Inspection on 24/05/07 for Ravensmere

This inspection was carried out on 24th May 2007.

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

The inspector 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 22/06/06

Ravensmere 11/02/06

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 Tim Thornton-Jones Unannounced Inspection 24th May 2007 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 Ravensmere DS0000015463.V341520.R02.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. Ravensmere DS0000015463.V341520.R02.S.doc Version 5.2 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 337585 Health and Home Limited Mrs Sheila Denis 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.V341520.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To provide care and accommodation for two service users, who are under 65 years of age whose details are known to the CSCI. 12th January 2007 Date of last inspection Brief Description of the Service: Ravensmere Rest Home is a care home operated by Health and Home Limited. The service is situated within 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 currently provides care and accommodation for up to 24 older people. The home is also registered to provide care for older people with dementia and mental disorders. Accommodation is provided on three floors in sixteen single and four double rooms. All but one room now has some form of en suite facility. A passenger lift provides access to most levels within the home. Four bedrooms at the home cannot be directly accessed by the lift. Service users being accommodated within these rooms must be able to negotiate some stairs. Limited parking is available at the front of the property, which has been laid to hard standing. There is a pleasant courtyard garden to the rear with outdoor seating. A copy of the homes Statement of Purpose is available in a folder in the homes lobby area or upon request. Current fees for the home were stated to be £551.25 per week although it is understood that this fee is dependent upon the specific service provided, particularly when providing a service to people with complex care needs. It was stated that there are no extra charges for example chiropody, toiletries, newspapers etc. Ravensmere DS0000015463.V341520.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place during one day. Managers, carers, service users and relatives were spoken with including a sample review of records and other documents held. Surveys were sent out to stakeholders prior to the inspection and a very good return was received. The surveys indicated overall that service users, relatives and healthcare professionals were happy with the service and several commented particularly well about the carers. Healthcare workers commented that the communication regarding service users needs between the healthcare team and the home had improved. The outcome of the inspection indicated that the service has been successful in addressing some previous shortfalls and continues to develop increasing good practice. What the service does well: What has improved since the last inspection? Some standards highlighted at the previous inspection have now been met and therefore represents a positive outcome for service users. Some parts of the premises have been improved by decoration. The Manager has now been registered with CSCI. Ravensmere DS0000015463.V341520.R02.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. The summary of this inspection report can be made available in other formats on request. Ravensmere DS0000015463.V341520.R02.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 Ravensmere DS0000015463.V341520.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon the inspected standards 1 and 3. Standard 6 does not apply to this service. This judgement has been made using available evidence including a visit to this service. Service users benefit from the approach used by the home to ensure that their assessed and known needs and preferences, as far as practicable, are understood and planned for before they enter the home. The information available about the home assists people with the process of indicating whether the service will meet their requirements. EVIDENCE: The service has recently revised the Statement of Purpose and following the inspection visit the revised document was viewed and confirmed as meeting the regulatory requirements. This document has been used throughout this report in helping to determine the service outcomes for service users. The Service Users Guide has also been revised and this too was deemed to meet the regulatory requirements. Ravensmere DS0000015463.V341520.R02.S.doc Version 5.2 Page 9 Admission criteria and assessment arrangements are specified within the Statement of Purpose. A sample was viewed based upon a recent admission and the process followed meets with the home’s policies and procedures and regulatory requirements. A trial period was offered and information about the service was available prior to admission. An introductory plan of care is compiled at the earliest opportunity based upon background information about the person and assessment information. The manager confirmed that all persons supported by the local authority have been assessed prior to admission. The sample taken demonstrated that local authority assessments were in place. The Manager advised that the service does not provide intermediate care service and therefore the key standard 6 was not assessed. Ravensmere DS0000015463.V341520.