Inspection on 18/07/08 for Ravenswood

This inspection was carried out on 18th July 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ravenswood 30/09/09

Ravenswood 06/07/09

Ravenswood 03/04/09

Ravenswood 28/07/06

Ravenswood 03/02/06

Ravenswood 28/10/05

Ravenswood 25/01/05

Ravenswood 05/05/04

Ravenswood 05/02/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOME ADULTS 18-65 Ravenswood Lansdown Road Westal Green Cheltenham Glos GL50 2JA Lead Inspector Mr Simon Massey Unannounced Inspection 18 & 22nd July 2008 10:00 th Ravenswood DS0000016553.V368821.R01.S.doc Version 5.2 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 DS0000016553.V368821.R01.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ravenswood DS0000016553.V368821.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ravenswood Address Lansdown Road Westal Green Cheltenham Glos GL50 2JA 01242 256900 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) Gloucestershire Community Care Group Mrs Mavis Ann Gardner Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Ravenswood DS0000016553.V368821.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Manager to complete NVQ level 4 Registered Managers Award by 2005. Manager to attend a Health & Safety for Managers course Date of last inspection 28th July 2006 Brief Description of the Service: Ravenswood House provides residential care for adults with learning disabilities who may present with behaviour that challenges. The home is a large detached house situated on a main road close to Cheltenham town centre. The location enables service users to access a range of local amenities. Accommodation is provided on the ground and first floor. On the ground floor there are three bedrooms, a large lounge, a separate dining room, kitchen, laundry, toilet and bathroom. On the first floor there are six bedrooms, one of which has en-suite facilities, a shower room, bathroom, office and sleeping in room. To the rear there is an attractive secure garden. To the front of the property there is a car parking area. The home has its own people carrier. Ravenswood is one of three homes owned by Gloucestershire Community Care Group. The home’s Statement of Purpose and Service User Guide provide information as to the services that the home provides. The current fee range for the home was not available at the time of the inspection. Ravenswood DS0000016553.V368821.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1star. This means the people who use this service experience adequate quality outcomes. This inspection took place on the 18th& 22nd July 2008. The Inspector met with the acting manager, several of the care staff, all of the service users and also the area manager. The Inspector also received a number of completed surveys in relation to this service. Records relating to staff recruitment and training, care planning, health and safety and medication storage and administration were examined. An inspection of the environment was also carried out. The Inspector also visited the area office where records relating to staffing were examined. What the service does well: What has improved since the last inspection? What they could do better: The home needs to register a manager and also ensure that there are sufficient management hours provided to run the home professionally and effectively. The needs to ensure that there are sufficient staff on duty to meet the needs of the service users in terms of accessing the community. The home needs to ensure that there are sufficient drivers on the staff team to meet the needs of the service users. The home could further improve its person centred approach to care planning to provide people with more individualised goals and objectives. The home could provide a more structured approach to independence training and more opportunities for service users in this area. The home needs to ensure that’s the fire risk assessment complies with current regulations. Ravenswood DS0000016553.V368821.R01.S.doc Version 5.2 Page 6 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. Ravenswood DS0000016553.V368821.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ravenswood DS0000016553.V368821.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home must ensure that all information in the Statement of Purpose is accurate and up to date. Service Users would benefit from information being presented in different formats using pictures and symbols. EVIDENCE: The home has had no admissions since the last inspection and currently have one vacancy. They have an admissions policy that complies with the regulations. The home has reviewed the Statement of Purpose and Service User Guide in April 2008 and copies were given to the Inspector. Part of the Statement Of Purpose was inaccurate, relating to the current registered manager situation. Prior to this inspection the Commission has written to the Provider asking for clarification of the future plans. Further reference to this is contained in the management standards section of the report. Consideration should also be given to producing these documents in formats that would be more understandable to some service users. An example in the home was seen of service user contracts that had been produced using pictures and symbols. The Service User Guide should attempt to provide more of a flavour of what life in the home is like for service users, and what people could and should expect if they choose to live there. Ravenswood DS0000016553.V368821.