Inspection on 09/03/06 for Ravenswood

This inspection was carried out on 9th March 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ravenswood 06/07/06

Ravenswood 14/09/05

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 Unannounced Inspection 9 March 2006 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.V286171.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 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.V286171.R01.S.doc Version 5.1 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.V286171.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th September 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.V286171.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. At the time of this inspection there were 23 people in residence. There was one vacancy in a shared bedroom. There was an inspection of the physical environment of the main building and annexe including a sample of bedrooms. Some improvements have been made to the environment as part of the ongoing future plans of the new proprietors. Bedrooms were all clean, adequately furnished and well personalised. There are good facilities in all rooms. All residents were seen and the majority spoken to together individually. All had positive comments about the care provided at Ravenswood and the high standards of care provided by the staff. Several new residents were spoken to and said that they had settled well into the home encouraged with the help and support of staff. An increase in the numbers of people requiring dementia care and with mental health needs was authorised some months ago and new residents admitted falling into those categories have settled and been integrated well into the home. Two visiting relatives were seen and similarly spoke very positively about the standards of care. There was a focus upon health care issues. Staff have awareness of the importance of close monitoring and early referral of health care matters to professionals when required. Regular weighing of residents is important and must be at least monthly. Attention to detail in relation to dental and optical needs are required as outlined in the report. The catering arrangements in the home must be reviewed. Absence of catering staff has resulted in unsatisfactory provision. This has been partly addressed with a proprietor now responsible for food preparation and provision. There is a good standard environment with committed staff group and good standards of care. A major extension to the home is awaiting planning permission. Ravenswood DS0000064271.V286171.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? The conservatory area has been re-carpeted with donation from relative of long-standing resident who died recently in the home. New chairs have been provided in the conservatory area. The ground floor corridor area has been re-carpeted. Fail-safe valves have been fitted to all baths to ensure safety of hot water temperatures. Commode pots/bottles are no longer placed in baths to dry. Inspection reports are now available in the reception area of the main building and annexe. The statement of purpose has been updated/revised. Ravenswood DS0000064271.V286171.R01.S.doc Version 5.1 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.V286171.R01.S.doc Version 5.1 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.V286171.R01.S.doc Version 5.1 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 There is adequate information to ensure an informed decision about choice of home. Prospective residents and their families are always invited to visit the home prior to admission. All prospective residents are assessed by the home prior to admission. In order to provide an equal service for self-funding residents the home are advised to seek a Care Management Assessment. It is recommended that self-funding residents are given the benefit of a review of placement after 6 weeks to ensure suitability of the placement, thus providing an equal service with funded residents. Ravenswood DS0000064271.V286171.R01.S.doc Version 5.1 Page 10 EVIDENCE: At the time of the last inspection it was recommended that the Statement of Purpose/Service Users Guide should be updated. This has been done and copy displayed in the home. It is also recommended that all residents are given a copy of the revised documents. Funded residents have copies of contracts with sponsoring Local Authorities. The home provides a contract with self-funding residents (not seen). Prospective residents are given the opportunity where possible to visit the home prior to admission. This was offered and generally taken up by residents spoken to who have been admitted since the last inspection. Residents are always seen prior to admission in their current environment and a preadmission assessment carried out and recorded by the home. The homes capacity to meet needs are outlined in the statement of purpose and reflected in the training provided for staff in the home. The home were recently given authorisation for 2 people to be admitted in the MD category (Mental Disorder). Two have been admitted and settled well, their needs being met. Staff have received training in this area of work. Care plans were seen in relation to recently admitted residents. A preadmission had been recorded by the home and for funded residents a Care Management assessment obtained. The home are advised to press for a Care Management Assessment where people are self-funding to attempt to provide and equal service. A resident admitted 1 month ago on a self-funding basis has not had a Care Management Assessment and therefore would not have the usual review of placement after 6 weeks. It is recommended that the home arrange such a review to include the resident and family. This will ensure clarity of suitability of placement and the ability to meet needs. Ravenswood DS0000064271.V286171.R01.S.doc Version 5.1 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, 8, and 10 Care plans were based upon assessed need and provided the required basic information to provide care. All residents must be weighed at least monthly and weekly where there are concerns about weight loss to enable close monitoring. Some action/clarification is required in relation to the dental and optical needs of a resident identified EVIDENCE: Care plans were sampled including those of recently admitted residents. Comprehensive information was generally provided based upon assessed need. The home always