Inspection on 03/02/06 for Ravenswood

This inspection was carried out on 3rd February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 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 18/07/08

Ravenswood 28/07/06

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 09/07/2008.

CARE HOME ADULTS 18-65 Ravenswood Lansdown Road Westal Green Cheltenham Glos GL50 2JA Lead Inspector Mr Simon Massey Unannounced Inspection 3rd February 2006 12:30 Ravenswood DS0000016553.V281745.R01.S.doc Version 5.1 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.V281745.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V281745.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ravenswood Address Lansdown Road Westal Green Cheltenham Glos GL50 2JA 01242 256900 01242 269033 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.V281745.R01.S.doc Version 5.1 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 October 2005 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. Ravenswood DS0000016553.V281745.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took lace over 3 hours on Friday 3rd February 2006. the inspector met with the deputy manager and senior care staff and also briefly with two other staff on duty at the time of the visit. Five service users were also observed or spoken to during the inspection. Records relating to care planning, staffing levels, medication and health and safety were examined. Certain parts of the environment were also inspected. A full inspection of the home took place on 28th October 2005 and the main focus of this visit was to follow up progress made towards requirements issued as a result this last inspection. The inspector is grateful for the co-operation of the staff and service users in completing this inspection. What the service does well: What has improved since the last inspection? The home has implemented the changes required following recent meetings with the fire department. More detailed recording of incidents of challenging behaviour have been completed by the staff. Ravenswood DS0000016553.V281745.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ravenswood DS0000016553.V281745.R01.S.doc Version 5.1 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.V281745.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected during this visit. EVIDENCE: There have been no admissions to the home during the past twelve months. Ravenswood DS0000016553.V281745.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6&9 The home has a care planning process in place that is detailed and person centred but would be further improved by the inclusion of specific protocols relating to the management of individual behaviours. More regular reviewing of care plans would help ensure that ongoing needs are better monitored. EVIDENCE: The personal files relating to five service users were examined. These had examples of regular recording that had been completed in sufficient detail and contained factual and observational information. The care plans are detailed with information about personal care needs, activities, weekly routines and review dates. The files contain details about how aggressive behaviour has been managed, and these incidents are also recorded on separate incident sheets. The record for one service user details how they were calmed down by the holding of their hands. The care plan needs to include guidance to staff on how this technique should be applied. The training that is planned for the managing of challenging behaviours should provide further guidance and ideas for the home on how to best record Ravenswood DS0000016553.V281745.R01.S.doc Version 5.1 Page 10 guidelines for the staff on the approaches and techniques to be employed for individual service users. Any service user who requires any form of physical intervention, regardless of how minimal, must have a protocol for this action contained in their care plan. The care plans also contain information relating to mobility, communication and individual strengths and needs. All risk assessments seen were up to date and had been recently reviewed. Two care plans examined appeared not to have had a formal review for over a year, though the deputy explained that certain elements had been reviewed during this period. All plans must be the subject of at least an annual review and these dates should be clearly recorded. A requirement is made in relation to this. Ravenswood DS0000016553.V281745.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 Positive relations with families and relatives help ensure needs are met and that the home maintains an open approach to the service it provides. EVIDENCE: The files showed recording of contacts with families and relatives. These show records of phone calls, letters, and visits to the home. The files also show regular visits to families being supported for some service users. It is evident that service user’s families have regular contact with the home and are supported to visit and socialise within the home. Ravenswood DS0000016553.V281745.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Personal care is delivered according to assessed needs and in a manner that promotes privacy and dignity. Involvement of outside professionals help support the meeting of emotional and physical health needs. Regular dental checks will further help promote the health of the service users. EVIDENCE: The medication storage and administration were examined and seen to be in order. The home have a list of staff who have completed medication training and are permitted to administer medication. Assessments have been completed on the ability of service users to self medicate. The home has a stock control system in place. All medication administered is counter signed and there was evidence that medication was being regularly reviewed either by the GP or from the Community Learning Disabilities Team. All files seen had a record of health appointments that had been supported and details of the outcomes of such appointments. Ravenswood DS0000016553.V281745.R01.S.doc Version 5.1 Page 13 Information was seen about how the home is pursuing the possibility of oral medication replacing the use of rectal diazepam. The deputy explained that the benefit of this would be the promotion of greater privacy and dignity for the individual service user in receipt of the medication. Records were seen of the recording of epilepsy and these appeared detailed and contained the information relating to antecedent behaviour. The records show that some service users have had no recorded dental treatment since 2004. There were also letters from the Dentist used by the home confirming their retirement. The deputy explained that an alternative dentist had now been found. All service users should receive an annual dental check and a requirement is made in relation to this. Ravenswood DS0000016553.V281745.