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon standards 7, 8, 9 and 10. This judgement has been made using available evidence including a visit to this service. Service users can expect to have their known and assessed needs met by carers who are supportive and caring. EVIDENCE: The care planning arrangements were sampled as part of the case tracking approach used. The sample demonstrated that the key elements of assessment, decision-making, review and monitoring were evident. The daily recording was comprehensive and linked to key elements within the plan of care. The plans seen had been reviewed appropriately and updated where necessary. The arrangements for links with healthcare professional such as GP’s and Community Nursing were well recorded and updated. All people living at the home are registered with a local GP. Various assessment data was evident and relevant to the healthcare needs of individuals. Ravensmere DS0000015463.V341520.R02.S.doc Version 5.2 Page 11 Information received from healthcare professionals indicated they considered the arrangement at the home to have improved since the current manager had been appointed. In discussion with the manager regarding healthcare matters, it was evident that a well-managed system of assessment and referral was in operation and that the relationship between the home and community professionals was communicative and co-operative. The lunchtime medicines administration was discreetly observed. Medicines are located within a mobile metal cabinet designed for the purpose. The carers who administered the medicines had received training and were observed to undertake the task in a careful, measured and professional manner. In practice, the administration record was checked by the carer and the medicines taken from the monitored dosage pack, placed in a small container and taken to each person, making sure the person had a drink and that the medicine had been taken by the person before returning to the record to sign the sheet. The cabinet was locked whilst the carer was away from it to maintain security and safety. The cabinet was well maintained and the administration associated with medicines received into and returned from the home checked as accurate. A full audit of all medicines was not undertaken on this occasion. As part of the inspection, opportunity was taken to speak with service users, relatives and to observe the interaction and practice between carers and service users. Throughout the lunchtime staff were very attentive and supportive to people who required varying degrees of help and encouragement. Carers were observed to be patient and offered positive choices to people and it was noticeable that carers were also alert to ‘keeping a supportive eye’ on people who needed less help but on occasions needing encouragement. This was undertaken in a discreet and empowering manner. Service users were cheerful and responded well to the approach of carers. Service users and relatives spoken with made positive remarks about the carers highlighting how helpful and cheerful they were. Relatives were pleased that whenever they visited they were made to feel welcome and particularly commented upon the polite manner in which they were received. Ravensmere DS0000015463.V341520.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon standards 12 to 15 inclusive. This judgement has been made using available evidence including a visit to this service. Services users can expect to be supported to exercise autonomy and choice about how they spend their time and to spend time with their relatives and friends. Service users can also expect to be provided with appealing and wellprepared meals. EVIDENCE: Two services users were spoken with during the inspection and several others for a short period. One person said that the staff were very kind and described the ways in which they supported the person on a day-to-day basis. The person stated they were not particularly interested in participating in activities. Activities are not scheduled or planned on a routine basis, although the Manager confirmed that occasional community based entertainers visit the home. Activities and social stimulation are undertaken on a day-to-day basis according to service user motivation and levels of interest. Carers were observed to engage with service users at various times during the day and taking time to have conversations although in the main these were brief as Ravensmere DS0000015463.V341520.R02.S.doc Version 5.2 Page 13 service users appeared only to cope with these type of interactions on a limited time basis due, it would appear, to the level of disability or mental health. One person was seen to go out accompanied by a carer. It was later confirmed that the person had been accompanied to the seafront. The service statement of purpose document has been recently reviewed to make clear to prospective service users and purchasers of the service the arrangement for activities, setting out the home ethos and philosophy. Based upon observation throughout the day of inspection the home was following its stated policy by engaging with service users when appropriate opportunity arises. This indicated a flexible approach to support and maximises service users capacity to exercise autonomy and choice. Relatives spoken with were supportive of the home’s view of choice and were complimentary about the way carer’s approach and support service users. The food provision was observed during the lunchtime meal. This was presented well and was of good proportion. One service user commented positively about the meals provided and two relatives expressed that during their visits they thought the food was of good proportion and looked appetising. Service users all appeared to enjoy the midday meal. Carers were observed to offer a positive choice and alternatives to people who were uncertain about whether they might like the second course. Those who required specially prepared meals were catered for and given appropriate support. The Manager advised that at the time of the inspection five people require assistance to eat a meal although this often varies. Ravensmere DS0000015463.V341520.R02.