Inspection on 11/02/06 for Ravensmere

This inspection was carried out on 11th February 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 but made no statutory requirements on the home.

Other inspections for this house

Ravensmere 24/05/07

Ravensmere 22/06/06

Ravensmere 28/09/05

Ravensmere 02/11/04

Ravensmere 13/05/04

Ravensmere 04/02/04

Ravensmere 18/12/03

Ravensmere 27/11/03

Ravensmere 18/09/03

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Ravensmere 13-15 Manor Road Westcliff On Sea Essex SS0 7SR Lead Inspector Ms Vicky Dutton, Ann Davey Unannounced Inspection 11th February 2006 08:30 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 Ravensmere DS0000015463.V283328.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 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. Ravensmere DS0000015463.V283328.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ravensmere Address 13-15 Manor Road Westcliff On Sea Essex SS0 7SR 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) 01702 330347 01702 330347 Health and Home Limited Manager post vacant Care Home 24 Category(ies) of Dementia - over 65 years of age (24), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (24) Ravensmere DS0000015463.V283328.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. To provide care and accommodation for three service users, who are under 65 years of age whose details are known to the Commission. 28th September 2005 Date of last inspection Brief Description of the Service: Ravensmere Rest Home is a care home run by a small limited company, Health and Home. Ravensmere Rest Home is situated in a Residential area in Westcliff on Sea. The home is close to the seafront and a short walk from bus routes, main line railway station and local shopping facilities. The home provides care and accommodation for up to twenty four older people. The home is registered to provide care for residents with dementia and mental disorders. Accommodation is provided on three floors in eleven single and four double rooms. All but one room now has en suite facilities. The home has recently undergone an extensive refurbishment process. This has included a large extension to the rear of the home were new communal space and a kitchen are provided. A passenger lift provides access to most levels within the home. four bedrooms cannot be accessed by the lift. Residents using those rooms must be able to negotiate some stairs. Limited parking is available at the front of the property. There is a courtyard garden ajacent to the new lounge area. Ravensmere DS0000015463.V283328.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over six and a half hours. As two inspectors were present this equated to thirteen hours of inspection time. On the day of inspection twenty one residents were being accommodated. All key standards were inspected at the announced inspection that took place on 28th September 2005. The report of this inspection is available at www.csci.org.uk. This inspection concentrated mainly on assessing the progress the home had made against the previous agenda for action. A tour of the building took place. Staff, care, medication and other records were randomly selected and inspected. Staff on duty were spoken with. One visitor and several residents were also spoken with. The home has no registered manager. The registered responsible individual was not available at the inspection. The inspectors were assisted by a senior carer at the home. The company secretary for Health and Home who has applied to be registered manager at the home was in touch with the inspectors over the telephone during the inspection and was given feedback on some of the main findings of the inspection. What the service does well: What has improved since the last inspection? Curtains have now been fitted in the main living area of the home to improve the environment for residents. The home has achieved an Investors in People award. Although one large item remains, the homes courtyard area has now been cleared of items, so there is now more space for residents to enjoy. Ravensmere DS0000015463.V283328.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. Ravensmere DS0000015463.V283328.R01.S.doc Version 5.1 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 Ravensmere DS0000015463.V283328.R01.S.doc Version 5.1 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): 4. Staff training and understanding needs to be improved so that resident’s needs are fully met. EVIDENCE: The home is registered to provide care for residents who suffer from dementia, and those who may have some form of mental health difficulty. Staffing records sampled did not show that adequate levels of training had taken place in these areas. Staff spoken with and observations during the inspection did not demonstrate that staff had a clear understanding of dementia or of the implications of this condition for resident care. See also comments under standard twelve. Ravensmere DS0000015463.V283328.