Inspection on 15/01/07 for Ravensworth Care Home

This inspection was carried out on 15th January 2007.

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

Ravensworth Care Home 12/03/09

Ravensworth Care Home 30/06/05

Similar services:

Hillside

Applegarth

122 Scorer Street

Byars Care Home

St Marys Nursing Home

Jubilee Villa Care Home

Bramble Lodge

Parkmanor Residential Home

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

CARE HOMES FOR OLDER PEOPLE Ravensworth Care Home Markham Road Duckmanton Chesterfield Derbyshire S44 5HP Lead Inspector Marie Bonynge Key Unannounced Inspection 15th January 2007 10:00 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 Ravensworth Care Home DS0000062116.V325599.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. 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. Ravensworth Care Home DS0000062116.V325599.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ravensworth Care Home Address Markham Road Duckmanton Chesterfield Derbyshire S44 5HP 01246 823114 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) Ravensworth Care Home Limited Mr Fred Renshaw Maxine Lynette Spray Care Home 26 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (26), Learning disability (2) of places Ravensworth Care Home DS0000062116.V325599.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th November 2005 Brief Description of the Service: Ravensworth Care Home is registered to provide personal care and accommodation for up to 26 older people in the category of (DE) Dementia including two places for named residents with learning disabilities and one place for a named resident with dementia, under 65 years of age. The home is located in the village of Duckmanton, on the outskirts of Chesterfield and Bolsover. It is close to a small number of shops and a pub. A bus route is within a short walking distance of the home. The accommodation is on two levels and has a dining room that is also used for activities. Three lounges are provided, including a smoking lounge. There are 18 single bedrooms and 4 double bedrooms. Large, well-maintained, accessible and enclosed gardens are to the side of the property. Car parking space is provided. The fees for this home are £308.20 - £343.10 Ravensworth Care Home DS0000062116.V325599.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place over one day in January and the duration of this visit was approximately 6 hours. Discussions took place with 4 residents, 2 relatives, 2 members of staff and the registered manager. Inspection methods used included a tour of the communal areas of the building, the medication storage area and the bedrooms of those residents who were spoken to during this visit. Case tracking was used for 3 residents and their care plans and associated records were examined. Staff training records, staff files and duty rotas were also sampled. Further information was provided by way of a completed pre inspection questionnaire. Some residents were unable to contribute directly to the inspection process because of communication difficulties, and health reasons but they were directly observed during the visit to see how well their needs were being met by staff. The previous inspection took place in November 2006 where 3 requirements were made and 6 recommendations were made. Progress has been made to either complete or partially complete these and this is reported on in the main body of the report. What the service does well: What has improved since the last inspection? New curtains, lighting and bedding have been provided in many of the bedrooms. Some new dining room chairs have been provided that are more in keeping with the needs and capabilities of some of the residents who live at the home and there are plans to replace all of the remaining chairs. Ravensworth Care Home DS0000062116.V325599.R01.S.doc Version 5.2 Page 6 Further progress has been made regarding the care planning documentation and further development is planned. The registered providers are now providing written reports of visits to the home to meet with regulatory requirements. 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. The summary of this inspection report can be made available in other formats on request. Ravensworth Care Home DS0000062116.V325599.R01.S.doc Version 5.2 Page 7 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 Ravensworth Care Home DS0000062116.V325599.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessment information was obtained that assisted in the home being able to meet the identified needs of residents. EVIDENCE: The care plans of three residents were examined as part of the case tracking process. These indicated that assessment information had been obtained prior to the admission of residents into the home. This included health and social services community care assessments where applicable. The registered manager also completed her own assessment to obtain a fuller picture of the needs of residents. This included a life history of the person and their preferred daily routines. The resident or their representative did not always sign the care plan and a recommendation has been made in respect of this. Ravensworth Care Home DS0000062116.V325599.