Inspection on 14/09/05 for Ravenswood

This inspection was carried out on 14th September 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ravenswood 06/07/06

Ravenswood 09/03/06

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Ravenswood 15 The Avenue Kidsgrove Stoke on Trent Staffordshire ST7 1AT Lead Inspector Peter Dawson Announced Inspection 14th September 2005 09:00 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 Ravenswood DS0000064271.V249804.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Ravenswood DS0000064271.V249804.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ravenswood Address 15 The Avenue Kidsgrove Stoke on Trent Staffordshire ST7 1AT 0121 358 2258 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) Mr Jasbir Singh Johal Mrs Surinder Kaur Johal Rita Lynne Scarlett Care Home 24 Category(ies) of Dementia - over 65 years of age (8), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (2), Old age, not falling within any other category (24) Ravenswood DS0000064271.V249804.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd March 2005 Brief Description of the Service: Ravenswood is a large pleasant, detached property set in secluded gardens of over an acre and very close to Kidsgrove town centre. The property has been extended to provide excellent facilities. Furniture, fittings and equipment are to a high standard and well maintained. The main building accommodates up to 19 people, the annexe in the grounds provides accommodation for up to 5 people on the ground floor. There are 4 shared bedrooms and a total of 5 ensuite bedrooms. The home has registration for up to 8 people with dementia and 2 people with mental health needs. There is presently no registration for people with a physical disability. Ravenswood DS0000064271.V249804.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. At the time of this announced inspection there were 20 people in residence including one person receiving respite care. There were 4 vacancies in the home which is unusual but result of several recent deaths in the home of longstanding residents. A pre-inspection questionnaire was completed by the Manager. Ten feed back forms were each received from residents and visitors (20 in total) and generally indicated satisfaction with the care provided at Ravenswood. Some indicated that they were not aware of inspection visits and did not have access to inspection reports. The home will make these available in future to all visitors. Feedback indicated that not all events had been notified to relatives in relation to accidents or referral to GP. The Manager will ensure that all staff are aware of the importance of this action. The ownership of the home has changed since the last inspection. The new proprietors keen to continue to make improvements to the home and there was evidence of this. The new proprietors have had meetings with staff and there has been a very positive opening dialogue. Relatives indicated they had been approached by the proprietor and saw this very positively. The new Proprietor and Registered Manager provided positive and open information to the inspector during the inspection which was helpful. Most residents were seen and a large proportion spoken to both in the main building and the annexe. All were very positive about the care they received and had not complaints. Two residents identified a matter relating to the dignity of a resident and the Manager will deal with this in a sensitive way. Two visitors were spoken to. One expressed a high level of satisfaction following his wife being transferred from a nursing home to Ravenswood. He visits at least one daily and is welcomed into the home and involved in ongoing discussions about his wife’s care. There were several examples of residents chosen lifestyles being accommodated. They a mentioned in the body of the report. The home has a very positive philosophy about this aspect of care. Several new residents were seen and indicated a high level of satisfaction with care provision, spoke highly of staff and indicated that staff had assisted them to settle quickly and well into the home. The home has recently been granted new category of MD (Mental Disorder) for admission of new residents and the numbers of DE (Dementia) increased from Ravenswood DS0000064271.V249804.R01.S.doc Version 5.0 Page 6 6 – 8 people. The Manager is aware of the importance of carefully integrating suitable persons into the home with those needs. Care plans were found to be good and comprehensive. Matters relating to health care were inspected and early identification of health care needs recorded and acted upon. This was a very positive inspection with the new proprietor and the Manager. What the service does well: What has improved since the last inspection? Recruitment procedures have been improved following previous requirement. All documentation is now in place for all new staff improving protection for residents. Health care record sheets have provided clearer and concise readily available information relating to health care matters. A fire risk assessment has been completed. Training for all staff in medication administration and first aid. Vast improvements to the toilet and en-suite areas with non-slip vinyl flooring fitted. This has particularly helped in relation to a specific continence management problem. Entertainment has been introduced into the home on a 2 weekly basis and much enjoyed and welcomed by all residents. Ravenswood DS0000064271.V249804.R01.S.doc Version 5.0 Page 7 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. Ravenswood DS0000064271.V249804.R01.S.doc Version 5.0 Page 8 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 Ravenswood DS0000064271.V249804.R01.S.doc Version 5.0 Page 9 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): 1-5 The statement of purpose has been revised. Further additions are required as discussed. There was evidence of pre-admission procedures being followed in the interests of residents. EVIDENCE: The previous statement of purpose required updating. There has been a change of ownership of the home also and a new statement been provided. Some further additions are required as discussed with the manager and proprietor. A copy of the statement of purpose will be given to all residents and copy available in the home for residents and visitors. Funded residents are provided with contracts by the Local Authority, self