carry out and record their own pre-admission assessments. These are supplemented for funded residents with Care Management Assessments. This information provides the basis for completion of the care plan. Ravenswood DS0000064271.V286171.R01.S.doc Version 5.1 Page 12 In relation to a recently admitted resident who was self funding and without the benefit of a Care Management Assessment the care plan was based upon the homes pre-admission assessment only and therefore was still in the process of being completed. It was recommended that Care Management Assessments are requested for all arranged admissions and also a review of all placements after 6 weeks. There was a focus upon health care issues and tracking during the inspection. The home has a good record of early referral to health care professionals There is now a health care record sheet for each resident outlining a chronological record of health care interventions. Regular health checks are carried out together with medication reviews by visiting GP’s. The husband of a resident with dementia care needs - admitted 6 months ago and who visits daily was seen and expressed general satisfaction with the care provided for his wife who he had moved from another home. He visits at least once daily and assists with feeding etc. (a good example of a shared care situation). Records reviewed with the relative indicated that there had been a weight loss of 14 lbs over a period of months and she had only been weighed on 3 occasions. A requirement to weight all residents on a monthly basis is made in this report and where there is significant weight loss then residents must be weighed weekly. – This applied also to another resident in the main building. There were 2 pairs of glasses provided for the lady mentioned (she was wearing neither), one was for reading (she does no longer reads) the other not – it was not possible to establish which pair of glasses should be worn and this must be established and care plan accordingly endorsed. There had also been loss of dental plate and the home should liase with the relative to provide suitable replacement. There are very positive working relationships between the home and 5 local GP practices and also the paramedic service –evidenced in recording. Hospital outpatient appointments are monitored and kept. Two relatives seen confirmed that they were informed of any changes in the health care of their relatives. Two additional categories to admit people with mental health needs were authorised some months ago following the required staff training. Two people have been admitted under that category. Both are visited by the CPN – one has regular depo. Injection – staff demonstrated a positive understanding of their needs and they have settled well into the home. Due to time limitation medication was not inspected on this visit. Personal care is provided with the required privacy and dignity. This was confirmed in discussions with residents and relatives. Ravenswood DS0000064271.V286171.R01.S.doc Version 5.1 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 Many examples were seen and confirmed by residents which indicated flexible routines and accommodation of chosen lifestyles. There has been an increase in activities and residents expressed satisfaction with them. There is an open visiting policy enjoyed by residents and visitors. The area of food provision must be reviewed and include the required number of hours for catering facilities in the home. EVIDENCE: There was evidence of chosen lifestyle principles being applied in the home and residents spoken to confirmed that their preferences and choices were known and acted upon. The homes flexible routines accommodate those lifestyles. There are 2 married couples in the home with the option to have a shared or separate space. Ravenswood DS0000064271.V286171.R01.S.doc Version 5.1 Page 14 Two residents have also chosen to share their time, life and space together which has been supported by staff in discussions with relatives and others, this was confirmed in discussions with the people involved who sated that their quality of life land motivation has been vastly improved. The husband of a resident visits usually twice daily demonstrating the open visiting policy and also the acceptance of the need for shared care. This arrangement is good, positive and supportive to both resident and visitor. There were other indications of flexibility of routines – residents arriving at staggered times for breakfast up to mid-morning. A resident seen in his bedroom has definite ideas about the times for his daily life, spending time in his room as her wishes, with many visitors, and deciding when or whether to come to the dining room for meals. Meals are served in his bedroom if preferred. There is no formal activities programme. Staff tend to arrange activities to suit the wishes and spontaneous needs of residents. This is a small home where close relationships are established between residents, staff and visitors. There is ongoing dialogue in the lounge areas and considerable 1:1 discussion/activity. Relatives tend to visit in the lounge areas and include other residents in their discussions, not just the resident they are visiting. Relatives had previously expressed the view that activities could be extended and this has been done. There is now regular fortnightly entertainment arranged and other activities stepped-up. Residents spoken to said that they were satisfied with the activity levels in the home. There was a focus upon food provision following a complaint made to the Environmental Health Officer. The basis being that there was no cook in the home. Care staff were visiting the kitchen area where they were usually not allowed and they were not changing their clothes/protective wear after providing care for residents. This was discussed in detail with the Proprietor and Manager. At the time of the last inspection a new cook had been appointed and a requirement made to provide food hygiene training for her and all catering staff. This was not arranged, she left the home after a short time. Since that time care staff and others have been involved in preparing food in the interim period. In fact a Proprietor has now commenced working as a cook having undergone food hygiene training. This is a recent change and there has been and continues to be a review of food provision, including new menus which residents have been involved in choosing. There