0000026327.V258197.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26,30 Residents live in a clean, comfortable house that is furnished and decorated to a high standard. EVIDENCE: The accommodation is a large Edwardian house in a residential area of Huddersfield. The home is comfortable and homely in appearance. The kitchen has been replaced and was being completed on the day of inspection. Residents said that they liked the new kitchen. The home is maintained to a high standard and was clean and tidy at the time of inspection. The inspector had the opportunity to view four bedrooms. Each was furnished to a good standard and all were personalised to reflect individuals’ tastes and interests. A chair lift is available for residents with mobility difficulties. The manager explained that no other adaptations are required at present. The laundry is based in the cellar and is equipped with a washing machine with a sluicing facility; there is a domestic tumble drier. A freezer currently housed in the laundry area is to be moved into a separate storage area of the cellar. The manager was advised at the time of inspection that the fire door in the cellar must not be propped open. It must be kept closed or a self-closing device fitted. This was rectified at the time of inspection. Ravensknowle Road DS0000026327.V258197.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,34 A new staff team, with the exception of the home manager, support the residents at this home. A review of staffing levels is necessary to make sure that there is always sufficient staff available. Recruitment practice at this home does not always protect the residents. Residents are not always offered the opportunity to be involved in staff recruitment. EVIDENCE: The staff team is made up of the registered manager, three full time care staff and a part time domestic. The service manager explained that he is in the process of reviewing the staffing levels at the home. The manager reported that, in the event of staff sickness or staff being on annual leave, the rota is difficult to cover. Two staff cover each shift during the day, and one staff member sleeps in at night. The home is not staffed during the day as all residents attend day placements although the manager stated that if any of the residents were unwell and needed to stay at home, the necessary staffing would be arranged. The recommendation made at the previous inspection to review the staffing levels on an annual basis using the Department of Health guidance has been repeated. Since the last inspection, the care team has changed. Two new care staff have been recruited and a staff member previously working as a domestic has taken up a care position. A new domestic has been appointed. Ravensknowle Road DS0000026327.V258197.R01.S.doc Version 5.0 Page 17 All staff recruitment records were examined as part of this inspection. All the required information was in place for four out of the five staff. There was no CRB or POVA check or application form in place for one staff member. The registered manager and service manager were advised of their responsibility to comply with the Care Homes Regulations in respect of staff recruitment. Adequate arrangements had been made by the end of the inspection to ensure that only staff that had the necessary checks were on duty. The provider informed CSCI the following day that the CRB and POVA check had been sent for. The requirement made at the last inspection in respect of staff recruitment records has been repeated. Residents did not have the opportunity to participate in the recruitment of the newly appointed staff or to meet them before they started working at the home. The service manager explained that new staff would usually be invited to visit the home and meet the residents prior to appointment so that residents have the opportunity to give their views, however on this occasion this did not take place. It is recommended that the provider consistently offers opportunities to residents to participate in the recruitment process. Ravensknowle Road DS0000026327.V258197.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,42 Residents benefit from living in a well run home. The manager is experienced and competent and is working towards the registered managers award. The home is maintained in line with safe working practices. EVIDENCE: The registered manager has many years’ experience working with people with learning disabilities. She is qualified to NVQ levels 2 and 3 in care and is currently working towards the registered managers award. Due to being off work for some time, the manager has not made the progress that she had anticipated and expects to have completed the award by the end of April 2006. The management approach at this home is open and positive. The manager communicates a clear sense of leadership and direction and acts as an excellent role model to the staff team in relation to care practice. Residents are encouraged to voice their opinions and any concerns about the service on a day-to-day basis in addition to regular residents’ meetings. Records of residents’ meetings are kept and the residents confirmed that a range of issues Ravensknowle Road DS0000026327.V258197.R01.S.doc Version 5.0 Page 19 are discussed at these meetings. Residents were relaxed with the manager and reported that the manager was approachable. Records regarding health and safety matters were in good order. There was evidence in the records that the required checks and maintenance of safety equipment is carried out. Fire alarm tests and drills are undertaken at the recommended frequency. Work place risk assessments are carried out and comprehensive policies and procedures for the health and safety of service users and staff are in place. Ravensknowle Road DS0000026327.V258197.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X 3 Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 3 X 1 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X 3 X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X 2 1 X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ravensknowle Road Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score 2 3 X X X 3 X DS0000026327.V258197.R01.S.doc Version 5.0 Page 21 Yes 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 YA6 Regulation 15 Requirement The registered person shall prepare a written plan as to how the residents needs in respect of his health and welfare are to be met. Unnecessary risks to the health or safety of residents are identified, and so far as possible eliminated. The service provider must obtain a CRB and POVA check for all staff working at the care home. Timescale of 1/6/05 unmet. Timescale for action 15/12/05 2 YA9 13 15/12/05 3 YA34 19 Schedule 2 30/11/05 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 2 Refer to Standard YA6YA41 YA33 Good Practice Recommendations Daily records should be kept to demonstrate how the individual service users’ needs are being met in line with their individual service user plan. The service provider should undertake an annual review of staffing levels in the home being informed by the DOH guidance on staffing levels. DS0000026327.V258197.R01.S.doc Version 5.0 Page 22 Ravensknowle Road 3 4 YA34 YA37 The service provider should offer service users the opportunity to particiapte in the recruitment of new staff. The home manager should achieve NVQ level 4 in care and management as soon as possible. Ravensknowle Road DS0000026327.V258197.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Ravensknowle Road DS0000026327.V258197.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. 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