funding residents are provided with contract by the home (not seen on this visit and will be examined on the next inspection). Ravenswood DS0000064271.V249804.R01.S.doc Version 5.0 Page 10 Prospective residents are given to opportunity where possible to visit the home prior to admission. All prospective residents are seen in their current environment and assessed prior to admission by the registered manager. The homes capacity to meet needs are outlined in the statement of purpose. Authorisation has been given to admit up to 2 people with mental health needs. Staff have received training in this area of work. Residents admitted since the last inspection were seen and their documentation confirmed that pre-admission procedures followed where possible. Care Management and the homes own assessments were on file and provided the basis for completion of care plans. Ravenswood DS0000064271.V249804.R01.S.doc Version 5.0 Page 11 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 - 11 The home has a good record of health care awareness and working with health care professionals. Personal care is provided with privacy and dignity. A matter raised by residents will be actioned by the Manager. Standards relating to health and personal care were found to be met. EVIDENCE: Care plans were sampled and found to be comprehensive and based upon assessed need. Plans are reviewed on a monthly basis by the home and placements reviewed with residents, relatives and social workers on at least an annual basis. Care plans for recently admitted residents were seen and had been compiled giving all relevant information to provide care. Risk assessment relating to resident activity were seen to be in place and reviewed also. The home has a good record if early identification of health care needs and referral to health care professionals. This includes physical and psychological matters. If there are concerns about behaviour or mental health status Ravenswood DS0000064271.V249804.R01.S.doc Version 5.0 Page 12 referral is made to social workers for re-assessment, to CPN/GP for review or specialist referral to Consultant Psychiatrist. There are positive relationships with the paramedic service and 5 GPs from local health centres. Regular checks on health and medication reviews were evident from documentation inspected and ongoing appointments with hospital specialists monitored and kept. The home have provided a health care record sheet for each resident following requirement of the last inspection, this gives a chronological record of all health care interventions. Relatives are kept informed of changes in health care needs, although relatives spoken to by the inspector indicated they had not always been advised of changes or of falls in the home. The Manager is keen to remedy this and will discuss the importance with staff and ensure staff contact relatives and record all such changes/events. Medication is provided by Lloyds chemists in Nomad cassettes (MDS). The system was inspected and there was accurate recording of medication given, regular reviews of medication and a safe system in place. Proposals to provide night time medication for a newly admitted resident no on any medication had been refused by the Manager. This is a positive approach in monitoring sedative medication being inappropriately prescribed. Personal care is provided with required privacy and dignity. Two residents did raise the question of the dignity of a confused man and the Manager will take steps to ensure his dignity is secured at all times. It is reported that residents see health professionals in the privacy of their bedrooms. The “treatment room” (used to store medication, care plans etc) must not be used for health personnel to treat residents. Privacy locks are provided on all toilet/bathroom areas. There have been 7 deaths in hospital and 4 in the home in the past 12 months. This is an unusually high number but includes several residents who have been resident for many years at the home. Dying and death was discussed in the context of those deaths and it was clear that the principles of Standard 11 had been sensitively and appropriately applied in all situations. Ravenswood DS0000064271.V249804.R01.S.doc Version 5.0 Page 13 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 - 15 Entertainment is now provided in the home fortnightly. This is a welcome addition. Staff continue to provide individual support and group activities on a daily basis. Relationships with families and friends are very positively promoted. Food provision is being reviewed/ improved to provide greater choice and satisfaction. EVIDENCE: Activities are initiated by staff on a spontaneous basis. Staff have been seen to provide group activates (bingo seen during inspection) but individual engagement and discussions between residents and staff are a positive feature in the home. There are close relationships/friendships established in this small home. At the time of the last inspection some residents indicated in feedback that social activities could be extended and this was recommended. Entertainers are now visiting the home (did not previously) on a fortnightly basis and residents clearly looking forward to and enjoying the experience. This further supplements the ongoing daily activities/communications in the home and is a positive addition. Ravenswood DS0000064271.V249804.R01.S.doc Version 5.0 Page 14 Routines of daily living indicated flexibility – residents arriving late for breakfast, meals served in bedrooms, visitors accommodated. Preferences of choice of rising, retiring, bathtimes and likes/dislikes are known and recorded for all residents. Chosen lifestyles are understood and positively promoted by the home – a recently admitted resident is visited usually twice daily by her husband and there is an open visiting policy supporting the concept of shared care. The visitor confirmed this to the inspector and expressed his delight in the changes following transfer from a nursing home. Another male short stay resident has visiting female friend who is encouraged to visit as often as possible. A couple resident at the home have decided to share their time, life and space together and this has been supported by the home, involving discussions with relatives etc. The couple are more than happy about the acknowledgment and support from staff in their decision and their wishes. They both state their quality