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Care planning at the home is generally comprehensive and provides an adequate basis to ensure that residents’ health and care needs are met. Development is needed to make sure that these are changed and updated to reflect resident’s current needs. Medication at the home is well managed. EVIDENCE: Each resident has an individual care file containing the care plan and other relevant information. Several care plans were sampled during this inspection. Those viewed were generally detailed, well completed, and incorporated risk assessments for relevant areas. Regular reviews of care plans were recorded. However these mostly indicated that there were no changes. This was not always the case and the actual care plans had not been updated. Daily records and care notes are kept separately from individual files, which may not encourage the full use of care plans. A relative of one resident was very happy with the level of care their relative is receiving. Records showed that resident’s health care needs are catered for and that medical assistance is sought as needed. District nurses are involved in care as appropriate to meet individual needs. Good nutrition records are maintained by the home to assist in monitoring resident’s health. Ravensmere DS0000015463.V283328.R01.S.doc Version 5.1 Page 10 Medication at the home is well managed. No anomalies were seen in records sampled. Staff said that they had only received in house medication training, but were able to explain appropriate practices. As pointed out at the previous inspection, the home’s controlled drugs cupboard needs to be reaffixed to a wall. A container of antibiotics was noted to be stored loose in the homes kitchen refrigerator. Any medication in this way should be kept in a sealed container to prevent any contamination of foodstuffs. The company secretary said that he intends to provide a separate medicines refrigerator. During the inspection staff were noted to treat residents with respect. Urgent attention is needed to make sure that residents’ privacy is always upheld. One Bathroom had a glass panel in the door that was not covered. A bedroom door glass insert had been covered with sticky back plastic but there were gaps in this. Windows in en suite areas did not all have obscured glass or have blinds fitted to protect residents privacy. Ravensmere DS0000015463.V283328.R01.S.doc Version 5.1 Page 11 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, 15. Some level of activity and interaction is provided at the home. However to reflect the homes stated specialisms, development work to fully assess and provide for residents individual occupational and activity needs must be undertaken. Visiting at the home is open. EVIDENCE: Residents preferred routines and activities are recorded to a degree on care plans, but this tends to be quite bland such as ‘enjoys watching TV’. As the home states that it offers specialist care for people with dementia and mental health needs, this is an area that must be better developed. Although they had a kind and caring approach to residents, and tried to engage them, staff did not demonstrate a good understanding of the needs of residents with dementia. Inappropriate activities such as word puzzles were offered to residents who were clearly not able to manage this. One resident spent the whole period of the inspection sitting on a hard dining chair, often slumped over asleep on the table. Other residents remained unengaged or asleep. The home has a large communal lounge and dining area. Sometimes the noise level was loud and confusing with the television left on loudly and music and singing going on in another area. This could be very stressful to residents who have dementia. An activities book identifies that activity sessions take place each day. There was however no indication that activities are set up to meet individual needs. Activities such as looking at magazines, playing balloons and Ravensmere DS0000015463.V283328.R01.S.doc Version 5.1 Page 12 watching television were recorded. At the previous inspection it was identified that three staff have undertaken training in ‘dementia and activity’. This training has yet to have a positive impact on resident care. Visiting at the home is unrestricted. During the inspection visitors were noted to come and go. One spoken with said that she was always made welcome and kept informed of issues concerning their relative. The home did allocate an area that could be used by relatives or visiting professionals. However this is now largely used by residents who smoke, so is in effect unusable as a visitor’s room. This standard was not fully assessed. The refurbishment of the home has included the provision of a new kitchen. Lunch on the day of inspection looked appetising and portions were a good size. Food stocks were plentiful, providing variety for residents. Residents spoken with said that the food at the home was good. Staff offered residents appropriate levels of help. Ravensmere DS0000015463.V283328.R01.S.doc Version 5.1 Page 13 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. Relatives feel that they can raise any concerns or issues and that these will be dealt with appropriately. To ensure that residents are fully safeguarded development is needed to ensure that all staff are trained in adult protection and in managing challenging behaviour. EVIDENCE: The home has a clear complaints process in place. To ensure that all interested parties are aware of how to raise concerns the procedure should be on display in the home. This was raised at the previous inspection. A relative spoken with said that they would feel comfortable in raising any concerns, but were not aware of any complaint procedure. Documentation viewed showed that a process is in place for recording and managing complaints. However the person in charge during the inspection was unaware of the complaints process, and apart from informing the company secretary, was unclear of what to do. Training records and staff spoken with indicated that not all staff have completed training in the protection of vulnerable adults. In particular the person in charge was not aware of what procedures would be followed if an incident should occur. The home offers placements to residents whose behaviour may be challenging. At the previous inspection it was identified that only four staff had completed video training covering this area of care. During the inspection one resident became