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users would benefit from the development of a more person centred approach to care planning. EVIDENCE: The home have stated in their recent AQAA that they intend to bring in an external professional to help them further develop the person centred planning approach they have adopted. The plans that are in place are detailed and cover a wide range of assessed needs and are presented in format that includes the use of pictures and symbols. They would be further improved with the identifying of person centred goals and objectives, both short and long term. Clearer recording of the reviewing of plans would be beneficial, and also the extent of the involvement of the service user in the process. The home hold regular service user meetings where all are encouraged to participate and discuss any aspect of their lives they choose, as well as suggesting activities or future trips or excursions. People are also encouraged Ravenswood DS0000016553.V368821.R01.S.doc Version 5.2 Page 10 to discuss any concerns they have about issues within the house. These meetings are well documented with the good use of symbols and pictures. The minutes document the individual contributions and any action points that have been identified. A number of risk assessments were seen and some of these where out of date and due for review. Improved person centred planning could improve the use and scope of these assessments to increase opportunities for service users. Ravenswood DS0000016553.V368821.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,15,16 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing shortages, lack of drivers and limited management cover are having an impact upon the service’s ability to provide a lifestyle that meets people’s needs. EVIDENCE: Records showed that regular activities and outings take place and service users able to express an opinion, said they were happy with the social and vocational activities they took part in. However, it was the view of the staff and management, and that of some of the parents, that this is area that has suffered due to staffing shortages and the increased needs of some of the service users. Further comments upon the staffing levels are in the staffing standards section. It was also evident that the home currently has a shortage of staff who are able to drive the home’s vehicle, which also further impacts upon the opportunities for service users to go out. Ravenswood DS0000016553.V368821.R01.S.doc Version 5.2 Page 12 All service users have weekly routines that they follow and these included for some people time at day centre, swimming, horse riding, and in-house activities such as arts and craft and a weekly music session facilitated by an outside professional. There are also occasional trips to the theatre, cinema, pub trips and walks around town. One person is able to travel independently and on the day of this inspection they had gone for a walk and to do some shopping. They also planned to have some lunch whilst they were out. It is evident that it is difficult for staff to accommodate spontaneous trips out due to staffing cover. Generally they are required to keep a minimum number of staff in the home to meet specific needs, and there is also currently a lack of drivers. Some people would benefit from regular walks around the town but this is not always possible to organise. Staff said that planned trips could usually be supported because they were able to organise addition staff in advance if necessary. There appears to be considerable periods of time which some service users spend within the house and the garden, without the opportunity for spontaneous or quick trips out. Some service users also appeared to have a lot of unstructured time during the day, and comments were seen in some of the daily records of staff expressing concerns about the amount of time one person was spending on their own in their bedroom. Better person centred planning could establish clearer structures for some people and also provide clearer opinions from service users on the amount and type of activities they wish to be supported to pursue. All service users should have the option of going out, or away, from the home on a daily basis. Records show regular contact is maintained with families and relatives, with visits and phone calls being logged and also service user being supported to go for stays with families. Comments from relatives confirmed that they are kept well informed of issues when appropriate and that they consider the home is good at liaising with them. All staff and service users were very positive about the quality of food provided and at the time of the visit the kitchen was well stocked with fresh and frozen food. The menus showed that choice is catered for and that healthy eating is generally encouraged. It was commented that it would better if some service users could have more opportunities in the kitchen to develop skills and that this was something that was not always possible due to staffing levels and risk. Service users are involved in choosing the menus and do have some opportunities for helping with the cooking and other domestic chores. Relatives also made positive comments about the food. Ravenswood DS0000016553.V368821.R01.S.doc Version 5.2 Page 13 Improved care planning would help people to develop daily and weekly routines and activities that suited their needs and also help identify the levels of staffing required at different times of the day. Ravenswood DS0000016553.V368821.