Inspection on 25/01/06 for Ravensknowle Road

This inspection was carried out on 25th January 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 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 13/10/05

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 25th January 2006 3:30 Ravensknowle Road DS0000026327.V271254.R01.S.doc Version 5.1 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.V271254.R01.S.doc Version 5.1 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.V271254.R01.S.doc Version 5.1 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.V271254.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th October 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.V271254.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector conducted this unannounced inspection between 3.30pm and 6.30pm. The inspector had the opportunity to meet with service users, staff, registered manager, service manager and senior area manager. The findings of this inspection are based upon feedback from service users and staff, observation of care practice and through examination of records. The findings of the inspection are positive. This is a well run home providing good quality care to the service users. All service users spoken to expressed their satisfaction with the service. What the service does well: What has improved since the last inspection? Criminal records bureau checks are in place for all staff. Ravensknowle Road DS0000026327.V271254.R01.S.doc Version 5.1 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. Ravensknowle Road DS0000026327.V271254.R01.S.doc Version 5.1 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.V271254.R01.S.doc Version 5.1 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): 2 Good arrangements are made for service users to spend time at the home before deciding whether or not they would like to live there. Pre-admission assessments are not always conducted as required. EVIDENCE: The service user most recently admitted to the home moved in almost a year ago. There was evidence in the records that a number of visits were arranged prior to moving in and good records were kept detailing how each visit went. There was also evidence that the move had been discussed at review meetings. A full assessment had not been undertaken prior to the service user moving in, although a review was conducted six months later. It is a requirement of the inspection that a comprehensive assessment is completed for all service users prior to them moving into the home. Ravensknowle Road DS0000026327.V271254.R01.S.doc Version 5.1 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 Individual care plans and risk assessments do not contain sufficient detail. Staff are good at empowering and supporting service users to make decisions and choices about their lives. EVIDENCE: The manager informed the inspector that there had been no further development of service user care plans and risk assessments since the last inspection, where they were found not to 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 manager reported that the revised care-planning tool was in the process of being implemented and that keyworkers were completing personal support plan assessments with service users and would then develop the care plans from this information. Service user files have been reorganised in preparation for the new system and the manager was able to give a clear account of how the revised system would Ravensknowle Road DS0000026327.V271254.R01.S.doc Version 5.1 Page 10 be implemented. The manager reported that all service user plans and risk assessments would be updated by the end of February 2006. Daily records are not currently being kept although this will be introduced as part of the new system. This will be assessed at the next inspection. The requirements made at the previous inspection in relation to care planning and risk assessments have therefore been brought forward. Service users confirmed that staff had consulted them as part of the assessment process and were aware that their individual care plans were being revised. Through discussion with service users and staff, and observation of care practice, there was clear evidence that service users are offered good support to make choices about their daily lives. The inspector observed the manager and a service user discussing employment opportunities and plans, and a service user explained that she is given the appropriate support to manage her financial affairs in a way that she is comfortable with. Ravensknowle Road DS0000026327.V271254.R01.S.doc Version 5.1 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 Service users are enabled to lead fulfilling, active lifestyles both in the home and outside of the home. EVIDENCE: Several service users living at this home are supported in employment, some paid and some voluntary. It was reported that a service user had been successful at an interview the previous day. Service users are supported to attend day services or their place of work through transport being made available, help with establishing the correct bus routes if travelling independently and regular reviews of placements. Service users told the inspector that they had busy social lives as well as work and education. On the day of inspection, four service users attended evening class at the local college. Service users talked of events, outings and parties that they have attended. Through discussion with staff and service users, it was evident that service users have regular contact with family and friends and have plenty of opportunities to pursue leisure activities both inside the home and in the community. A service user reported that she was due to go to Australia for a month with her family in the near future. Ravensknowle Road DS0000026327.V271254.R01.S.doc Version 5.1 Page 12 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): 20 Medicine management is good at this home. EVIDENCE: All medication checked could be reconciled with records. Good systems are in place for the management of medicines. The manager reported that all service users had been asked if they would like to be supported to self medicate, however all declined. The manager explained that she would be completing a risk assessment with one service user in respect of self medication to prompt further discussion about whether this is something she would like to pursue. Ravensknowle Road DS0000026327.V271254.R01.S.doc Version 5.1 Page 13 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): 22,23 Good procedures are in place to enable service users to discuss any concerns or complaints. Good policies, procedures