agitated. Staff did not manage the situation well, and one said ‘don’t be naughty’. This was not appropriate. Ravensmere DS0000015463.V283328.R01.S.doc Version 5.1 Page 14 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, 20, 21, 23, 24, 25, 26. Although the refurbishment process at the home has been completed there are still some concerns about the suitability and safety of the environment provided for residents. EVIDENCE: The home has just undergone an extensive refurbishment and extension programme. In spite of this many environmental issues remain. The company secretary stated that a handy person is currently employed to attend to all the remaining jobs. However there seems to be no recorded or systematic approach to this. Issues identified as urgent on previous visits to the home, and for which timescales for action were set, have not yet been attended to. The new extension at the home provides a large and pleasant lounge and dining area. Since the previous inspection this area has been finished off by the provision of coulourful curtains. The dining area is quite cramped and does not provide sufficient room for twenty four residents to sit up and eat at a table should they wish to do so. The current arrangement is that two large tables are set up in a ‘T’ shape so that residents all sit together. This restricts Ravensmere DS0000015463.V283328.R01.S.doc Version 5.1 Page 15 their options, and does not encourage them to make choices about where and who they might like to sit with. At lunchtime during the inspection some residents ate their lunch in armchairs from over bed style tables. Others were assisted with feeding whilst remaining in easychairs. This practice means that residents may not have the opportunity for a change of outlook or position for many hours at a time. This further reduces opportunities for activity and stimulation. The home has only two assisted bathrooms. A third one is available but has yet to have the floor mounted bath seat properly set up. In a letter to the commission dated 7th November it was stated that this would be completed by 30th November. All rooms have en suite facilities. The small size of many of these makes their use by residents, particularly where assistance is required, as in most cases, impractical. In one en suite area the toilet has yet to be connected. The home does not provide a sluice facility to assist with hygeine maintenance. The refurbishment process did not include consultation with an occupational therapist or other professional to ensure that the environment, aids and adaptations were suitable for the residents. Grab rails are provided in toilet areas to assist residents. The call bell system has been upgraded, but at inspection no call bells were provided in the communal areas of the home. At the previous inspection the company secretary said that no residents would use them, but undertook to ensure that these were put in place. This has not happened. The home is registered to provide care for residents with dementia. Appropriate levels of signage are not provided to assist them. In one bedroom wardrobes were labelled with the wrong names. Wheelchairs around the home were noted not to have footplates attached. The refurbishment process did not upgrade resident’s bedrooms to current standards. Wardrobe space is limited in some rooms. Most rooms have no lockable storage or bedside lighting. Residents do not have the option of keeping their rooms locked, as most bedroom doors are not fitted with locks. Many rooms do not have a homely feel, and some furnishings are shabby or broken. A shared and a single room for a potential new admission were viewed. In the single room the furnishings were shabby, with holes in the back of the wardrobe and the chest of draws labelled from a previous resident. The en suite was very small with the toilet not connected. In the shared room there was no dividing curtain, no lampshades, no headboards on the beds and no bedside/over bed lighting. An easy chair in the room was broken and potentially dangerous. It was concerning that staff and management at the home felt that these rooms would provide a suitable environment for a new resident to move into. Rooms provided must be suitable to meet residents assessed needs. The environment provided should not restrict residents potential for independence. During the inspection two staff, after to going to find footplates for the wheelchair, struggled to assist a resident in a wheelchair Ravensmere DS0000015463.V283328.R01.S.doc Version 5.1 Page 16 out of a bedroom where door/corridor angles were tight and restricted. This was clearly causing some distress to the resident. On the day of inspection the home was mainly well heated and ventilated. Radiators in two rooms on the second floor were cold and it was noted that additional freestanding heating had been provided. On the day of inspection the home seemed generally clean and, apart from isolated areas, was odour free. The laundry area of the home, although functional is not yet completed. There is no ceiling in place. A sink has now been fitted but this is not plumbed in so there are no suitable hand washing facilities for staff. This poses an infection control risk. Again, in a letter to the Commission dated 7th November it was stated that these works would be completed by 30th November 2005. The laundry area only provides one washing machine. It is questionable whether this is adequate for the size of the home, and allows no ‘safety net’ in the event of a breakdown. The person in charge was unsure of what would happen in such a situation. The laundry is situated in an internal part of the building. It is unclear how the room will be ventilated once the ceiling is in place. Some equipment in