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning and risk assessment procedures generally assist in the promotion of the safety and welfare of residents, however this may be comprised where risk assessments do not meet with the needs of residents and are not regularly reviewed and updated. Systems are in place that contributes to the promotion and maintenance of residents’ health and ensures access to health care services. EVIDENCE: Discussions held with relatives demonstrated that the care provided was of a good standard and met the needs of individual residents. Three residents said that they felt their privacy was maintained and that members of staff were respectful in their manner. Residents and relatives who were spoken with said that care staff were ‘kind’ and ‘caring’. Ravensworth Care Home DS0000062116.V325599.R01.S.doc Version 5.2 Page 10 The care plans of three residents were examined in detail as part of the case tracking process. Continuity of care came from verbal hand over sessions on each shift and by using the care plans and daily records. Discussions with residents and direct observations of care supported the view that residents’ needs were well met. The overall standard of care was said to be good and residents individual needs and preferences were documented. Risk assessments for the prevention of falls, nutrition, skin integrity and moving and handling had been developed although they had not been regularly and consistently reviewed. A trigger risk assessment for tissue viability had begun to be introduced for use with all residents in response to a requirement made at the previous inspection of this service. Different assessment tools were also being used so that a consistent picture could not be gained of the risks presented. This could potentially place residents with high and variable needs at risk. A requirement has been made in respect of this. Daily records were generally detailed and gave a good overall picture of the care of the person so as to assist in tracking and monitoring the care of residents. Residents had access to professions allied to medicine such as the optician, chiropodist and dental services. Medication systems were generally in good order. Members of staff were proactive in seeking medication reviews for residents where a need was indicated. Medicines’ training has been completed by all members of staff that are responsible for the administration of medication. Two recommendations from the previous inspection report have been implemented. Ravensworth Care Home DS0000062116.V325599.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities and recreational pursuits are provided that are varied and generally meet with the individual expectations and preferences of residents. The meals are good and provide a varied and appealing diet. EVIDENCE: An activities co-ordinator has been employed to undertake the main organisation of the social and leisure programme. Discussions with a group of residents on this visit supported the view that the home provides suitable activities. Residents said that they enjoyed playing bingo, dominoes, singing along to the music sessions and participating in games. Relatives said that they also joined in some of the activities when they were in the home. Residents were playing dominoes and cards on this visit. All of the residents spoken to say that the standard of food provided was good and they always enjoyed the meals provided. Two residents said that they had been provided with an alternative to the menu today, as they did not eat meat Ravensworth Care Home DS0000062116.V325599.R01.S.doc Version 5.2 Page 12 and this was always the case. A choice was said to be available and both residents confirmed that drinks and snacks were readily available. Visitors were made welcome in the home and visiting times were not restrictive. Daily routines were flexible and residents said that they were encouraged to maintain choice over their daily lives. An enclosed garden to the rear of the property provided a safe and pleasant area for residents to walk and sit in. One resident said that one of the things they most enjoyed was being able to go out in the garden in the better weather. Ravensworth Care Home DS0000062116.V325599.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies and procedures were in place that assisted in ensuring that the welfare of residents was safeguarded. Residents feel that their concerns are taken seriously and acted upon. EVIDENCE: A complaints procedure was available that met with the guidelines of a response being made to any complaint within 28 days. Discussions with residents confirmed that they felt confident that any concerns would be listened to and appropriate action would be taken. No complaints have been received by the CSCI and no complaints had been received by the home. Relatives said that they felt confident that if they voiced any concerns they would be dealt with appropriately and they would approach the manager or a member of staff. Discussions with residents indicated that they would approach the manager or a member of staff if they needed to and were confident that their concerns would be listened to. A copy of Derbyshires safeguarding adults policies and procedures were in place that assisted in ensuring that the welfare of residents was safeguarded. The registered manager and the majority of care staff had attended Derbyshires’ training regarding awareness in safeguarding adults. There was a commitment for the remainder of the staff to attend training. Ravensworth Care Home DS0000062116.V325599.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is generally well decorated, comfortable and well maintained. EVIDENCE: Residents spoken to say that they like the home and they were pleased with the standard of their individual accommodation. A designated smoking lounge is provided as well as two other lounges and a large lounge / dining area. Residents were encouraged and supported to bring in some of their personal possessions including photographs and items that were important to them. An ongoing programme of redecoration and replacement of carpets and soft furnishings was in place although this was largely implemented on an, ‘as and when basis’ as opposed to a planned and proactive approach. A requirement has been made on a number of occasions regarding this, however the Ravensworth Care Home DS0000062116.V325599.R01.S.doc Version 5.2 Page 15 registered manager has plans to complete an audit of the environment therefore this requirement has been made a recommendation. A programme of replacing the dining chairs with chairs suitable for the needs of individuals had commenced. The timescale for this requirement has therefore been extended. The home was clean and free from offensive odours. Ravensworth Care Home DS0000062116.V325599.