Inspection on 06/12/05 for Ravensmount

This inspection was carried out on 6th December 2005.

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

Ravensmount 15/01/09

Ravensmount 11/08/08

Ravensmount 13/08/07

Ravensmount 22/01/07

Ravensmount 04/07/05

Ravensmount 25/11/04

Ravensmount 13/07/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Ravensmount Alnmouth Road Alnwick Northumberland NE66 2QG Lead Inspector Anne Urwin Brown Unannounced Inspection 6th December 2005 12.15 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 Ravensmount DS0000060366.V255948.R02.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Ravensmount DS0000060366.V255948.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ravensmount Address Alnmouth Road Alnwick Northumberland NE66 2QG 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) 01665 603773 01665 603773 ravensmount@tiscali.co.uk Moorlands Care Homes (N.E.) Limited Mrs Margaret Walton Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Ravensmount DS0000060366.V255948.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th July 2005 Brief Description of the Service: Ravensmount is a large detached house that has been extended to provide more spacious accommodation. It is registered to accommodate up to thirty older people. Moorland Holdings NE Ltd is the service provider. Ravensmount is located on the edge of Alnwick and there is a local bus service to Alnwick town centre from just outside the home. Main line train services run from Alnmouth a few miles away. There are attractive public rooms in the home and all bedrooms have en-suite toilet and washbasin. Accommodation is arranged over three floors and a shaft lift is fitted. Ravensmount DS0000060366.V255948.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection involved talking to the manager, seven residents and six staff, a tour of the building and inspection of records. What the service does well: What has improved since the last inspection? What they could do better: More attention is needed to the general maintenance and refurbishment of the home as a large number of issues were identified. An appropriate programme of maintenance and refurbishment must be introduced. During the inspection a number of radiators were not working and repairs were needed. In one resident’s bedroom the use of an adaptor and two extension leads from one 13 amp plug was presenting a fire risk. These matters were the subject of an immediate requirement notice issued on the day of the inspection. The home’s management were required to address these issues within one week. A further visit confirmed that this had been done. There is a need to ensure all staff are aware of the need to respect residents’ privacy and further training is required. The provision of activities is limited and there is a need to provide a more varied programme for residents. Ravensmount DS0000060366.V255948.R02.S.doc Version 5.0 Page 6 Call system points must be fitted in the conservatory to ensure that residents are able to summon assistance as required. This matter was outstanding from the previous report. A number of issues were identified as needing attention and these were: • • • • • • • • • • Room 1- the window cannot be opened. Room 12 - the ceiling needs redecoration. Room 32 - paint to be removed from en-suite floor and ceiling to be repainted. Room 36 - bathroom refitting work to be completed as there is only one other bathroom on the first floor. The landing carpet needs replacement on the second floor as it is worn and is a trip hazard. Vinyl flooring was lifting in one bathroom on the first floor and was a potential trip hazard. A number of attic space doors are not secured. The bathroom floor had been washed and no sign was in use to warn residents. Most bedroom doors were propped open by wooden chocks and this practice must be reviewed. A broken cistern in the staff toilet requires replacement. Locks should be fitted to residents’ bedrooms that allow residents to lock their rooms, but also allow staff to access the room in an emergency. Residents should be provided with a key to their rooms unless a risk assessment suggests this may present a hazard. This matter was outstanding from the previous two inspection reports. 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. Ravensmount DS0000060366.V255948.R02.S.doc Version 5.0 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 Ravensmount DS0000060366.V255948.R02.S.doc Version 5.0 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): 6 Ravensmount does not provide intermediate care. EVIDENCE: Records and discussion with the staff confirmed that intermediate care is not provided at Ravenmount. Ravensmount DS0000060366.V255948.R02.S.doc Version 5.0 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, 9, 10 Each resident has an individual plan of care, however there is a need for more consistent recording and review of these. Some records are well kept, but others are not being updated to show changes. Residents are protected by the policies and procedures for dealing with medicines. Residents are satisfied that they are treated with respect and their right to privacy is upheld, however during the inspection one resident was receiving personal care from staff with the door open. EVIDENCE: Care plans are maintained and most showed a good level of information. Some plans had not been updated to reflect changes in care needs. A system for checking records by senior staff must be introduced to ensure that these are regularly updated to show any changes in care needs. The removal of a resident’s zimmer frame to prevent them walking unaided must be risk assessed and agreed with the resident and/or their family and the care manager. Written guidance is in place for staff dealing with residents’ medicines. Records are kept of the ordering, administration and disposal of medicines. Ravensmount DS0000060366.V255948.R02.S.doc Version 5.0 Page 10 Arrangements for the storage of medicines are satisfactory. Risk assessments are carried out if a resident administers their own medicines. Residents’ have lockable storage in their rooms. Records inspected during the inspection were in