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 29 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to access the healthcare professionals they require to ensure that physical and emotional health needs are met. Satisfactory arrangements are in place for the handling, storing and administration of medication, promoting service users’ wellbeing. EVIDENCE: Clear records are kept of health appointments that have been supported and of the outcomes from these. People have had regular check ups and these have all been recorded. Staff have also had to manage some specific medical conditions over the past twelve months and whilst this has proved quite challenging, appropriate advice was sought and correct procedures put into place. The home have accessed the services of the Community Learning Disabilities Team for various service users and appropriate records are kept of advice and guidance that has been provided. The medication storage and administration was examined and found to be in order The home has implemented a system that provides clear guidance for Ravenswood DS0000016553.V368821.R01.S.doc Version 5.2 Page 15 administering, storing and recording. All staff must complete medication training before they are assessed as being competent to perform this role. Ravenswood DS0000016553.V368821.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has arrangements and procedures in place for the protection of service users but these would be improved if greater confidence could be given to relatives around the complaints procedure and the home complied with the regulation to complete 37 notifications. Service users would benefit from staff receiving training in the managing of challenging behaviours. EVIDENCE: Some comments were received form parents that they were unaware of the formal complaints procedure they should follow and one person commented that the home did not always respond promptly to concerns that they had raised. However people also said they felt confident raising issues with the acting manager and that the home always took their concerns seriously. It is recommended that the home ensure all families are made fully aware of the complaints procedure the home has in place and how they can access this if they need to. Service users have had the homes complaints procedure regularly explained in their home meetings, and this is recorded in the minutes. All staff have undertaken Adult Protection training and staff and service users were observed interacting in a respectful and relaxed manner. All service users appeared confident and relaxed within their home. The home keeps good records of any injuries that may occur and explanations for how these may have happened. It is recommended that more detail could be added to some of these to record what action, or investigation, was Ravenswood DS0000016553.V368821.R01.S.doc Version 5.2 Page 17 undertaken by the management. This is particularly important when it has been impossible to establish the cause of an injury. Records show that physical restraint is sometimes required in respect of one service user, and that this was also required in respect of another person who no longer lives at the home. The Commission were informed of some of these incidents but not all. When restraint has to be employed the exact nature of the incident and the technique used should be recorded. There are also no specific guidelines in place for the techniques to be used and staff have also not yet received the training in relation to this. The care plans must provide specific guidelines on when and how restraint is to be used and how this should be documented afterwards. Recently an allegation was made by a staff member and this was not reported to the Commission. The acting manager referred the matter on to the head office who apparently dealt with the matter. The Commission have written to the Provider requesting further details. Whilst this matter does not seem to directly concern the service users, it should have resulted in a Regulation 37 notification. Ravenswood DS0000016553.V368821.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is homely and comfortable and service users are supported and encouraged to personalise their living space and be involved in decisions relating to redecoration of the home. EVIDENCE: The home was clean, hygienic and reasonably well maintained and decorated at the time of this visit. Two relatives also commented upon the cleanliness of the home, saying that it was always clean when they visited and that they had never experienced unpleasant odours or evidence of a lack of hygiene. Some parts of the home have recently been decorated and also some flooring has been replaced. The front room, which was previously the dining room, is now an activity/sitting room, which staff and service users commented was a better use of the space. The rear garden is well maintained and provides a safe and private area for the service users. Ravenswood DS0000016553.V368821.R01.S.doc Version 5.2 Page 19 Ravenswood DS0000016553.V368821.