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Training needs to be provided for staff to ensure that best practice is followed in the managing of some challenging behaviours. EVIDENCE: The Manager and Registered Provider are currently researching for the appropriate training that was required as a result of the previous inspection. When this is booked the home must let the Commission know of the dates and the source of the training. Ravenswood DS0000016553.V281745.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected during this visit. EVIDENCE: Ravenswood DS0000016553.V281745.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32 & 33 Further training that is being planned will improve the care and support provided by staff in the managing of challenging behaviour. Long shifts and excessive hours worked by some staff could potentially affect the quality of care and support being provided. Increased staff meetings could improve the effectiveness of the staff team EVIDENCE: There is currently one vacancy in the home and also one new staff member who has transferred from another home within the same organisation. The deputy manager explained that the process for transferring staff records to the home was underway and would be completed shortly. The inspector also spoke to the Registered Provider who confirmed that they were in the process of providing all the required information to the home. Reference to the training required around challenging behaviour is made under standard 23. The manager is currently completing a staff training matrix. This will provide a more a systematic approach to the monitoring of the required statutory training and also provide evidence of the additional training that is being supported by the home. Ravenswood DS0000016553.V281745.R01.S.doc Version 5.1 Page 17 The deputy manager gave an example of how staff are aware of the need to deescalate some behaviours. An observation of one service user’s behaviour was recorded and advice passed on to the rest of the staff team through the recording in the personal file. Both the Deputy and Senior carer were able to demonstrate a professional understanding of the complex needs of the service users and the strategies employed within the home to meet these needs. The deputy manager confirmed that the staff had received input from the manager at a staff meeting around the need for more detailed recording of certain situations. Records show that the home has only had 4 staff meetings in the previous 14 months and a recommendation is made that these are held on a more regular basis. The Manager was on a day off at the time of this inspection so it was not possible to examine certain records relating to staff training and recruitment. The staffing rotas’ show that required staffing levels are being maintained and also that the home has experienced relatively little sickness absence over the previous 6 months. The rotas show that occasionally some staff are working extremely long shifts, occasionally working a double shift followed by a sleep in duty. These are generally additional hours to cover sickness or annual leave. Whilst in some circumstances long shifts are unavoidable, the inspector is unhappy with staff undertaking shifts within the house, which can last in some instances for 36 hours. The Manager is required to monitor this situation and provide some guidance for the staff responsible for co-ordinating the rota. The potential drawbacks to service users receiving care and support from staff who have already worked in excess of a full shift need to be clearly explained. Staff were observed communicating and interacting with service users in a sensitive and professional manner, and the service users appeared comfortable and relaxed within the home. Ravenswood DS0000016553.V281745.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 42 A shortfall was identified in the recording of fire tests but steps have been taken by the home to provided improved fire safety. EVIDENCE: The Manager was not working on the day of this unannounced inspection but the home appeared to be running efficiently in their absence. The office was well ordered and information was easily accessible. The majority of recording was well written and paperwork was appropriately dated and signed. The home has now implemented all the changes required to the fire safety arrangements made as a result of a recent consultation with the fire department. The new locks are now in place and guidance as been provided for the staff team. A member of staff has been allocated the responsibility of being the homes “fire officer” and was booked onto a fire prevention and safety course for the week beginning 6th February. Ravenswood DS0000016553.V281745.R01.S.doc Version 5.1 Page 19 Records of fire testing show that the last test was completed on 7/01/06 and no record of tests have been recorded since then. A requirement has been made in relation to this. The home have been completing regular evacuations and fire drills which have been recorded. Ravenswood DS0000016553.V281745.R01.S.doc Version 5.1 Page 20 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 X 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 X 23 2 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 3 32 3 33 2 34 x 35 x 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 3 x LIFESTYLES Standard No Score 11 x 12 X 13 X 14 X 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x X X X X X 2 x Ravenswood DS0000016553.V281745.R01.S.doc Version 5.1 Page 21 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 YA23 Regulation Requirement Timescale for action 28/02/06 2 YA42 3. YA34 12(1)13(7,8)18(1)ci The home must provide training for staff in the area of managing challenging behaviours, as described in the text (requirement from previous report) 23(4) © (V) The home must ensure that fire alarm testing is completed weekly and recorded 17(2) schedule 4 The home must ensure that the required staff details are available within the home. Progress being made (previous timescale 31/01/06) 13(1)(b) The home must ensure that service user have the opportunity for annual dental checks. The home must ensure that all care plans are reviewed annually and that review dates and input are clearly recorded The home must monitor the length of shifts and DS0000016553.V281745.R01.S.doc 31/03/06 31/03/06 4 YA19 30/06/06 5 YA6 15(b) 30/06/06 6 YA33 18(1)(a) 31/03/06 Ravenswood Version 5.1 Page 22 hours worked by care staff and provide guidance to the staff preparing the rota. 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 YA23 YA33 Good Practice Recommendations The home should provide the training identified in Req 1 from a training organisation that is accredited by BILD The home should have a minimum of 6 staff meetings a year. Ravenswood DS0000016553.V281745.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Ravenswood DS0000016553.V281745.R01.S.doc Version 5.1 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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