Inspection on 30/06/05 for Ravensworth Care Home

This inspection was carried out on 30th June 2005.

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

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

Other inspections for this house

Ravensworth Care Home 12/03/09

Ravensworth Care Home 15/01/07

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 Unannounced Inspection 30th June 2005 at 10:00am 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. RAVENSWORTH CARE HOME C52 CO2 S62116 Ravensworth V236874 300605 Stage 4.doc Version 1.40 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 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 Ltd Maxine Lynette Spray Care Home only 26 Category(ies) of DE(E) 26 registration, with number DE 1 of places LD 2 RAVENSWORTH CARE HOME C52 CO2 S62116 Ravensworth V236874 300605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Two places for 2 named individuals in the category of (LD) and one place for 1 named individual in the category of (DE) under the age of 65 years. 2. That all the required actions are taken as per the site visit report within 6 months of the date of registration. Date of last inspection 23rd November 2004 Brief Description of the Service: Ravensworth is a care home registered to provide personal care and accommodation for up to 26 older people in the category of (DE) Dementia including 2 places for 2 named residents with learning disabilites and 1 place for 1 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 2 storeys with a dining room that is also used for activities. 3 lounges are provided including a smoking lounge. There are 18 single bedrooms and 4 double bedrooms. Large enclosed gardens are to the side of the property that are well maintained and accessible. Car parking space is provided. RAVENSWORTH CARE HOME C52 CO2 S62116 Ravensworth V236874 300605 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day in June 2005. The main focus of this inspection was to follow up the progress made regarding the requirements and recommendations made at the last inspection of the service and to monitor progress in relation to the conditions of registration. The home has made an application to the CSCI to re register 26 places in the category of (DE) Dementia and this application has been approved. The home has met many of the national minimum standards and is working towards the completion of the conditions of registration. A tour of the environment was made on this visit, discussions were held with residents and staff and generally positive comments were made to the Inspector. Some of these have been included in the main body of the report. Inspection methods used included the sampling of records such as care plans, staff training and recruitment files and staffing rotas. What the service does well: What has improved since the last inspection? The gardens have been enclosed and a sun canopy has been installed outside the smoking lounge that opens onto a patio with seating. This has enabled residents to enjoy the fresh air and walk around the gardens. Specialist dementia training has been accessed by some of the senior staff and further training is planned. Induction and foundation training has been implemented since the last inspection. Some improvements have been made regarding the environment including the provision of radiator guards, domestic lighting, the upgrading of 2 showers and the fitting of window restrictors. RAVENSWORTH CARE HOME C52 CO2 S62116 Ravensworth V236874 300605 Stage 4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. RAVENSWORTH CARE HOME C52 CO2 S62116 Ravensworth V236874 300605 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection RAVENSWORTH CARE HOME C52 CO2 S62116 Ravensworth V236874 300605 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 and 4 New residents are admitted into the home on the basis of an assessment that contributes to residents being assured that their needs can be met. EVIDENCE: Three residents care plans were examined. These indicated that assessment information had been obtained prior to the admission of these residents and the home had completed its own assessment. The Registered Manager and 2 other senior members of staff had attended specialist training regarding nutrition in older people with dementia. This was said to have been useful and staff were putting the principles into everyday practice. 