Inspection on 13/12/06 for Ravenswood Nursing Home

This inspection was carried out on 13th December 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ravenswood Nursing Home 03/07/08

Ravenswood Nursing Home 28/06/07

Ravenswood Nursing Home 04/10/05

Ravenswood Nursing Home 13/12/04

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Ravenswood Nursing Home 47 Lower Bristol Road Weston Super Mare North Somerset BS23 2PX Lead Inspector Paul Grey Unannounced Inspection 13th December 2006 10:00 X10029.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 Nursing Home DS0000062326.V321112.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 Older People and 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 Nursing Home DS0000062326.V321112.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ravenswood Nursing Home Address 47 Lower Bristol Road Weston Super Mare North Somerset BS23 2PX 01934 412091 01934 644343 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) Extrafriend Limited Awaiting Registered Manager Application Care Home 36 Category(ies) of Dementia (36), Dementia - over 65 years of age registration, with number (36), Mental disorder, excluding learning of places disability or dementia (36), Mental Disorder, excluding learning disability or dementia - over 65 years of age (36) Ravenswood Nursing Home DS0000062326.V321112.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. May accommodate up to 36 persons aged 50 years and over who have dementia and may also have mental disorder. Staffing notice dated 23/6/1997 applies Manager must be a RN on parts 3 or 13 of MNC register With regard to the ratio of double rooms to single rooms, Extrafriend Ltd undertake to come up with plans for proposed measures in order to reduce the number of double rooms to comply with current legislation. Such plans will be entered into a 5 year timeframe from the date of purchase subject to the requirements of all parties including CSCI and the local planning department. 04/10/05 Date of last inspection Brief Description of the Service: Ravenswood nursing home is located on a main bus route into the centre of Weston-super-Mare. The home has easy access to the seafront, a number of local parks and local shops. Ravenswood is a large period building adapted to meet the needs of service users requiring nursing care. The home cares for up to 36 service users with mental health or age related health problems. The home charges the local authority rate of £527 a week. Ravenswood Nursing Home DS0000062326.V321112.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a six hour period and was conducted by one inspector. During this time the inspector met and spoke with one relative, the service user group, 2 staff members and the homes acting manager. A tour of the premises was completed prior to an observation of staff delivering care to the service user group. Following this the inspector audited records with the manager. This was the first inspection conducted since the recent and unexpected death of the homes Registered Manager. This unexpected loss has been well managed by the service provider who has recently appointed a new manager, (Mrs Debbie Crawford), to provide the team with the guidance and leadership. The inspector notes the team and manager have pulled together well during this difficult time. The inspector recognises the efforts and contributions made by Mrs Crawford and the service provider during this difficult time. The inspector recommends the manager familiarise herself with the National Minimum Standards, the Care Standards Act and the role of Registered Manager in the private sector. The inspector has made two Recommendations and one Requirement regarding the management and administration of the home. What the service does well: What has improved since the last inspection? What they could do better: A number of minor omissions had been identified regarding the assessment of personal care needs for one service user. The manager quickly addressed these omissions and altered care for the individual concerned. Ravenswood Nursing Home DS0000062326.V321112.R01.S.doc Version 5.2 Page 6 The service provider needs to support the training needs of the newly appointed manager. Specifically relating to the managers understanding of the National Minimum Standards, the Care Standards Act and issues such as Protection of Vulnerable Adults. 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 Nursing Home DS0000062326.V321112.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Ravenswood Nursing Home DS0000062326.V321112.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 Quality in this outcome area is Adequate The service consults its assessment information to see if it can meet the prospective individual’s needs before they offer a placement. Evidence suggests that prospective residents have a needs assessment carried out before they are admitted to the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Ravenswood Nursing Home DS0000062326.V321112.R01.S.doc Version 5.2 Page 9 The Inspector sampled 4 care files, spoke to service users, the manager and observed care being delivered. The assessment of service user needs was generally good. However there were minor omissions in one file sampled. These were concentrated around the personal care needs of one service user. These were identified by a social worker and addressed by the manager at the time of inspection. Care files sampled contained a robust assessment of nursing needs, detailed risk assessments, a falls assessment and review of the service user’s likelihood to gain pressure sores. The assessment procedures were appropriate for the service user group and clearly identified a wide range of psychological, physical and social needs. At the time of inspection no service users were receiving intermediate care. Ravenswood Nursing Home DS0000062326.V321112.