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon standards 16 and 18. This judgement has been made using available evidence including a visit to this service. The complaint policies and procedures within the service are robust and enable service users and their representatives to make representations about the service if they have concerns or are dissatisfied with the service received. The arrangements for safeguarding vulnerable adults are suitable to protect people from harm. EVIDENCE: The home was in possession of the local authority (Southend Borough Council) adult protection policy and also has produced a comprehensive internal policy and procedure. Recommendation was given that specific contact details would benefit from being included within the service procedure to ensure that carer’s are clear about who and how to contact within the local authority should a referral become necessary. There have been no reported safeguarding issues in relation to this service during the period since the previous key inspection. Based upon the sample of staff files and training information, carers have undertaken training about safeguarding vulnerable people. Ravensmere DS0000015463.V341520.R02.S.doc Version 5.2 Page 15 A complaint procedure and whistle blowing procedure was in place. The home has investigated one complaint since the previous inspection. The complaint was advised by the registered person to be not upheld. Ravensmere DS0000015463.V341520.R02.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate based upon standards 19, 22, 24, 25 and 26. This judgement has been made using available evidence including a visit to this service. Service users can expect to live in a safe and clean environment with access to specialist equipment to maximise their independence, however to ensure their safety the equipment should be regularly reviewed. EVIDENCE: A tour of the building was undertaken including all communal areas and some bedrooms. The building, overall, is adequately decorated although being of a Victorian era the premises does require regular and ongoing maintenance and improvements to be regularly reviewed. National Minimum Standards advise that a programme of routine maintenance and renewal of the fabric and decoration of the premises is produced and implemented with records kept. Whilst ongoing improvements have been made, it is recommended that the Ravensmere DS0000015463.V341520.R02.S.doc Version 5.2 Page 17 Registered Person set out the future improvements and developments for the service and share these with the Registration Authority as soon as practicable. The front access to the home has been improved by converting to an optional ramp access. The accommodation seen was mainly adequately decorated and service users and relatives spoken with said they thought the surroundings were satisfactory although some unspecified areas could be improved. The home has three bathrooms that include shower facilities. All bedrooms with the exception of one double have en-suite (toilet and hand wash basin). Five of the bedrooms have inclusive shower facilities. The service has a lounge dining room and also a quiet sitting area. The dining room does not accommodate all people who may wish to sit within this area. Service Users do take their meals in part of the sitting room using an individual table. Whilst this is not ideal, service users did manage well, some with support from carers. These arrangements remain as they were at the time the service registration was transferred under the Care Standards Act 2000. Adjacent to the dining room is an enclosed courtyard where service users sometimes choose to take meals in suitable weather. On the day of the visit, it was a hot day and service users were making use of the area. On 24th May 2007 the Registered Person advised the CSCI that an outbreak of Vomiting and Diarrhoea had occurred. A total of six service users were affected. The Manager contacted the Health Protection Agency and appropriate precautions and tests were undertaken. The Environmental Health Department of Southend Borough Council was advised. The symptoms subsequently subsided and the matter resolved. As part of an Environmental Health visit on 31st May 2007, the Borough Council advised, in a subsequent letter of the visit, to the registered person that some aspects of the food safety management system and implementation for this system required some improvement. We recommend that the measures advised within this report be implemented where necessary to ensure an improved outcome for service users. National Minimum Standards recommend the suitability of the building be formally assessed by a person with special knowledge of the service user group. The organisation does employ a moving and handling trainer who is able to make an assessment about the type and level of equipment in use although it may be worthwhile to seek a view from, for example, a specialist group concerned with dementia, about the layout of the building prior to any proposed improvements. The report from Southend Borough Council regarding Health and Safety matters highlighted that mechanical moving and Ravensmere DS0000015463.V341520.R02.S.doc Version 5.2 Page 18 handling equipment, including the passenger lift, was not subject to a suitable maintenance