has been a meeting with residents to discuss changes and choices. The Manager was adamant that care staff had changed protective clothing before entering the kitchen after providing personal care to residents. Ravenswood DS0000064271.V286171.R01.S.doc Version 5.1 Page 15 Most care staff have received basic food hygiene training. The new cook will provide a service from 9.30 a.m. and the home must now review the total catering arrangements for the home to include a kitchen presence from 7.30. a.m. This was agreed and is a requirement of this report. Food provision has improved in the home. New proprietors have increased the quality and quantity of food available. There has been an accent upon quality improvements e.g. regular local supplies of fresh meat, vegetables, fruit etc and purchase of proprietary brands of many foods purchased. Residents said that they were very satisfied with the food provision and changes. A couple stated that they now enjoyed a daily cooked breakfast, in fact 6 people now have regular cooked breakfasts. Some said that they have minor variations of this e.g. egg on toast as preference. There are choices of meals at all times. This was evidenced in menus and confirmed by residents. There is an attractive dining area with well laid, attractive tables presenting a good eating/social environment. There was a discussion with the Proprietor and Manager concerning the serving of food. Meals are pre-plated and it was suggested the home could consider introducing self-choice and service from dishes on tables for some residents, thereby improving service and furthering independence and choice, which the home pursues positively in many other areas of care. Ravenswood DS0000064271.V286171.R01.S.doc Version 5.1 Page 16 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 Complaint & Protection were met. EVIDENCE: There is a complaints procedure in place which complies with Regulation 22. All residents have had a copy of the procedures and a copy is posted in the home for visitors. 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. Two complaints have been received by the Commission and will be investigated. There is a policy/procedure relating to abuse. All staff are given a copy and sign to confirm that they have read and understand the document. Staff are aware of the broad definitions of abuse. Ravenswood DS0000064271.V286171.R01.S.doc Version 5.1 Page 17 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 established their own improvement programme with very positive input. Hot water controls have now been fitted to all baths. The red bag system for infected linen has been introduced improving infection control practice. Commode and urine pots are no longer placed in the baths, but still washed in the bathrooms. This will be improved with the building of a new extension planned to commence soon. Fire safety will be reviewed by the Fire Officer as required. Repair of the food store door is required. Ravenswood DS0000064271.V286171.R01.S.doc Version 5.1 Page 18 EVIDENCE: The home has an excellent location, set in extensive peaceful, private and secluded grounds yet only 50 metres for the town centre. The location is suitable for the stated purpose of the home. Residents use the garden area extensively throughout the summer months with a range of suitable seating provided for their comfort. There is a high standard physical environment which has been extended/improved over the years. Furniture, fittings and equipment are generally to a good standard. The present proprietors purchased the home in 2005 and have already provided many improvements. They have submitted plans to the Borough Council for approval of a large extension to the home to increase the number of beds and facilities. Since the last inspection new carpet has been fitted in the conservatory area. Money donated by relative of a former long-standing resident who died recently in the home, has been used. Additionally new seating has been provided by the proprietors making an attractive area overlooking the superb garden. The carpet has been replaced in the ground floor corridor area. The new proprietors have fitted fail-safe valves to all baths in the home, including some in bedroom en-suite areas. This has improved safety in relation to full-body emersion. It had been assumed that these had been fitted by the previous proprietors. Communal and bedroom areas are adequately furnished and ther has been an ongoing refurbishment programme in those areas. The new proprietors have also addressed some areas that required cumulative maintenance. All bedrooms have lockable facility to lock from inside. These can be opened by staff in an emergency. All bedrooms have a lockable facility for valuables/medication. At the time of the last inspection a requirement was made to fit a self-closing device to a door in the corridor area adjoining the entrance to the kitchen. This has been done, but the door was wedged open on this visit. The Manager reported that a resident had fallen at that point trying to open the door. The Inspector is concerned about the fire risk to people in the building in the event of a kitchen fire as no protection is offered. A requirement is made and the Fire Officer asked by the Inspector to visit and assess the risk and advise on the specific requirements to protect residents. Ravenswood DS0000064271.V286171.R01.S.doc Version 5.1 Page 19 A requirement was made in the last report to check all self-closing fire doors to ensure they closed onto the door rebates. Some work has been done but the Fire Officer will also advise on that matter. The door to the food store adjacent to the kitchen area was off its hinges. This must be repaired and made safe. A requirement was made at the last inspection that commode pots/bottles must not be placed in baths in the interests of infection control. This has been addressed, receptacles are washed individually in the bathroom area and returned to bedrooms immediately. There are still some infection control risks as the home does not have a sluice and pots are still washed in bathroom/toilet area used regularly by residents. This will change with improved facilities once the planned extension is completed. Meanwhile an audit is required of all bedpan pots/urine bottles which must be replaced if in an unsatisfactory state and present a potential infection control problem. The red bag system of bio-degradable system of handling infected linen/clothes has been introduced following a requirement of the last report and has reduced handling and improved infection control. Throughout the home the standards of cleanliness were high and there were no mal-odours. Ravenswood DS0000064271.V286171.