Inspection on 04/10/05 for Ravenswood Nursing Home

This inspection was carried out on 4th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 13/12/06

Ravenswood Nursing Home 13/12/04

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

CARE HOMES FOR OLDER PEOPLE Ravenswood Nursing Home 47 Lower Bristol Road Weston-Super-Mare North Somerset BS23 2PX Lead Inspector Paul Grey Announced 4 October 2005 th 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 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 Nursing Home D53-D02 S62326 Ravenswood Nursing Home V241881 041005 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Ravenswood Nursing Home Address 47 Lower Bristol Road, Weston-Super-Mare, North Somerset, BS23 2PX Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01934 412091 01934 644343 Extrafriend Ltd Mrs Margaret Olwen Haley Care home with nursing 36 Category(ies) of Dementia (36) registration, with number Dementia - over 65 (36) of places Mental Disorder (36) Mental Disorder - over 65 (36) Ravenswood Nursing Home D53-D02 S62326 Ravenswood Nursing Home V241881 041005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate up to 36 persons aged 50 years and over who have dementia and may also have mental disorder. Staffing notice dated 23/06/1997 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. Date of last inspection 6th May 2005 Brief Description of the Service: Ravenswood nursing home offers care for up to 36 service users with mental health or dementia needs. The home is a large period building adapted to meet the needs of service users and is situated in a suburb of weston super mare with good access to local bus routes. Ravenswood Nursing Home D53-D02 S62326 Ravenswood Nursing Home V241881 041005 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection focused on the delivery of care. The inspection was conducted in the presence of the manager and the service provider. The inspector took evidence from two visiting professionals, one relative, four staff members and six service users. The inspector found a well run home, content service users, a positive, satisfied team and a very strong service. The inspector commends the entire staff team, and service providers on a well run home. What the service does well: What has improved since the last inspection? 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 Nursing Home D53-D02 S62326 Ravenswood Nursing Home V241881 041005 Stage 4.doc Version 1.40 Page 6 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 Standards Statutory Requirements Identified During the Inspection Ravenswood Nursing Home D53-D02 S62326 Ravenswood Nursing Home V241881 041005 Stage 4.doc Version 1.40 Page 7 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 standard(s) 1,3,4 The home provides potential service users with an extensive statement of purpose allowing them to make an informed choice when considering the home. The inspector noted evidence that service users are comprehensively assessed prior to moving into the home. Service users know that the home will be able to meet their needs EVIDENCE: The inspector was forwarded a copy of the home is statement of purpose. The statement of purpose was comprehensive meeting the requirements of the national minimum standards. However, the inspector also noted that the statement of purpose clearly outline is the homes philosophies and values and aspirations. These appear to be underpinned by staff at the home. The inspector noted that the statement of purpose is a working document of and commends the staff team. The home exceeds national minimum standards. Ravenswood Nursing Home D53-D02 S62326 Ravenswood Nursing Home V241881 041005 Stage 4.doc Version 1.40 Page 8 The inspector sampled three care files. In all files sampled the inspector noted clear and full preadmission assessment. The inspector noted that the admission process reviewed issues from personal care and physical well-being through two social interests, hobbies and religious or cultural needs. The assessment package was sufficiently detailed to meet National minimum standards. The inspector noted a clearly documented outline of any specialised services offered by the home. For example care offered to one service user of Asian descent. This good practice. The inspector noted evidence from observation that staff collectively and individually have sufficient skills and experience to deliver appropriate care. Ravenswood Nursing Home D53-D02 S62326 Ravenswood Nursing Home V241881 041005 Stage 4.doc Version 1.40 Page 9 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 standard(s) 7 and 10 The service users health, personal and social needs are set out in an individual plan of care. Service users are treated with respect and the right to privacy is upheld. EVIDENCE: The inspector audited three plans of care. The inspector was able to track assessed needs from the admission assessments, to planned delivery of care in the care files. The service users plan set out the action taken by the home to care for the service users. Service user plans audited by the inspector were comprehensive; well maintained and appeared to meet service users assessed needs. The inspector noted care plans were regularly reviewed and meet National minimum standards. The inspector noted staff knocked on all doors prior to entry, addressed the service user by their preferred name. Staff had been taught how to address Ravenswood Nursing Home D53-D02 S62326 Ravenswood Nursing Home V241881 041005 Stage 4.doc Version 1.40 Page 10 service users appropriately and understood the need to respect the dignity and privacy of the service user. Ravenswood Nursing Home D53-D02 S62326 Ravenswood Nursing Home V241881 041005 Stage 4.doc Version 1.40 Page 11 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 standard(s) 12,13,15 Service users experience the lifestyle they expected at the home. Service users are able to maintain contact with friends and family. Service users receive a wholesome and varied diet. EVIDENCE: The inspector noted statement evidence from staff and professionals, that the routine of living within the home is flexible and varied and designed to meet the service users needs. The management team attempts to offer service users the opportunity for leisure and social activities within the home or, (with additional funding), outside of it. The ethos of the home stresses individualised care, the inspector noted evidence of this in practice. The inspector spoke to one family member. Feedback regarding the home and the standard of care for very positive. The family member felt welcome and involved in care within the home. The inspector noted that service does not impose restrictions on service users visits within reasonable social hours. The inspector observed a meal during inspection. Food prepared at Ravenswood appeared pleasant and appealing. The general atmosphere at lunch was relaxed and pleasant. Two service users spoken with commented on Ravenswood Nursing Home D53-D02 S62326 Ravenswood Nursing Home V241881 041005 Stage 4.doc Version 1.40 Page 12 the food positively, saying they enjoy it and the menu was sufficiently