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes recruitment practices assisted in the safeguarding of residents. The home has a commitment to training that supports staff in the work they do. EVIDENCE: A sample of staffing rotas was examined that included the week of this visit. These indicated that the home was staffed in accordance with the recommended guidance and to meet with the assessed needs of residents. There were 17 residents accommodated with either medium or low dependency needs. Residents and staff spoken with said that staffing levels were generally satisfactory and met with the needs of residents. Relatives commented that there was always a member of staff available if required. There were 3 care staff on duty for the morning and afternoon / evening shifts and two care staff at night. Additional hours were provided for the cook, kitchen assistant and cleaning and laundry duties. The registered providers also took an active interest in the home and worked additional hours to those on the rota. Training records were sampled that indicated that a comprehensive training programme was in place that reflected the needs of those residents accommodated. Mandatory training had been completed that included fire Ravensworth Care Home DS0000062116.V325599.R01.S.doc Version 5.2 Page 17 training, moving and handling, and food hygiene. In addition some staff had accessed a course regarding diet, nutrition and the care of people with dementia. The activities co-ordinator had completed a course in the leadership of chair based exercises to increase the independence of frail older people. This met with the identified needs of residents. The home has continued to invest in training for National Vocational Qualifications and has exceeded the target of 50 of care staff achieving NVQ 2 and 3 to 90 . The home is commended for exceeding this standard. Two staff files were examined that demonstrated the home had a thorough recruitment procedure and included the information required by regulations. Both files contained CRB checks, proof of identity and two written references. Ravensworth Care Home DS0000062116.V325599.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run in the interests of residents, with a strong and approachable management and a stable and well trained staff group. These assist in ensuring the health, safety and welfare of residents and staff. EVIDENCE: The registered manager has completed the NVQ level 4 training in management and care. Discussions with residents, relatives and staff indicated that the home is generally well run and that the manager and staff are approachable. A system for quality assurance was in place that included resident questionnaires. However the system is not fully developed and the results of Ravensworth Care Home DS0000062116.V325599.R01.S.doc Version 5.2 Page 19 these questionnaires have not been formally collated and incorporated into the homes development plan. Although there is a commitment to improvement in the home this has not been formalised into an annual written development plan. A recommendation has been made in respect of this (see standards relating to the environment). The registered providers continue to have a ‘hands on’ presence in the home and are now completing regulation 26 reports as part of the quality assurance process. Information was provided that indicated that certificates of maintenance were held, that health and safety issues were addressed and that equipment was serviced regularly, these included gas safety, electrical systems and appliances. The CSCI was being notified of any events covered by Regulation 37 and the manager was monitoring the incidence of any falls or accidents. Ravensworth Care Home DS0000062116.V325599.R01.S.doc Version 5.2 Page 20 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Ravensworth Care Home DS0000062116.V325599.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 2 (b) Requirement Care plans and risk assessments must be reviewed and updated regularly and thoroughly in accordance with recommended guidance and changing needs. Dining room chairs suitable to meet the assessed needs and capabilities of residents must continue to be provided and incorporated into the homes development plan. Timescale for action 01/04/07 2. OP19 23 (2) (n) 01/06/07 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 OP33 Good Practice Recommendations Feedback to service users/prospective service users on the summary results of satisfaction surveys should include published findings for inclusion in the Service User Guide. The resident or their representative should sign the care plan where possible and the reasons for not doing so DS0000062116.V325599.R01.S.doc Version 5.2 Page 22 2. OP7 Ravensworth Care Home 3. OP33 should be recorded. The registered person must develop an annual development plan as identified in standard 33.2. Ravensworth Care Home DS0000062116.V325599.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 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 Ravensworth Care Home DS0000062116.V325599.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!