of life has been vastly improved. Some changes/improvements to food provision have been made by the new owners. Some residents felt their could be improvement which they indicated in feedback forms sent to the Commission. Menus are currently being reviewed to provide more adventurous dishes, at the same time allowing traditional fayre, required by many residents to continue to be an option. The changes in process will be fully discussed with residents prior to new menu compilation. The objective is to give varied choice of dishes and a high quality diet. Ravenswood DS0000064271.V249804.R01.S.doc Version 5.0 Page 15 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 Standards relating to Complaints and Protection were found to be met. EVIDENCE: There is a complaints procedure in place which complies with Regulation 22 and all residents have a copy of the procedure. There is a suggestion box in the reception area for other or anonymous complaints or expression of views. The home has not received any complaints since the last inspection. The Commission have not received any complaints since the last inspection. There is a policy/procedure relating to abuse. All staff are given a copy and sign to confirm that. Staff are aware of the broad definitions of abuse. The home have provided a policy required at the last inspection, relating to aggression from residents. Ravenswood DS0000064271.V249804.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 - 26 There is a good standard environment. The new proprietors have commenced their own improvement programme. Hot water fail-safe devices are not fitted to bathrooms and this must be done immediately in the interests of safety. The inspector had been advised by the former owners that these had been fitted but this was not correct. Some improvements are required in relation to infection control and requirements are made in relation to this. EVIDENCE: The home has an excellent location, set in extensive peaceful, private and secluded grounds yet only 50 metres from the town centre. The location is suitable for the stated purpose of the home. Residents use the garden area extensively throughout the summer months and a gazebo and range of suitable seating provided for their comfort. Ravenswood DS0000064271.V249804.R01.S.doc Version 5.0 Page 17 There is a high standard physical environment improved and maintained over the years. Furniture, fittings and equipment are generally to a good standard. Discussions with the new proprietor of the home revealed that there did not appear to be fail-safe valves fitted to the 3 bathrooms in the home, although the previous owners had indicated there were controls. The new proprietor understands the importance of providing adequate controls for hot water for full body submersion and will act swiftly to provide controls on the three baths He wishes also to consider possible controls on all hot water outlets in resident areas. Weekly random tests of hot water areas must continue regardless. Improvements to the environment have already been made by the new proprietors. Non-slip vinyl floor has been installed in all toilet and en-suite areas, the main objective being to assist in continence management and the management of mal-odours. The flooring is well fitted, attractive and made the required improvements. New carpets have been fitted in the corridor areas in the main building and annexe. Communal and bedroom areas of the home are adequately furnished and there has been an ongoing refurbishment programme in those areas. Bedrooms are furnished individually and there is good personalisation of bedrooms with personal effects. All bedrooms have lockable facility for valuables/medication as required. The door to the toilet area in the annexe could not be opened easily and this requires attention. Some aspects of infection control require attention: In the main building and annexe commode pots and urine bottles were washed and stored in the baths. This practice must cease in the interests of good infection control practice and the Manager will ensure alternative processes are put into place. It is strongly recommended that the “red bag” system for handling incontinent laundry should be introduced to reduce the manual handling of soiled laundry thereby improving infection control. This would also save staff time. Standards of cleanliness throughout the home are consistently high with good cleaning routines in place. Ravenswood DS0000064271.V249804.R01.S.doc Version 5.0 Page 18 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`- 30 Staffing levels are satisfactory to meet the needs of the resident group. Required statutory training has been provided for all staff with the exception of Food & Hygiene for catering staff, this must be arranged. NVQ training meets required targets. Recruitment procedures have been improved and are now satisfactory. There is an indication that staff are suitably trained and competent to meet the needs of residents. EVIDENCE: One part time recently appointed care assistant has left after reliability proved inadequate, there is presently a vacancy. New cooks have been appointed but require food hygiene training. The staff group are fairly static in this home, there is always a relaxed atmosphere and good staff commitment to resident care. The staffing levels remain the same as required at April 2002 levels. The weekly number of care hours are 542. This is for the main building with capacity for 19 residents and the annexe with 5 residents. There is one person on duty in the annexe throughout the 24 hour period. There are presently 4 vacancies for residents in the main building which is unusual for this home but Ravenswood DS0000064271.V249804.R01.S.doc Version 5.0 Page 19 the staffing level must be maintained in consideration of the dependency levels and geography of the home. Staff records were sampled. Recruitment procedures have improved with required documentation in place. This was a requirement of the last report and has been provided as required. All documents in Schedule 2 are now provided for new staff. All CRB checks, references, etc. had been obtained as required. NVQ training in the home has been good. There are 20 care staff and 11 have completed NVQ2 training or above. A further 8 are being proposed for courses commencing early 2006. The home does in fact meet the required standard of 50 of NVQ trained staff by 2005. There has