contract. We recommend that this matter be considered to ensure the health and safety aspect of the equipment protects service users. The service provides care and support to people who have mobility difficulties and the level and type of equipment was reviewed with the manager. The Manager confirmed that one mobile and two fixed hoists were available. One bathroom has overhead tracking fitted. Other mobile equipment was stated to include ‘Slider sheets’, assisted moving belts, various mobility hoist slings, and one ‘banana board’ for transfers. The Southend Borough Council report previously referred to also highlighted a need for the home to ensure that a safety check schedule for equipment is put in place and that a wider selection of hoist slings be available for use by people of varying sizes. We recommend that the measures advised by the Borough Council be implemented as part of safeguarding health and safety standards. There were no unpleasant odours found in any of the areas visited. furniture and fittings seen were adequate. The Ravensmere DS0000015463.V341520.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon standards 27 to 30 inclusive. This judgement has been made using available evidence including a visit to this service. Service users can expect to be protected by the home’s recruitment practice and be cared for by a staff team who attend training to keep their practice up to date on a regular basis. EVIDENCE: The service has developed a training schedule, which is focussed upon the key practice requirements in delivering the service in accordance with the Statement of Purpose. Each staff member works through a series of predetermined training associated with the care role such as moving and handling, food hygiene and safeguarding vulnerable adults, for example. The training is followed by an assessment of competence and knowledge. This is repeated periodically and is monitored by the senior management. The training material available is comprehensive and progressive in terms of acquiring skills and knowledge and some training is provided externally to the service in practice associated with care of people with dementia, mental health and infection control for example. The training and development approach is co-ordinated and delivered by the Manager, who is a qualified Further Education trainer and a Healthcare professional. Training records are maintained appropriately. Ravensmere DS0000015463.V341520.R02.S.doc Version 5.2 Page 20 Carer recruitment was checked via a sample of files and these were in accordance with the checks and information required by regulation. Checks included Criminal Record Bureau (CRB) and POVA 1st, references and validation of identity for example. Staff deployment remains similar to the previous inspection in that the registered person stated that a professional judgement is made, based upon a variety of management information including discussion with the manager and care staff. The registered person stated that such a method was successful in determining the required level of support, taking into account the skills and experience of the carers. The inspection did not conclude that the care staff compliment was failing service users, although it was not possible to be clear about the methodology used to calculate the level of care hours required to meet the needs of people at the home. The manager confirmed that during the last whole working week prior to the inspection the care hours deployed had been 350. The National Minimum Standard was not being met because no clear assessment method was identified. This matter was discussed at length with the registered person, who agreed to formulate a policy and procedure document that clearly sets out the various criteria used and the method adopted to arrive at a safe number of deployed hours to meet service users health and welfare needs. All carers are foreign nationals. A high proportion of carers employed at the service are nurse qualified following training and learning in their country of origin. The registered person confirmed that at least 50 of carers hold a qualification to at least equivalent to NVQ level 2. The manager confirmed that 10 of the 13 carers employed are nurse qualified. It is recommended that a full list of care workers, together with their obtained qualifications be compiled to enable an accurate review of the proportion of qualified carers to be more easily identified. The registered person is advised that only suitable nurse training may be accepted as appropriate, for example carers who may have previously trained as midwives, whilst achieving some degree of care practice knowledge and competence, would not be considered as fully appropriate for calculating the numbers of carers who are ‘qualified equivalent’. As previously stated within this report carers were observed throughout the day of inspection and some were spoken with individually about the work they do at the home. The conclusion reached was that the care team work well together and communicate appropriately to support service users and presented as having a strong sense of commitment to service users. Ravensmere DS0000015463.V341520.R02.S.doc Version 5.2 Page 21 Relationships between those who work and live at the home appeared genuine and carers were consistently observed to be considerate, polite and helpful. This was also the overview of information obtained from service users and relatives spoken with on the inspection day and from surveys prior to the visit. Ravensmere DS0000015463.V341520.R02.