and practice protect service users at this home from abuse or harm. EVIDENCE: A satisfactory complaints procedure is in place containing all the required information. Service users spoken to said that they had no complaints about the service and that they liked living at the home. Service users were aware of the complaints procedure and said that they would be comfortable about raising any concerns with the manager or staff. No complaints have been received at this home in the last twelve months. The manager said that the complaints procedure is discussed at resident meetings. Adult protection procedures are in place in addition to the Kirklees multiagency guidelines. Staff have received training in adult protection and the manager explained that this is discussed in staff meetings and individual staff supervisions. No referrals regarding adult protection matters have been made in the last twelve months. Two senior staff within the organisation also have the role of adult protection coordinators. Ravensknowle Road DS0000026327.V271254.R01.S.doc Version 5.1 Page 14 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): EVIDENCE: Not assessed on this occasion. Ravensknowle Road DS0000026327.V271254.R01.S.doc Version 5.1 Page 15 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): 32,33,34,35 Staff have positive relationships with service users. Relevant training is provided to staff. An effective staff team supports service users. Staff recruitment practice and procedures at this home are good. EVIDENCE: Care practice at this home was observed to be positive. Staff interact positively and respectfully with service users. Service users spoken to all commented on how much they liked the staff and that they got on well with them. It was apparent from the interactions observed that service users have positive relationships with staff and appeared to be comfortable in their presence. At the time of inspection, both the senior area manager and residential services manager were at the home. Service users also commented on the positive relationships they have with senior members of the organisation. Staff working at the home have a range of skills and experience. Of five staff, 4 have had previous experience of working in a care setting and 2 staff (including the manager) are qualified to NVQ level three in care. The service manager reported that two staff would commence NVQ training upon Ravensknowle Road DS0000026327.V271254.R01.S.doc Version 5.1 Page 16 completion of the LDAF award. All new staff complete the Learning Disability Award Framework induction and foundation training. It was apparent, through discussion with staff and observation of care practice, that staff have a good understanding of the needs of the service users living at the home. Staff training records show that staff have attended relevant training courses and that there is a training and development programme. Staff recruitment records were examined and found to contain all the required information. No new staff have commenced at the home since the last inspection, however the manager stated that service users would be invited to participate in the recruitment process at the next opportunity. The staff team has not changed since the last inspection. A staffing review has been completed as recommended at the previous inspection although no changes have occurred as yet. There are two staff on duty per shift and occasionally three depending on activities that have been arranged. Only one staff member and the home manager are able to drive the home’s transport therefore the rota is planned with this in mind. This has an impact on the time available to the manager to undertake management tasks as she is often providing transport when on shift. Regular staff meetings are held and minutes of these meetings are kept. Ravensknowle Road DS0000026327.V271254.R01.S.doc Version 5.1 Page 17 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): 37,39 Service users benefit from living in a well run home. Good quality assurance systems are in place at this home. EVIDENCE: The registered manager is working towards NVQ level 4 in care and management and said that she had completed four units towards this. The manager holds an NVQ level 3 in care and has significant management experience within the Bridgewood Trust. Training records demonstrate that the manager regularly attends training to update her knowledge and skills. The organisation uses the ISO 9000 quality assurance system. In addition to this formal system, feedback is sought from service users through resident meetings and service user questionnaires that are completed prior to individuals’ annual reviews. The views of family, friends and stakeholders are also sought during the review process. Ravensknowle Road DS0000026327.V271254.R01.S.doc Version 5.1 Page 18 Monthly unannounced visits are conducted by the service manager in line with Regulation 26 of the Care Homes Regulations 2001 and a report is produced and a copy sent to CSCI. The manager explained that service users are encouraged to give feedback about the service they receive in an informal setting as well as using the formal systems. She reported that lots of discussion takes place during mealtimes. Ravensknowle Road DS0000026327.V271254.R01.S.doc Version 5.1 Page 19 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 Standard No Score 1 X 2 1 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 1 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 X 2 X 3 X X X X Ravensknowle Road DS0000026327.V271254.R01.S.doc Version 5.1 Page 20 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 Timescale for action 28/02/06 2. YA9 13 3 YA2 14 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. 15/12/05 unmet. Unnecessary risks to the health 28/02/06 or safety of residents are identified, and so far as possible eliminated. 15/12/05 unmet. An assessment of service users’ 28/02/06 needs must be conducted prior to service users moving into the home. A copy of the assessment must be available in the service users’ records. 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 YA6 YA41 Good Practice Recommendations Daily records should be kept to demonstrate how the individual service users’ needs are being met in line with DS0000026327.V271254.R01.S.doc Version 5.1 Page 21 Ravensknowle Road their individual service user plan. 2. YA37 The home manager should achieve NVQ level 4 in care and management as soon as possible. Ravensknowle Road DS0000026327.V271254.R01.S.doc Version 5.1 Page 22 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. 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