use at the home was not being maintained in a hygienic condition to protect residents. This included a track hoist and a raised toilet seat. Ravensmere DS0000015463.V283328.R01.S.doc Version 5.1 Page 17 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, 29 The home has a stable core group of staff. Development work is needed to ensure that recruitment procedures are established, and maintained to a high level to ensure the safe care of residents. EVIDENCE: The home has a stable group of core staff. Residents and a relative spoke well of the staff at the home, and positive interactions were observed. The homes rotas were viewed and showed that staffing levels at the home are currently being maintained at two/three care staff and one person in charge during the day, and two awake night care staff. Dependency levels at the home are quite high due to dementia and some resident’s mental health needs. Staffing levels therefore need to be kept under review to ensure that resident’s needs can be fully met. Of particular concern are night staffing levels. The building is on three floors and staff reported that nights can be very busy, as many residents require assistance. The company secretary reports that he is happy to flexible with staffing levels in response to residents needs. However this flexibility was not evidenced. Staff spoke of the recent difficult time with a new resident when no additional resources were provided to help them manage. Staff files were sampled and some anomalies were evident. One recently recruited member of staff had no file available, so it was not possible to see that a suitable recruitment process had taken place to safeguard residents. On arrival at the home this member of staff was working unsupervised with a resident. The company secretary stated that the Criminal Records Bureau check for this member of staff was in place but being ‘sorted out’. Although it Ravensmere DS0000015463.V283328.R01.S.doc Version 5.1 Page 18 was stated that this member of staff was on their induction and had only worked at the home for three or four weeks, they were clearly shown on the homes rotas from 19/12/05. It was advised that the recruitment records for this member of staff must be made available to CSCI early in the week following the inspection. Ravensmere DS0000015463.V283328.R01.S.doc Version 5.1 Page 19 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, 34, 37, 38. So that residents are cared for safely, and the home managed effectively, staff left in charge of the home must be given the appropriate level of knowledge and skills. Development is needed to make sure that staff are fully trained in core areas such as food hygiene. EVIDENCE: Not all elements of these standards were assessed. In spite of previous requirements and correspondence Health and Home had consistently failed to put forward a suitable applicant to become the registered manager at the home. The home has therefore been without a manager for over two years. This has not been an acceptable situation, and has called into question the fitness of the company. The company secretary has now applied to be the registered manager at Ravensmere Rest Home. The staff member in charge of the home at the time of the inspection was very helpful, and was knowledgeable in some areas. However they had been left in Ravensmere DS0000015463.V283328.R01.S.doc Version 5.1 Page 20 a vulnerable position with insufficient knowledge and information left at their disposal. They were unaware of how long the company secretary was to be away for, or of what to do if they were unable to contact him, or another director, in the event of an emergency or other situation. The company secretary stated that he was aware that he needed to develop staff in these areas. Although standard 33 was not assessed at this inspection it was positive to note that the home achieved an Investors In People award in December 2005. There was no evidence at this inspection to suggest that the home is not financially viable. An in date employers liability certificate was in place. Records at the home are held securely and resident and staff confidentiality maintained. It was noted that the homes certificate of registration was not on display. Not all staff files were checked, but those sampled and staff spoken with indicated that moving and handling training has recently taken place. A current gas safety certificate could not be located. This was of particular concern as the area where one boiler is located is currently being ventilated by a large hole that has been made in the external wall of the building. The ‘keep locked’ doors to this area were found to be open presenting a potential hazard to residents. The company secretary was advised that a copy of the homes gas safety certificate must be forwarded to the CSCI during the week following the inspection. An accident record is maintained at the home. From this is was seen that the CSCI is not always notified of events as required under regulation 37. An example of this is a resident who sustained a fractured wrist. The person in charge was not aware of this requirement. To ensure adequate standards of hygiene kitchen cleaning schedules need to be developed and adhered to. At this inspection dirty cloths were noted to be in use. Containers used for the storage of cereals were worn and dirty looking. On the day of inspection the person cooking did not hold an appropriate food hygiene certificate. He stated that he had been given a book by the Company Secretary and was due to attend training soon. Through discussion it was shown that the cook did have an awareness of appropriate practices. Ravensmere DS0000015463.V283328.R01.S.doc Version 5.1 Page 21 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 X 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 2 2 2 X 1 2 1 STAFFING Standard No Score 27 2 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X 3 X X 2 1 Ravensmere DS0000015463.V283328.