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 Quality in this outcome area is good Each resident has a Plan that has been agreed with them. This is written in plain language, is easy to understand and considers all areas of the individual’s life including health, personal and social care needs. The plan also includes an assessment of risk to the service user and any necessary action to minimise this risk. This judgement has been made using available evidence including a visit to this service. Ravenswood Nursing Home DS0000062326.V321112.R01.S.doc Version 5.2 Page 11 EVIDENCE: The Inspector observed care being delivered to the service user group. Care was observed in both downstairs sitting rooms, one bedroom and in the dining room area. This was compared to care plan documentation and information provided by staff. Care staff were able to outline how they were meeting the service user’s care planned needs. The Inspector reviewed four plans of care. All 4 plans of care met national minimum standards. Care planning was based on a comprehensive assessment process with clear documentation of the service user’s needs. One service user file had two minor omissions during the admission process. These had been identified by the social worker and addressed by the home. The care plans reviewed had been drawn up where possible with the involvement of the service user. All care plans had been regularly reviewed and included comprehensive risk assessments and assessment for the prevention of falls. In spite of the omissions in one service user file, the standard of care planning and assessment remained generally good. Documentation at the home indicated that service users have access to health care services such as the local GP, chiropodist, district nurse, or specialist health services should these be needed. The manager was able to outline how the home involved independent parties should it need support in meeting the service users’ needs. The Inspector observed evidence that the service was able to monitor the psychological health of those in its care. During the observation of care , the Inspector saw staff in the process of assessing the mental health of one service user. Nursing staff at the home identify those at risk of developing pressure sores and take preventative measures. During a tour of the premises the inspector noted a range of turning charts to indicate that service users at risk of pressure sores were regularly turned and checked in accordance with their assessment. All service users at the home are registered with a GP. The Inspector reviewed the policy and processes for the administration and storage of medication. Medication is administered by the registered nurse on duty. Staff were able to explain the process to the Inspector. Staff showed the Inspector the home’s policies and procedures and appeared to have a clear understanding of their role. All medicines were securely stored and stock levels balanced with the records of medication. There were no crossings out or omissions on the record of medication given. Touring the premises, speaking with staff and observing care delivered, the Inspector observed staff treating service users with respect and dignity at all times. One service user required support with personal care during the Ravenswood Nursing Home DS0000062326.V321112.R01.S.doc Version 5.2 Page 12 inspection. The staff member was aware of the service user’s need for dignity and took them to private location to address their personal care needs. Interactions observed by the Inspector were good with staff and service user alike appearing to enjoy a positive relationship. Service users were addressed by their preferred name and wore their own clothing. Any service user sharing a room had privacy screens to ensure their privacy and dignity are not compromised. Ravenswood Nursing Home DS0000062326.V321112.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, and 15 Quality in this outcome area is good The routines of the home are planned around the resident’s needs and wishes. Staff listen to residents and make considerable effort to provide a flexible service. Family and friends feel welcome and know they can visit the home at any time. Staff make time to talk to visitors and share information with the agreement of the resident. This judgement has been made using available evidence including a visit to this service. Ravenswood Nursing Home DS0000062326.V321112.R01.S.doc Version 5.2 Page 14 EVIDENCE: The daily routines at the home are flexible and designed to meet the needs of the service user. Service users religious beliefs were clearly documented. The Inspector found evidence that the home had assessed service user’s specific religious and cultural needs and had attempted to meet them. The Inspector noted that the home had made alternative dietary arrangements for one service user and could demonstrate how they met his dietary needs. Staff on duty demonstrated a good awareness of these needs’. The Inspector spoke with one visitor at the time of inspection. The visitor said they felt welcome to the home and had no cause for concern. There is open access to the home and relatives could visit at any reasonable hour. During the tour of the premises the inspector spoke with the cook and several service users about food at the home. Service users who were able to express an opinion felt food was acceptable and in reasonable sized portions. The home has a 4 weekly rotating menu which varies with the season. Ravenswood Nursing Home DS0000062326.V321112.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good The service has a complaints procedure that is up to date, very clearly written, and is easy to understand. Systems are in place to ensure that residents rights are respected in all areas of their life. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a clear and comprehensive complaints procedure. The inspector spoke with a relative. They were aware they could make a complaint to the manager but were unsure of the exact process. The inspector noted there have been no official complaints. The inspector spoke with staff and the manager about protecting service users from abuse. Staff spoken with had received training and had a clear understanding of what may constitute abuse. The inspector outlined the Protection of Vulnerable Adults process to the new manager. Staff speaking Ravenswood Nursing Home DS0000062326.V321112.R01.S.doc Version 5.2 Page 16 with the inspector had a clear understanding of their role in relation to identifying or reporting abuse. Those who may be unsuitable to work with vulnerable adults would be referred for inclusion on the protection of vulnerable adults register. The home has a range of policies designed to protect the service users. Ravenswood Nursing Home DS0000062326.V321112.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good The home has a well-maintained environment, which is a pleasant, safe place to live. The home is well lit, clean and tidy and smells fresh. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Ravenswood Nursing Home DS0000062326.V321112.R01.S.doc Version 5.2 Page 18 During the inspection process, the Inspector conducted a tour of the premises. The Inspector noted that the home was well cared for with a regular schedule of maintenance. The home and its grounds were tidy, safe and attractive. The premises were clean and hygienic throughout with no offensive odours at the time of inspection. The Inspector reviewed the laundry facilities which were appropriate in size and layout for the number of service users. Washing machines in the laundry were able to wash clothing at 65°C to reduce the risk of cross infection. The home has appropriate hand washing facilities located prominently in areas were infected material or clinical waste may be handled. Ravenswood Nursing Home DS0000062326.V321112.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29 and 30 Quality in this outcome area is good Rotas show well thought out and creative ways of making sure that the home is staffed efficiently, with attention given to busy times of the day. The service ensures that all staff within its organisation receives relevant training to help them support the service user group and understand their needs. The service has a good recruitment procedure. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Ravenswood Nursing Home DS0000062326.V321112.R01.S.doc Version 5.2 Page 20 The inspector spoke with staff and service users then observed care being delivered. The staff rota was also reviewed, along with personnel and training records. Care staff felt that there were enough staff on duty over a 24 hour period. Each shift is run by a qualified nurse. The nurse is supported by between 5 and 6 Health Care Assistants. The home also has cleaning staff and a cook on duty throughout the normal working day. The manager is also on duty 5 days a week and is not included in the staff numbers. The inspector observed staff interactions were kind, unhurried. On reviewing the staff rota, the inspector noted the home has sufficient staffing with little use of agency or temporary staff. After observing care, the inspector sampled 5 staff records in depth. Then reviewed 3 further records for appropriate Criminal Record Bureau checks and Protection of Vulnerable Person checks. All files sampled showed evidence of a recruitment procedure. This complied with national minimum standards. New staff are provided with a comprehensive induction. The manager was able to demonstrate this induction process. Staff said the induction was a good introduction to working at the home and felt it provided information they needed to work in the home. Staff have paid training days to enable them to remain up to date. Ravenswood Nursing Home DS0000062326.V321112.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Ravenswood Nursing Home DS0000062326.V321112.R01.S.doc Version 5.2 Page 22 31, 33, 38 Quality in this outcome area is adequate The Manager has the required qualification and experience and is competent to run the home. The home has sound policies and procedures, which the manager effectively reviews and updates. The home has a good record of meeting relevant health and safety requirements and legislation. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of inspection the home had an acting manager who was going to apply for Fit Person Interview with the Commission. The acting manager is a registered nurse with 18 years experience of caring for the older person. The inspector saw a job description for the role of manager and noted clear lines of accountability at the home. During the inspection process, the manager was advised of the expectations of the Commission and the role of the manager in meeting both the National Minimum Standards and the requirements of the Care Standards Act. At the time of inspection the manager was not fully aware of the effect of the standards on her role. This was subject to a recommendation by the inspector. The acting manager provided examples of the home’s quality monitoring system. The inspector noted evidence of the use of objective self monitoring tools such as questionnaires, a quality audit review of administration and assessment and external questionnaires. The inspector noted evidence of an annual development plan, which was based on service user, relative and external professional feedback. The acting manager was able to provide documentary evidence that feedback is actively sought from the service user group where possible. Whilst with the manager, the inspector reviewed how the home protects the safety of staff and service users. The manager was able to provide a detailed list of mandatory training for the staff group. The inspector reviewed 8 staff at random. These staff had undergone manual handling, fire safety, infection control and first aid. Staff were able to outline infection control procedures and explain how soiled personal items were cleaned and stored so as to prevent cross infection. Ravenswood Nursing Home DS0000062326.V321112.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 x 3 3 4 x 5 x 6 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 ENVIRONMENT Standard No Score 19 3 20 x 21 x 22 x 23 x 24 x 25 x 26 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 2 32 x 33 3 34 x 35 x 36 x 37 x 38 3 Ravenswood Nursing Home DS0000062326.V321112.R01.S.doc Version 5.2 Page 24 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 OP31 Regulation 8 (1) a Requirement The Inspector requires the service must have a registered manager. Timescale for action 28/02/07 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 OP31 Good Practice Recommendations The Inspector recommends the manager should research the National Minimum Standards to develop a clearer understanding of her duties and responsibilities under the Care Standards Act. The Inspector recommends the service provider perform a training needs analysis for the newly appointed manager. 2. OP31 Ravenswood Nursing Home DS0000062326.V321112.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Text phone: 0845 015 2255 or 0191 233 3588 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 Nursing Home DS0000062326.V321112.R01.S.doc Version 5.2 Page 26 - 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. 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