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,33,34 & 35 adequate. Quality in this outcome area is This judgement has been made using available evidence including a visit to this service. The home has an established and motivated team of staff but staffing levels are insufficient to meet the needs of the service users in terms of supporting activities, trips out and use of transportation. EVIDENCE: On the first day of the inspection there were three staff on duty including the deputy manager, who was undertaking care duties, including being the driver for the shift. This ensured that basic needs and support were provided but meant that two staff had to remain in the home due to the needs of other service users. The manager of the home is now working as the area manager for all the homes run by the same Provider, and whilst they remain the registered manager for the service the deputy is in day-to-day charge. However the manager’s hours have not been replaced and the deputy on many shifts has to undertake the full range of care tasks. This is unsatisfactory and has a direct impact upon the opportunities available to the service users in terms of trips out into the community. Ravenswood DS0000016553.V368821.R01.S.doc Version 5.2 Page 21 On the second day of the inspection the acting manager had supported a medical appointment, driven the service users to a day centre and was also responsible for the preparation of the main meal of the day. Concerns were also mentioned by some parents about the staffing levels and how this could impact upon opportunities for people to be taken out for trips, or even short walks into town. During the inspection one service user was observed asking to be taken out but was told that this was not possible and that she would have to wait until the afternoon, when it might be possible. This was done sensitively and appropriately, but staffing levels are having a limiting effect on the opportunities for activities. Further reference to this issue is made under the management standards. Staff were observing interacting and supporting service users in a positive and respectful manner and were able to demonstrate a good understanding of individual needs. People said they thought they worked well as team, communicating well and supporting each other. Staff appeared professional in their approach and motivated towards meeting the needs of the service users. Questionnaires received back from parents and comments from service users were all very positive about the staff. One parent said, “ they are excellent, I am always made welcome and they keep me well informed”. Another relative commented, “the staff work incredibly hard and always do their best”. One parent commented upon that the staff had “dealt meticulously” with an ongoing health situation. Another commented that the service users are treated as “individuals” and that they have always have found their son “happy and well cared for”. Another comment was “ he has a great rapport with the staff at Ravenswood, particularly his key-worker and is treated with respect and affection”. One service user commented that their key-worker was ”really nice, he helps me with things and we go out to the pub together sometimes”. There was some inconsistency in the use of “makaton” sign language, with some staff being observed as using it all the time with some service users whilst others relying on their own approach. This is something that was also commented upon by parents who felt that it could be more consistently used by the staff team. All staff are up to date with the required statutory training and updates have been booked for those people whose refreshers are due shortly. The majority of staff have completed NVQ training. All new staff must undertake the LDAF training, which is assessed during their initial months before they would move onto to NVQ training. The recruitment files for the new staff were examined and seen to be in order with all the correct pre-employment check being completed and recorded. The main staff files are kept in the company’s head office but an up to date staffing list containing the required information is stored in the office in the home. Ravenswood DS0000016553.V368821.R01.S.doc Version 5.2 Page 22 Staff have received supervision, with notes being recorded and people said they felt well supported by the management. The home has regular staff meetings, though staff shortages have meant that it has been difficult to get full attendance at some of these meetings. Concerns have been raised in the past about the lack of training provided in the managing of challenging behaviours, particularly in relation to low arousal, de-escalation and the use of physical intervention. Physical intervention is occasionally required to avoid self-injury, avoid conflict between service users and protect staff from injury. A requirement was made that further training was provided but this training did not include the required components. It is essential that staff only use techniques for which they have been trained. Ravenswood DS0000016553.V368821.