been staff training in First Aid, Fire Awareness, Food & Hygiene and medication since the last inspection. All staff administering medication have not received accredited training. Virtually all staff have received first aid training, half have received updated training since the last inspection the remaining half planned for October 2005 at which point all staff will have received updated training to last for 3 years. A moving and handling course is planned and the home are reminded that new employees must not be involved in moving residents unless they have received such training. Supervision is in place for all staff. The Manager supervises Senior Carers and Senior carers supervise care assistants. Ravenswood DS0000064271.V249804.R01.S.doc Version 5.0 Page 20 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): 31-33 and 36 - 38 There is evidence of open management in the home promoted by the new proprietors. The Manager has the experience to run the home and is undertaking the necessary study to complete the Registered Managers Award. Residents and observations indicated the home is run in the best interests of residents. Staff supervision is in place and policies/procedures ensure protection of residents. Two aspects of Safe Working practices relating to infection control practice require action which was discussed and agreed with proprietor and manager. The discovery that hot water controls had not been fitted to baths was not known to the inspector, manager or proprietor and requires urgent action to ensure safety. Ravenswood DS0000064271.V249804.R01.S.doc Version 5.0 Page 21 EVIDENCE: The Manager has the required experience to run the home and has completed NVQ3. She has just commenced training in NVQ4 which is a requirement of the standards by 2005. The Registered Manager works hands-on on the rota and provides a positive lead in the home. There is an open approach in managing the home which is communicated to staff. It was suggested that surveys available to new residents to record levels of satisfaction with service should be extended to all residents on an annual basis. There are regular residents meeting which are minuted. Anonymous suggestions and comments can be made by residents and visitor if they wish. Some relatives indicated in feedback forms that they were unaware of arranged inspection visits and did not see inspection reports. A notice of pending inspection is posted in the main building but not the annexe and this will be done in future. Inspection reports are not available to residents and visitors and these will now be made available for all visitors. Residents finances were not inspected on this visit. The financial viability of the home was discussed in detail with the new owners prior to purchase and there are strong indications of finance being available to the proprietors which secures the financial viability of the home. The proprietors are planning an extension to the home in the future. Safe Working Practices were inspected as follows: All staff have received moving and handling training and required updates. Further training only required at this time for new staff. Fire records were seen and all checks and servicing of fire equipment had been carried out as required. Some action is required in relation to fire doors. The door next the kitchen in the ground floor corridor must be fitted with a self closing device immediately to ensure safety. All fire doors must be checked so that self closing devices close onto the door rebates to provide the required protection in the event of fire. First aid training has been provided for all staff and updates arranged or completed. This is adequate to ensure one trained person on duty at all times. Ravenswood DS0000064271.V249804.R01.S.doc Version 5.0 Page 22 Food hygiene training has been provided for most care staff but newly appointed catering staff have not received such training. This is required as soon as possible and exposes the home in the event of any outbreak of food related infection. Two aspects of infection control practice require action as stated previously: 1. Commode pots must not be placed in baths. 2. Use of the red bag system (degradable) for incontinent laundry would greatly improve infection control practices. Regular servicing of equipments were sampled and had been carried out at required intervals. Automatic hot water temperature controls on baths must be fitted immediately as stated previously. The kitchen area was not inspected on this visit. This will be carried out on the next unannounced inspection. The premises are secure and there are restrictors on all opening windows. Risk assessments are in place as required for all resident activity. All incidents required to be reported to the Commission under regulation 37 had been received. There has been an improvement in notifications of accidents as required to the Commission. Ravenswood DS0000064271.V249804.R01.S.doc Version 5.0 Page 23 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 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 3 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 3 18 3 2 3 3 3 3 3 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x x 3 3 2 Ravenswood DS0000064271.V249804.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? NO 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 38 Regulation 23(4) Requirement Fit self-closing device to corridor door to ensure protection in the event of fire and check all selfclosing fire doors close directly onto the door rebates. Pre-set valves must be fitted to all baths as a matter or urgency Commode pots/bottles must not be placed in baths in the interests of infection control. The disposable red bag system for incontinence laundry is recommended. Door to toilet in annexe to be repaired to provide ease of access Provide food hygiene training for all catering staff. Timescale for action 14/09/05 2 3 25 26 13(4)(a) 13(3) 14/09/05 14/09/05 4 5 19 38 23(2) 16(2)(j) 14/09/05 30/10/05 Ravenswood DS0000064271.V249804.R01.S.doc Version 5.0 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard 33 1 Good Practice Recommendations Inspection reports must be made available in the home for residents, visitors and staff. Additions to the Statement of Purpose are needed as discussed. Ravenswood DS0000064271.V249804.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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