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate based upon standards 31, 33, 35, 36 and 38. This judgement has been made using available evidence including a visit to this service. Service users can expect to live in a home that is managed by a competent and experienced person who provides leadership and support to the care team. EVIDENCE: The registered manager is both experienced and qualified in healthcare and further education. In discussion the manager was able to demonstrate a clear understanding of supporting carers and leadership skills. The care management systems are well maintained overall. The home is developing a quality assurance and monitoring approach. At the time of writing this report the service had not completed and returned its Ravensmere DS0000015463.V341520.R02.S.doc Version 5.2 Page 23 Annual Quality Assurances Assessment (AQAA). The most recent stakeholder questionnaires from the service were sent out July 2006. The results had been collected and some analysis has been undertaken but no resulting action plan has been produced. It is recommended that the quality assurance system to have clear quality statements on which a measure can be drawn about the perceived quality of the service based upon consultation with consumers about their experience of the service. There was indication that quality specifications had been used to ensure that a reliable measure of quality is being achieved although the questions asked within the questionnaires were based upon qualitative aspects of the service provided. We sent surveys to consumers via the home to request information about their satisfaction with the service. A total of 24 surveys were returned. These were from relatives, service users and healthcare professionals. Overall, the views expressed by all stakeholders were positive. A number commented that the service had considerably improved over the recent few months. A high proportion of opinion centred upon the kindness and attentiveness of carers and this aspect was seen throughout the inspection visit. The links between the home and relatives were stated to be positive. The home does not hold cash in safe custody on behalf of service users as any additional expenses to the weekly fees are invoiced separately. Concern about health and safety matters had been raised by Southend Borough Council Environmental Health Department and at the time of writing this report, the registered person had not confirmed to the Council that the matters they had raised had been addressed by the home. Health and safety matters were considered regarding fire protection and supporting systems such as emergency lighting and portable appliance testing, and the safety related systems were being regularly reviewed by a contractor. There were no obvious hazards noted. Based upon the report/letter received by Southend Borough Council highlighting concerns regarding health and safety we recommend the matters stated are responded to and resolved as appropriate. The support and supervision of carers was reviewed. The formal supervisory sessions are recorded within a well-planned document, and based upon the sample, were undertaken on a regular basis. Each carer has a supervisory contract, which sets out the roles and responsibility for both parties to the supervisory process, which reflects good practice. In observation there was a sound team spirit and carers worked co-operatively with each other indicating a team approach to the tasks in hand. The Manager undertakes some on-thejob supervision discreetly and appropriately as required and also receives regular supervision. Ravensmere DS0000015463.V341520.R02.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 X 3 3 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X N/A 3 X 2 Ravensmere DS0000015463.V341520.R02.S.doc Version 5.2 Page 25 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 OP33 Regulation 24(1)(5) Timescale for action The service is required to 31/08/07 establish and maintain a system for evaluating the quality of the services provided and provides for consultation with service users and their representatives. There must be at all times 31/08/07 suitably qualified, competent and experienced persons working at the care home in numbers appropriate to meet the health and welfare needs of service users. Previous requirement date of 01/04/06, 14/8/06 and 31/03/07 not met. Requirement 2 OP27 18(1)(a) Ravensmere DS0000015463.V341520.R02.S.doc Version 5.2 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 Refer to Standard OP19 Good Practice Recommendations National Minimum Standards advise that a programme of routine maintenance and renewal of the fabric and decoration of the premises is produced and implemented with records kept. Whilst ongoing improvements have been made, it is recommended that timescales for improvements and developments are set out for service users and this plan copied to CSCI as soon as practicable. The safeguarding adults procedure is recommended to be reviewed to ensure that information is included to link the home procedure with the Local Authority procedure; i.e. contact names and numbers. Following the recent visit/inspection by Southend Borough Council it is recommend that the response to the Council is copied to CSCI to inform on the developments and plans the home is making to improve health and safety monitoring. You are recommended to seek advice regarding ways in which the home environment could be improved to assist people with a dementia. 2 OP18 3 OP26 4. OP22 Ravensmere DS0000015463.V341520.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ravensmere DS0000015463.V341520.R02.S.doc Version 5.2 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. 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!