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? Yes 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 OP4 Regulation 18 Requirement Staff must receive training appropriate to the work they are to perform. This refers to the need for all staff to receive training in dementia care. Timescale for action 01/04/06 2. 3. OP7 OP10 15 12 4. OP12 16 Previous requirement of 01/02/06 not met. Care plans must be kept updated 01/04/06 and reviews undertaken identify and record any changes. The registered person(s) must 14/03/06 make arrangement to ensure that the home is run in a manner that respects the privacy and dignity of residents. This refers to the issues raised in the body of the report. The registered Person(s) must 01/04/06 ensure that the routines of daily living and activities made available, are flexible and varied to suit service user’s expectations preferences and capacities. This refers to the need for all service users to have meaningful activity and stimulation in accordance with their assessed needs. DS0000015463.V283328.R01.S.doc Version 5.1 Page 23 Ravensmere 5. OP16OP26 OP38 18 Previous requirement of 01/01/05 and 01/02/06 not yet fully met. Staff must receive training appropriate to the work they are to perform. This refers to the need for staff left in charge to have sufficient knowledge and skills to manage any situation and keep residents safe. 01/04/06 6. OP18 13 The registered person(s) must 01/04/06 ensure that residents are protected from harm. This refers to the need for all staff to be trained in adult protection issues, and in managing challenging behaviour. Previous requirement of 01/02/06 not met. Sufficient dining space and choice must be provided for the number of residents registered for. Previous requirement of 01/01/06 not met. 01/05/06 7. OP20 23 8. OP21OP19 23 The registered person(s) must provide sufficient assisted bathing facilities. 14/03/06 9. OP22 23 The premises must be suitable to 01/05/06 achieving the aims and objectives of the home. This refers to the need for appropriate aids and signage to be available to assist residents with dementia. Accommodation must be provided for each service user, which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. This refers to DS0000015463.V283328.R01.S.doc 10. OP24OP25 12, 16 01/03/06 Ravensmere Version 5.1 Page 24 the issues identified in the body of the report. Previous requirement of 01/02/05 not met. 11. OP26OP19 13, 16 The home must provide suitable and adequate laundry facilities. This includes proper hand washing facilities to maintain infection control. Previous requirement of 01/12/05 not met. 12. OP27 18 The registered person(s) must ensure that at all times sufficient staff are deployed to meet the health and welfare needs of residents. This refers to the need for a review of night and day staffing levels to be undertaken with the process and outcome being sent to CSCI. The registered person must operate a robust and thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. POVA 1st checks/CRB checks must be undertaken before staff commence their duties. Previous requirement of 01/12/05 not met. 14. OP30 18 01/04/06 Staff must receive training appropriate to the work they are to perform. This refers to the need for all staff to receive a comprehensive induction into the home and care practices. This standard was not fully assessed at this inspection and is carried forward. 01/04/06 01/03/06 13. OP29 19 01/03/06 Ravensmere DS0000015463.V283328.R01.S.doc Version 5.1 Page 25 15. OP33 24, 26 The Registered person must ensure that the home has effective quality assurance and quality monitoring / audit systems in place. Systems must seek the views of all stakeholders. The results of any surveys must be made available and sent to the CSCI. Visits as required under regulation 26 must be undertaken on a regular basis and copies of reports sent to the CSCI. This standard was not assessed at this visit. Regulation 26 visit reports are still not being received by CSCI on a regular basis. Previous requirement of 01/02/06 not yet fully met. 01/04/06 16. OP36 18 The registered person must ensure that care staff receive regular formal supervision. This standard was not assessed at this inspection and the requirement is therefore carried forward. 01/04/06 17. 18. OP37 OP38 CSA 28 13, 18 A current certificate of registration must be displayed. The registered person(s) must attend to the health and safety issues identified in the body of the report. 14/03/06 14/03/06 19. OP38 23 Up to date safety certification 16/02/06 must be sent in to the CSCI in respect of gas equipment used in the home. Ravensmere DS0000015463.V283328.R01.S.doc Version 5.1 Page 26 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. 3. 4. 5. 6. Refer to Standard OP7 OP9 OP9 OP13 OP16 OP22 Good Practice Recommendations The practice of keeping daily records and care notes separate from care planning information should be reviewed. The homes controlled drug cupboard needs to be re-fixed securely to a wall. Medication stored in the home refrigerator, must be stored properly. Suitable facilities should be provided for visitors. The homes complaints procedure should be on display for residents and visitors. Call bells should be provided in all rooms and communal areas. Ravensmere DS0000015463.V283328.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Ravensmere DS0000015463.V283328.R01.S.doc Version 5.1 Page 28 - 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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