18 residents were accommodated on this visit with varying levels of dependency. The registration of the home now reflected the category of those residents accommodated as required at the last inspection of the home. Residents had signed their care plans (where able) to say that they had been given a copy of the homes statement of purpose and service user guide and this had been updated to include residents views of the home. 2 recommendations have therefore been met. RAVENSWORTH CARE HOME C52 CO2 S62116 Ravensworth V236874 300605 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, 8 and 10 The health care needs of residents were generally being met and further development of care plans will contribute to underpin this care. EVIDENCE: A plan of care was in place for the 3 residents whose care records were examined. The daily records were informative and the daily routines of residents were detailed including their likes and dislikes and interests. Discussion took place with the Registered Manager about developing the care plans to cover all aspects of standard 3.3 to detail the action that needs to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the residents. A system was in place for reviewing the care plans and records evidenced that health care needs were being maintained. These included access to chiropody services, dental services and the optician. A falls risk assessment and nutritional risk assessment had not been introduced and the requirements made in respect of this at the last inspection have been carried forward. RAVENSWORTH CARE HOME C52 CO2 S62116 Ravensworth V236874 300605 Stage 4.doc Version 1.40 Page 10 Staff were directly observed to respect the privacy of residents for example by knocking on doors before entering bedrooms. Residents reported that they thought that staff treated them with respect. RAVENSWORTH CARE HOME C52 CO2 S62116 Ravensworth V236874 300605 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, 14 and 15 The routines of daily living and general activities in the home provided for a relaxed atmosphere that generally met with the preferences expressed by residents. EVIDENCE: Activities in the home were provided on a regular basis in accordance with a written programme. This was largely based on the preferences and choices expressed by residents. One resident told the Inspector how they enjoyed playing cards and that the activities organiser had obtained some large print books for them. Dedicated activities hours were provided and assistance was given to those residents who were not able to participate in activities independently. Discussions with residents indicated that they were supported to maintain contact with family / friends and representatives. Information about advocacy services was available. Residents were supported in bringing personal possessions with them into the home. Advice had been sought regarding nutrition and the presentation of meals in older people with dementia. This was an area of good practice in the home. The lunch time meal was observed to be appealing and residents reported that they thought the food was good. RAVENSWORTH CARE HOME C52 CO2 S62116 Ravensworth V236874 300605 Stage 4.doc Version 1.40 Page 12 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 and 18 The policies and procedures of the home contributed to safeguarding residents. EVIDENCE: Residents spoken with said that they would speak to a member of staff if they were worried about anything or were not happy with an aspect of the home. Many of the residents were not able to advocate for themselves, however staff had attended training regarding Derbyshire’s protection of vulnerable adult procedures and these were in place in the home. A complaints procedure was in place and the Inspector was advised that a copy of the complaints procedure had been given to every resident or their representative. RAVENSWORTH CARE HOME C52 CO2 S62116 Ravensworth V236874 300605 Stage 4.doc Version 1.40 Page 13 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, 20, 21, 22, 23, 24, 25 and 26 The home is generally well maintained and furnished, that affords residents a comfortable and homely environment. However hot water temperatures were not being maintained at a safe level, which potentially posed a risk to residents. EVIDENCE: The home was generally well maintained and comfortably furnished. Progress has continued to be made regarding the implementation of a planned programme of works that has included the provision of radiator guards, domestic style lighting in residents’ individual accommodation and the provision of window restrictors and at least 2 accessible double sockets. Two shower rooms have been upgraded to provide improved bathing facilities. The carpet in the smoke room has also been replaced. The garden has been enclosed with fencing and residents reported that this was one of the good things about the home. 7 requirements made at the last inspection have therefore been met and full compliance with the conditions of registration is expected to be achieved within the given timescales. RAVENSWORTH CARE HOME C52 CO2 S62116 Ravensworth V236874 300605 Stage 4.doc Version 1.40 Page 14 The water from the hot water outlet in the bath of the first floor bathroom was recorded as being 48.7C using a digital thermometer. This was in excess of 43C and was hot to the touch, posing a potential risk to residents. The Registered Manager agreed to lock the door of this bathroom to prevent it from being used and an immediate requirement was left in respect of this issue. The temperature of hot water from the bath taps was not being recorded as required at the last inspection. RAVENSWORTH CARE HOME C52 CO2 S62116 Ravensworth V236874 300605 Stage 4.doc Version 1.40 Page 15 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) 27, 29 