good order. During the inspection it was noted that there is frequent use of chocks to hold bedroom doors open. During the tour of the building a resident was receiving personal care from staff with the bedroom door open. Staff confirmed that privacy and dignity is included in staff induction training. Some staff were observed knocking on residents’ doors. Resident said that they felt satisfied that staff were aware of issues relating to privacy and dignity. Arrangements are in place for ensuring residents’ clothes are named and returned to them after laundry. No one is required to share a room unless it is his/her choice. Ravensmount DS0000060366.V255948.R02.S.doc Version 5.0 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, 14 Residents find the lifestyle experienced in the home generally matches their expectations and preferences, although some people felt that more activities are needed. Some residents are encouraged to retain interests they had before moving into the home. Residents are helped to exercise choice and control over their lives. EVIDENCE: Residents said that they are able to make choices about their daily routines, including when they get up and go to bed. Staff confirmed that residents are able to make choices about their daily routines, meals and personal and social relationships. Residents interests are recorded, however there is no record of activities kept. Staff said that there are regular bingo sessions and quizzes, but there was no evidence of any other organised activities. Residents said that at times they felt more activities or outings would provide them with more stimulation. Some residents are encouraged to keep up previous interests, including knitting and art and this is to be commended. Ravensmount DS0000060366.V255948.R02.S.doc Version 5.0 Page 12 Residents are encouraged to retain control of their own money for as long as possible. Staff said that risk assessments are carried out when there are concerns that a resident can no longer manage their money. There are discussions with the resident, family/care manager before making a decision about this. Senior staff confirmed that advice is provided if a resident wishes an advocate to represent their views. Residents are encouraged to bring in personal possessions when they come to live in the home and rooms show evidence of this. Access to records is referred to in policies and procedures as well as the residents’ guide. Residents said that they had not asked to see their records, but felt sure that they could see them if they wanted. Ravensmount DS0000060366.V255948.R02.S.doc Version 5.0 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): 18 Residents are protected from abuse. EVIDENCE: Written guidance is in place for dealing with allegations of abuse. Staff were aware of the procedures to be followed in the event of an allegation being made. One incident involving two residents has occurred since the last inspection and appropriate procedures were followed. Ravensmount DS0000060366.V255948.R02.S.doc Version 5.0 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, 25 Concerns were identified about outstanding requirements from previous reports concerning replacement of carpets on the top floor, lack of call system points in two sitting areas and the need for locks on bedroom doors that allow residents to lock their rooms, but also allows staff access in an emergency. The last issue was outstanding from the inspection carried out on 25 November 2004. An action plan was available, but targets were not met. There was evidence that an appropriate maintenance programme is not in place. EVIDENCE: The manager reported that an action plan was available identifying repairs required, but a high of number of issues had not been addressed. This action plan has been supplied to the owner. Outstanding issues include: • • • • Room 1- the window cannot be opened. Room 12 - the ceiling needs redecoration. Room 32 - paint to be removed from en-suite floor and ceiling to repaint. Room 36 - bathroom refitting work to be completed as there is only one other bathroom on the first floor. DS0000060366.V255948.R02.S.doc Version 5.0 Page 15 Ravensmount • • • The landing carpet needs replacement on the second floor as it is worn and is a trip hazard. A broken cistern in the staff toilet requires replacement. Call system points are needed in the conservatory. In addition during the inspection other concerns noted included: • • • • Vinyl flooring was lifting in one bathroom on the first floor and was a potential trip hazard. A number of attic space doors are not secured. The toilet floor had been washed and no sign was in use to warn residents. Most bedroom doors were propped open by wooden chocks. During the inspection the central heating system was not working throughout the home. Some of the radiators in public rooms and residents’ rooms were not working. Staff reported that the plumber is waiting for parts and will be coming back to replace/repair radiators. In view of the cold weather an immediate requirement was issued to the home’s management that the central heating system is checked to ensure all radiators are in good working order and that areas used by residents are heated appropriately. It was noted that halogen heaters are being used to supplement the heating and this practice must be discontinued in view of the fire safety risks. During a tour of the building it was noted that in room 15 there were more than seven electrical items running from one thirteen amp plug using two extension leads and one adaptor. The items included television, nightlights, radios, table and floor lamps. The light in room 15 is poor and attention needs to be given to providing better lighting. The wallpaper in this room is coming away from the wall. A halogen heater was also being used in this bedroom that could present a fire hazard. An Environmental Health inspection was carried out on 2/12/05 and this identified ten items of requiring further action. Ravensmount DS0000060366.V255948.R02.