varied. The inspector noted documentary evidence of a four weekly rotating menu. Ravenswood Nursing Home D53-D02 S62326 Ravenswood Nursing Home V241881 041005 Stage 4.doc Version 1.40 Page 13 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 standard(s) 16, 18 Service users and their relatives may be confident that complaints will be acted upon. Service users are protected from abuse. EVIDENCE: The inspector noted evidence of a clear and comprehensive complaints procedure. The inspector spoke with one relative. They were aware of the complaints procedure and felt it was made sufficiently clear. The inspector noted there have been no recent complaints. The inspector spoke with staff regarding protecting service users from abuse. Staff spoken with had received training and had a clear understanding of what may constitute abuse. Staff h also understood their role in relation to reporting potential abuse. Staff who may be unsuitable to work with vulnerable adults would be referred by the nurse in charge for inclusion on the protection of vulnerable adults register. The policies within the home protect the service users. Ravenswood Nursing Home D53-D02 S62326 Ravenswood Nursing Home V241881 041005 Stage 4.doc Version 1.40 Page 14 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 standard(s) 19,23,24,26 Service users live in a safe and well-maintained environment. Service users own rooms suit their needs. Service users live in safe comfortable bedrooms with their own possessions around them. The home is clean pleasant and hygienic. EVIDENCE: The inspector noticed a wide range of improvements and updating of the general decor. The inspector was shown how the routine maintenance of the home was improving the standard of the environment. The inspector noted a programme ongoing improvements and maintenance regarding general decor and carpets throughout the home. This was good practice. The home complies with the requirements of the local fire service and environmental health. Ravenswood Nursing Home D53-D02 S62326 Ravenswood Nursing Home V241881 041005 Stage 4.doc Version 1.40 Page 15 The bedrooms at Ravenswood meet National minimum standards space requirements. The rooms are large enough service users to have two chairs for visitors should they wish. Service users are provided with their own room, which is furnished and equipped to ensure the service users comfort and safety. Where possible service users own goods can be placed in the rooms, subject to health and safety assessment. All rooms are fitted with locks to allow privacy, but are accessible to staff in case of emergencies. These are all risk assessed. The inspector noted a marked improvement in the homes general environment. The home has always been clean and hygienic, but the inspector noted an improvement in this area. The homes laundry facilities are sited well away from any food preparation areas. The home has policies and procedures for the control of infection and disposal of clinical waste. Cleaning staff informed the inspector they had been trained on how to do with spillages of various sorts and were aware of infection control. The home is washing machines have a specified programme to meet disinfection standards. Ravenswood Nursing Home D53-D02 S62326 Ravenswood Nursing Home V241881 041005 Stage 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 Service users are supported and protected by the homes recruitment policy. EVIDENCE: The inspector audited three staff files. Staff files contained to written references, appropriate to the staff member. CRB and protection of vulnerable adults checks. All staff receive a statement terms and conditions. The manager was able to give examples of how the home’s recruitment procedure was used to screen out unsuitable staff. The inspector noted a particularly robust procedure. Ravenswood Nursing Home D53-D02 S62326 Ravenswood Nursing Home V241881 041005 Stage 4.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36 The home is managed by the person who is fit to be in charge. The home benefits from the ethos, leadership and management approach of the home. The home is run in the best interests of the service users. Staff are appropriately supervised. EVIDENCE: The manager is a qualified nurse with in excess of the commissions required two years senior management experience. The homes manager has an appropriate management qualification and has undertaken further training to update and knowledge. The manager and senior staff are also familiar with the conditions and diseases associated with old age. Ravenswood Nursing Home D53-D02 S62326 Ravenswood Nursing Home V241881 041005 Stage 4.doc Version 1.40 Page 18 The inspector noted that both the manager of Ravenswood, and the service provider demonstrate a positive, open and inclusive commitment to both staff and service users. The inspector noted this commitment was evident in the way the home was run, physical changes to the building, documentation and more importantly from staff and service user statement. The inspector commends the manager and service provider for their efforts in this area, the home exceeds national minimum standards. The inspector was provided with examples of the home’s quality monitoring system. The inspector had some time to discuss this with the service provider Mr Hollis. The inspector noted evidence of an annual development plan, which was based on review of service user and external agencies feedback. The inspector also noted documentary evidence of self monitoring. The inspector noted statement and documentary evidence that feedback is actively sought from service users and relatives about service is provided by the home. Both relatives and professionals spoken with gave very positive evidence indicating that the home indicating that the home actively responds to any feedback. The homes policies and procedures are regularly reviewed in the light of any changing legislation. The home exceeds national minimum standards. The inspector noted documentary evidence of appropriate TOPPS compliant induction training. The inspector noted documentary and statement evidence that staff receive formal supervision on at least six occasions over the year. The inspector recognises that the home provides support and supervision in excess of this, often informally. Staff are supervised on a continual basis. Ravenswood Nursing Home D53-D02 S62326 Ravenswood Nursing Home V241881 041005 Stage 4.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 4 x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 4 x x x 3 3 3 x STAFFING Standard No Score 27 x 28 x 29 4 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 4 4 x x 3 x x Ravenswood Nursing Home D53-D02 S62326 Ravenswood Nursing Home V241881 041005 Stage 4.doc Version 1.40 Page 20 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 Regulation Requirement Timescale for action 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 Good Practice Recommendations Ravenswood Nursing Home D53-D02 S62326 Ravenswood Nursing Home V241881 041005 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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