and 30 The numbers and skill mix of staff generally met with the assessed needs of residents, however the recruitment practices of the home do not fully serve to protect residents. EVIDENCE: Staffing rotas were examined for the month of June 2005. These indicated that staffing levels met with the numbers and needs of those residents accommodated on this visit. Not all of the hours that were worked by some of the staff on the rota were fully detailed and did not indicate in what capacity the person was working i.e. as cook or as a carer. Two staff files were examined, these indicated that a POVA First check and completed CRB check had been returned for both members of staff. Improvements had been made regarding the homes recruitment practices and 2 requirements have been met that were made at the last inspection report. However 2 written references had not been obtained for one member of staff, the references were verbal only. A programme of structured induction and foundation training had been introduced since the last inspection and this had been completed by new members of staff. This requirement has therefore been met. RAVENSWORTH CARE HOME C52 CO2 S62116 Ravensworth V236874 300605 Stage 4.doc Version 1.40 Page 16 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, 33, 36 and 37 The home is generally well run with management systems in place that contribute to meeting the home’s stated purpose, aims and objectives. EVIDENCE: The Registered Manager has completed level NVQ 4 in management and care. Most of the requirements and recommendations made at the last inspection have either been met or partially met and that Registered Manager was aware of the shortfalls identified. The Proprietors had a strong ‘hands on’ presence in the home, however Regulation 26 reports were not being completed. This has been identified in the previous inspection report. Systems for the implementation and completion of formal supervision were in place. Records were securely stored and generally in good order with the exception of those records identified in the main body of the report. RAVENSWORTH CARE HOME C52 CO2 S62116 Ravensworth V236874 300605 Stage 4.doc Version 1.40 Page 17 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 3 x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 2 x x 2 2 x RAVENSWORTH CARE HOME C52 CO2 S62116 Ravensworth V236874 300605 Stage 4.doc Version 1.40 Page 18 YES 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 OP7 Regulation 15 (1) Timescale for action Care plans must set out in detail Previous the action that is needed to be timescale taken by care staf to ensure that 30.08.04. all aspects of the health, New personal and social care needs of timescale the service users are met. From 01.10.05 inspection report 06.05.04. A falls risk assessment with Previous particular attention to the timescale prevention of falls must be 01.01.05. New completed for all service users. From previous inspection report timescale 23.11.04. 01.10.05 A nutritional assessment must be Previous completed for service users on timescale admission and subsequently on a 01.01.05. periodic basis. From inspection New report 23.11.04. timescale 01.10.05 Dining room chairs suitable to Prevous meet the assessed needs and timescale capabilites of residents must be 01.04.05. provided and incorporated into New the homes development plan. timescale From inspection report 23.11.04. 01.10.05 Locks suited to service users 01.07.05 capabilities must be fitted to service users private accommodation and accessible to staff in emergencies subject to consultation with the Fire Version 1.40 Page 19 Requirement 2. OP7 12 (1) (a) (b) 13 (4) (c) 3. OP7 12 (1) (a) (b) 13 (4) (c) 4. OP19 23 (2) (n) 5. OP24 12 (4) (a) RAVENSWORTH CARE HOME C52 CO2 S62116 Ravensworth V236874 300605 Stage 4.doc 6. OP25 13 (4) (c) 7. OP29 19 (1) (b) Officer. From inspection report 23.11.04. The registered person must ensure that radiator temperatures do not exceed 43C. Two written references must be obtained prior to employing a member of staff. From inspection report 23.11.04. The registered person must develop an annual development plan as identified in standard 33.2. From inspection report 23.11.04. The registered person must complete Regulation 26 visit reports. From inspection report 23.11.04. Records required by regulation for the protection of service users must be maintained, accurate and up to date. 01.10.05 8. OP33 24 (1) (a) (b) 9. OP33 26 (1) 10. OP37 17 Previous timescale 01.01.05. New timescale 01.09.05 Previous timescale 01.03.05. New timescale 01.09.05 Previous timescale 01.01.05. New timescale 01.09.05 01.10.05 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 RAVENSWORTH CARE HOME C52 CO2 S62116 Ravensworth V236874 300605 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Cardinal Square Nottingham Road Derby DE1 3QT 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 RAVENSWORTH CARE HOME C52 CO2 S62116 Ravensworth V236874 300605 Stage 4.doc Version 1.40 Page 21 - 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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