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 30 Residents’ needs are met by the numbers and skill mix of staff. Residents are in safe hands at all times. Staff are trained and competent to do their jobs. EVIDENCE: There were five care staff including one senior carer on duty at the time of this inspection. Three domestic staff are on duty each morning and the cook and two kitchen domestics. There are appropriate numbers of domestic staff. Staffing at night is adequate. Appropriate staffing levels were confirmed on the rota available. Residents said that there are sufficient staff to meet their needs and that staff respond promptly when they ask for help. Staff said that there are enough staff to cover the rota. Arrangements are in place for staff to access appropriate training in care. At the time of this inspection five staff were almost completed National Vocational Training at Level 2 and two were just starting this course. Two staff were starting Level 3 and one Level 4. Staff confirmed that they are able to undertake appropriate training in caring for older people. The manager confirmed that a training and development programme is in place for staff. Ravensmount DS0000060366.V255948.R02.S.doc Version 5.0 Page 17 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, 35, 38 The manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Residents are encouraged to control their own money except where they do not wish to or lack the capacity to do so. Safeguards are in place to protect residents’ interests. General arrangements are in place to protect and promote the welfare of residents. There is a need for domestic staff to use warning notices when they have washed bathroom flooring. EVIDENCE: The manager has a social work qualification and is experienced in caring for older people. A written job description is in place for the manager. There are clear lines of accountability within the home and the manager meets regularly with the owner. The manager undertakes regular training and records confirm this. Ravensmount DS0000060366.V255948.R02.S.doc Version 5.0 Page 18 Written guidance is in place for dealing with residents’ money. Records are kept of any money held on behalf of residents. Receipts are kept for any transactions. Samples of the money held for residents were checked and these corresponded with the money held. Arrangements for storage of residents’ money are satisfactory. Each resident has lockable storage in his/her room to keep valuables or money safe. Staff have regular training in moving and handling, first aid, fire safety, food hygiene and infection control and records confirm this. Written guidance is in place for Health and Safety and Infection Control. Appropriate records are kept of regular testing and servicing of the fire alarm and fire equipment. Records are kept of fire training and of fire drills and these show appropriate arrangements are in place. Accident records are maintained in an appropriate form. During the inspection it was noted that a bathroom floor was wet and no warning notice was in place. Staff confirmed that they receive appropriate induction training that includes information about safe working practices. Records confirm this. Ravensmount DS0000060366.V255948.R02.S.doc Version 5.0 Page 19 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 1 X X X X X 2 X STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 3 Ravensmount DS0000060366.V255948.R02.S.doc Version 5.0 Page 20 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 OP10 Regulation 12 Requirement Residents’ privacy must be respected at all times. A review of staff training is required to ensure all staff are aware of issues relating to privacy and dignity. An activity programme must be introduced and a record kept of all sessions arranged. The central heating system must be checked and radiators not working must be repaired or replaced. The provision of electrical sockets in room 15 must be reviewed and steps taken to ensure sufficient points are available. The use of adaptors and extension leads must be discontinued where the power used exceeds 13 amps. Call system points must be fitted in the conservatory to ensure that residents are able to summon assistance as required. This matter is outstanding from the report of 4 July 2005. The sitting area outside the DS0000060366.V255948.R02.S.doc Timescale for action 28/02/06 2 3 OP12 OP25 16 23 28/02/06 16/12/05 4 OP25 23 16/12/05 5 OP22 23 31/01/05 6 OP19 23 31/01/06 Page 21 Ravensmount Version 5.0 7 OP19 23 second floor flat must be redecorated. The carpet in this area and at the entrance to the lift on the second floor requires replacement. This matter is outstanding from the previous two reports. The issues identified within this report as outstanding must be addressed to ensure the environment is safe, well maintained and comfortable for residents: • Room 1- the window cannot be opened. • Room 12 - the ceiling needs redecoration. • Room 32 - paint to be removed from en-suite floor and ceiling to be repainted. • Room 36 - bathroom refitting work to be completed as there is only one other bathroom on the first floor. • The landing carpet needs replacement on the second floor as it is worn and is a trip hazard. • Vinyl flooring was lifting in one bathroom on the first floor and was a potential trip hazard. • A number of attic space doors are not secured. • The bathroom floor had been washed and no sign was in use to warn residents. • Most bedroom doors were propped open by wooden chocks and this practice must be reviewed. • A broken cistern in the staff toilet requires replacement. DS0000060366.V255948.R02.S.doc 28/02/06 Ravensmount Version 5.0 Page 22 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 OP24 Good Practice Recommendations Locks should be fitted to residents’ bedrooms that allow residents to lock their rooms, but also allow staff to access the room in an emergency. Residents should be provided with a key to their rooms unless a risk assessment suggests this may present a hazard. This matter is outstanding from the previous two reports. Ravensmount DS0000060366.V255948.R02.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Ravensmount DS0000060366.V255948.R02.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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