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 30 Staffing levels have been maintained at previously required levels. There has been staff training is several areas of statutory training. All staff have completed Moving & Handling training/updates since the last inspection. The home meets the required numbers of NVQ trained staff. EVIDENCE: Staffing levels are reported to be maintained as required at the previous levels. The weekly levels remain at approximately 542 hours per week. Staffing rotas were not seen on this visit. The home has a split-site with 19 residents in the main building and 5 in the annexe, which has to be staffed separately by one person throughout the 24hour period. The number of care staffing hours is adequate for the needs of the current resident group. There has been inadequate staffing for catering services in the home since the last inspection. At that time 2 new cooks had been appointed but subsequently left. Food provision has been handled in the interim period by care and other staff which has been unsatisfactory. Ravenswood DS0000064271.V286171.R01.S.doc Version 5.1 Page 21 As mentioned in Standard 15 above the home must review the catering arrangements in the home and provide adequate staffing at required times. Some positive moves have already been made in this direction. Staffing records were not inspected on this visit. NVQ training in the home has been good. There are 20 care staff and 11 have completed NVQ2 training or above. Other staff including some over 25 years where funding has been difficult have commenced courses. The home has exceeded the required 50 of NVQ trained staff recommended and training continues. One member of staff has commenced NVQ4 training. Other staff training since the last inspection has included moving & handling training for all, a diabetes course for 10 staff and most have completed Food Hygiene and First Aid training. COSHH training is presently being arranged. Supervision is in place for all staff. The Manager supervises the Senior Carers who supervise care assistants. Ravenswood DS0000064271.V286171.R01.S.doc Version 5.1 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected 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 an open approach to management in the home which is run in the best interests of residents. A review by the Fire Officer, of safety in the kitchen area of the home is being arranged by the inspector. EVIDENCE: The Manager has the required experience to run the home, has completed NVQ3 and commenced study for the required Registered Managers Award since the last inspection. She anticipates completion of the award by September this year The Registered Manager works hand-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. Ravenswood DS0000064271.V286171.R01.S.doc Version 5.1 Page 23 The new proprietors have a daily presence in the home and there is daily and open access to them from residents. Residents meetings are held regularly and minutes kept (not seen). All have a copy of the complaints procedure and there is a suggestion box in the reception area for comments – anonymously if preferred. Inspection reports are now available in the reception area of the main building and the annexe. Financial viability was discussed in detail prior to purchase with the new owners, who now plan a major extension to the home. Planning permission is awaited. Financial availability and viability are evident. Safe Working Practices were inspected as follows: Fire records were seen and all checks and servicing of fire fighting equipment had been carried out as required. A requirement to fit self-closing device to corridor area approaching the kitchen has been done but the inspector is not entirely satisfied with the fire protection afforded in that area and will request a visit by the Fire Safety Officer. Some remedial work is also indicated in relation to correct self-closing of other fire doors which do not close directly onto door rebates. A fire risk assessment is in place and updated as required. Moving & Handling training has been provided for all staff as required in the last inspection report. Adequate numbers of staff have received First Aid training sufficient to ensure one trained person is on duty at all times. Some improvements have been made in the area of infection control practice with the introduction of degradable bags for infected linen. Commode pots are no longer placed in baths. An audit of commode pots/urine bottles is needed with replacements as necessary. Automatic hot water temperature controls have now been fitted to all baths including those in en-suite areas. The premises are secure and there are restrictors on all opening windows. Risk assessments are n place for all resident activity. All incidents required to be reported to the Commission under regulation 37 have been received. Ravenswood DS0000064271.V286171.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x x 3 3 2 Ravenswood DS0000064271.V286171.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 3 4 5 6 Standard OP38 OP19 OP15 OP26 OP8 OP8 Regulation 23(4) Requirement Timescale for action 10/03/06 31/03/06 31/03/06 31/03/06 10/03/06 31/03/06 Fire Officer to review fire safety in area of the entrance to kitchen 23(2)(b) Food store door must be refixed on hinges 16(2)(i)(j) Review and ensure appropriate hours and allocation of work for catering staff. 13(3) Audit pedpan pots/urine bottles and replace as necessary 12(1) All residents must be weighed monthly and weekly where there are concerns about weight loss 12(1) Clarify and record glasses to be worn by resident identified and liase with relative concerning replacement dentures. Ravenswood DS0000064271.V286171.R01.S.doc Version 5.1 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP5 Good Practice Recommendations It is recommended that a formal review of placement after 6 weeks is provided for self-funding residents. Ravenswood DS0000064271.V286171.R01.S.doc Version 5.1 Page 27 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. Extracts may not be used or reproduced without the express permission of CSCI Ravenswood DS0000064271.V286171.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!