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Inadequate temporary management arrangements are having a detrimental effect on the running of the home and the outcomes for service users. EVIDENCE: The registered manager has become the area manager for the three homes run by the same Provider, but remains at present the registered manager for this service. The deputy is currently the acting manager. This situation has been in place for several months. The new Statement of Purpose states that they are being put forward as the new manager but no application has yet been submitted and the acting manager was unable to confirm this would be happening. The management and care hours which were previoulsy done by the manager have not been replaced, which has left the home very short of management hours. The acting manager has been expected to continue working the majority of their hours in direct care. This has been made even more difficult Ravenswood DS0000016553.V368821.R01.S.doc Version 5.2 Page 24 by staff sickness, which is being covered from within the existing staff group. Staff have also been undertaking waking nights duties due to sickness absence in this position as well. Very little agency cover has been used and the home does not have an extensive group of bank or relief on which it can call. It is unrealistic to expect a home of this size, with the complex needs of the service users who live there, to function professionally and efficiently without a fulltime manager. Whilst it is reasonable for the manager to occasionally perform care tasks and occasionally work care shifts, it is unrealistic to expect a person to manage a home whilst they are mainly working care shifts. A home must have sufficient management cover to ensure that it can be run effectively and safely. The situation is exacerbated by the acting manager also working without a deputy, as these hours have also not been replaced. The Commission had written to the Provider prior to this Inspection asking for clarification of the plans for the registered manager position. A requirement is made in this report that the home be provided with a full-time registered manager and sufficient management hours to ensure that the home is run effectively. The acting manager, previously the deputy manager, has done an excellent job in maintaining standards as best as they can, often by working long hours. It was evident that they have attempted to keep up with various administration tasks, support the staff team and have also identified various improvements that they would like to make to the care planning system. At the time of this visit the home had one vacancy and also one person was living away from the home temporarily whist undergoing an assessment. Even with the home being two vacancies below its maximum number the acting manager is required to undertake care shifts to ensure that the service users needs are met as best as is possible. There is an urgent need for the home to be provided with sufficient management hours, not only to maintain standards, but to implement the improvements that are needed. The registered manager, who is currently working as the area manager, has been completing the regulation 26 visits and written reports were available in the home. Whilst this provides a degree of scrutiny and support, this is not an ideal situation when they are still the registered manager. The Inspector was informed that the Provider has purchased a quality assurance system that will be implemented across the organisation. The home have previously surveyed people connected with the home, but this process has not been implemented for a while. All health and safety checks and test have been completed and recorded, including fire testing and servicing. An up to date fire risk assessment was not available and the home needs to ensure that the fire risk assessment is appropriate to the task, and that it is correctly reviewed and dated when in place. Some of the fire doors in the home were not closing properly and this Ravenswood DS0000016553.V368821.R01.S.doc Version 5.2 Page 25 must be investigated and remedied. Regular tests of these doors should ensure that they are correctly maintained. Ravenswood DS0000016553.V368821.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 x LIFESTYLES Standard No Score 11 X 12 2 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 X 3 X X 3 x Ravenswood DS0000016553.V368821.R01.S.doc Version 5.2 Page 27 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA23 Regulation 37 Requirement The home must ensure that all notifiable incidents are reported to the Commission under the requirements of Reg. 37. This must include any incidents when service users are restrained and issues relating to staff conduct The home must ensure that staff only employ restraint techniques for which they have been trained and that are part of an agreed care plan strategy The home must register a manager The home must ensure that sufficient staffing levels are provided to meet the needs of service users in terms of accessing the community The home must ensure that sufficient management hours are provided to ensure the efficient running of the service The home must ensure that all risk assessments are reviewed and correctly dated The home must ensure that it has a current fire risk DS0000016553.V368821.R01.S.doc Timescale for action 30/09/08 2. YA23 18(c )i 30/09/08 3. 4. YA37 YA33 8 18(1)(a) 30/10/08 30/10/08 5. YA37 12(1)(a) 30/10/08 6. 7. YA9 YA42 13(4)(b) 23(4) 30/10/08 30/10/08 Ravenswood Version 5.2 Page 28 assessment in place 8 YA42 23(4) The home must ensure that all fire doors are correctly maintained and close properly 30/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA22 YA6 YA23 Good Practice Recommendations The home should ensure that all relatives are aware of the homes complaints procedure The home should continue to develop and improve its approach to person centred planning The home should ensure sufficient detail is recorded when documenting injuries to service users Ravenswood DS0000016553.V368821.R01.S.doc Version 5.2 Page 29 . 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