Inspection on 03/05/05 for Ravensworth Lodge

This inspection was carried out on 3rd May 2005.

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

Ravensworth Lodge 18/04/07

Ravensworth Lodge 28/12/05

Ravensworth Lodge 02/02/05

Ravensworth Lodge 18/08/04

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

CARE HOMES FOR OLDER PEOPLE Ravensworth Lodge 3 Belgrave Crescent Scarborough North Yorkshire YO11 1UB Lead Inspector Karen Ritson Unannounced 3 May 2005 09:45 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 Lodge J53_JO4 S7668 Ravensworth V222776 030505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Ravensworth Lodge Address 3 Belgrave Crescent Scarborough North Yorkshire YO11 1UB 01723 362361 01723 375867 N/A Yorkshire Friends Housing Society Limited 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) Mrs Suzanne Elizabeth Sellers PC Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Ravensworth Lodge J53_JO4 S7668 Ravensworth V222776 030505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 2 February 2005 Brief Description of the Service: Ravensworth Lodge is a four storey detached property which has been operating as a care home since 1950. The home provides personal care and accomodation for a maximum of 24 older people. It is owned by Yorkshire Friends Housing association Ltd and whilst it is run by this organisation of Quakers, admissions are not restricted to any religious denomination. The home is situated close to Scarborough town centre and is conveniently located near all main community facilities including the public transport network. Restricted parking is available at the roadside nearby the home. The home has 24 single rooms, 16 of which are ensuite. There is a passenger lift to all floors. Two rooms are only accessible by several steps , requiring the occupants of these rooms to be reasonably ambulent. Both baths are assisted; one is a Parker bath and the home also provides a walk in shower. Access to the building is by steps or ramp. A garden with a summerhouse is to the rear of the property. Ravensworth Lodge J53_JO4 S7668 Ravensworth V222776 030505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place on May 3rd 2005, between 9:45am and 16:50pm. The manager Suzanne Sellars was available throughout the day. Five service users and four visitors were spoken to during the inspection. Their comments are included in the text of this report but all were positive regarding the care offered by this home. Two members of staff were also interviewed. A relaxed and comfortable atmosphere was evident throughout the day. Suzanne Sellars has settled into her role well and presents a professional and competent style of management. The inspector would like to thank all service users, visitors, staff and the manager for their assistance in completing this inspection. What the service does well: What has improved since the last inspection? What they could do better: Quality assurance results should be published to assist prospective service users to form a view of the home and to make a decision regarding admission. All certification regarding staff training should be kept on the premises for inspection. Ravensworth Lodge J53_JO4 S7668 Ravensworth V222776 030505 Stage 4.doc Version 1.30 Page 6 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 Lodge J53_JO4 S7668 Ravensworth V222776 030505 Stage 4.doc Version 1.30 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 Lodge J53_JO4 S7668 Ravensworth V222776 030505 Stage 4.doc Version 1.30 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) 3 6. Service users needs are thoroughly assessed and they are assured that those needs will be met. No intermediate care is offered by the home. EVIDENCE: A detailed assessment is carried out prior to the service user being admitted to the home and this is developed following admission. It includes risk assessments and a record of consultation with the service user. A care plan is drawn up from this. Service users said they felt staff knew what their care needs were and felt reassured that their care needs would be met. The home does not offer intermediate care. Ravensworth Lodge J53_JO4 S7668 Ravensworth V222776 030505 Stage 4.doc Version 1.30 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, 9 and 10 Service users personal care and health care needs are met. Service users are safeguarded by the homes policies, procedures and practice regarding the administration of medication. Individuals are treated with respect and dignity. EVIDENCE: A care plan is drawn up with the recorded agreement of the service users or third party. This covers all required areas of care and includes risk assessments for all areas of vulnerability including pressure care and continence. It is also reviewed monthly. All contact with health care and other care professionals is recorded on file and written feedback from quality assurance documentation confirmed that such professionals felt staff at the home followed advice given and worked in a cooperative way with them. Service users said they knew that care plans were kept but that they had little interest in studying what was recorded. All said they felt their health was a priority with care staff and that it was regularly monitored. Medication is suitably kept and administered. Certificated evidence of care workers medication training is required. Staff were observed treating service users with respect and dignity. Policies and procedures are in place to support this. Service users said their views and feelings were taken into account. Ravensworth Lodge J53_JO4 S7668 Ravensworth V222776 030505 Stage 4.doc Version 1.30 Page 10 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. Service users are enabled to live as full and varied a life as possible. Individuals retain a high level of choice and control over their lives. The food is of a good quality and is served in an appetising way. EVIDENCE: All service users said they were encouraged and enabled to live as full and independent life as possible. Some took part in the outings offered by the home and the activities arranged. An activities organiser had been newly recruited and it was her first day in post on the day of inspection. She was spending time discussing service users interests with them and had begun to form a plan to organise an event around V.E. day amongst other things. Those service users who wish to attend church are helped to do so. One service user was spending her afternoon painting with watercolours in her room and a member of staff accompanied one person to the bank in the morning. All said they would be helped to go out if they wished to. The visiting policy stated that visitors may call at any time, and service users confirmed that this was the case. Many of the service users resident at Ravensworth Lodge have retained a degree of independence and are able to go out unaided or with minimal assistance. Those who have the capacity to organise their own finances are encouraged to do so. Those who wish to self medicate have secure facilities made available for the storage medication following a risk assessment and the Ravensworth Lodge J53_JO4 S7668 Ravensworth V222776 030505 Stage 4.doc Version 1.30 Page 11 service user signs a self-medication form. A midday meal was observed. There was a good choice and service users said the food was of a consistently high standard. Tables were attractively set out and the food was well presented. Service users who wished to rearrange their mealtime said they were not put under any pressure and could have their meal whenever they returned from an outing, for example. Diabetic diets are catered for and other diets by arrangement. Ravensworth Lodge J53_JO4 S7668 Ravensworth V222776 030505 Stage 4.doc Version 1.30 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 home responds well to complaints and service users are confident that their concerns are listened to and acted upon. The home protects the welfare of service users and service users feel safe. EVIDENCE: Service users said that they were consulted over all areas of their lives within the home and were encouraged to speak out if there were any issues they were dissatisfied with. The manager had provided a complaint and comments book, which was easily accessible in the upper lounge. No comments had been written. Service users said that they would prefer speaking to a member of staff directly if they had a concern. Visitors said they felt sure any concerns would be listened to. One visitor said that when she had commented on an issue, the member of staff concerned, and subsequently the manager had treated her with great care and respect. The problem had been sorted out immediately. Several complaints had been made and recorded from members of staff regarding other staff members or conditions of service and these had been investigated with all findings also recorded. The complaints policy and procedure supported the manager’s comments about the homes’ attitude to complaints. Staff were aware of the potential for abuse within a care setting and all spoken to had received abuse training. Staff were also aware of what would happen in a POVA investigation and understood the requirement for staff to have a POVA check prior to employment. All service users said they felt safe within the home and said that staff were without exception, kind and helpful. Ravensworth Lodge J53_JO4 S7668 Ravensworth V222776 030505 Stage 4.doc Version 1.30 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, 21 and 26 Service users are cared for in a safe environment. They have sufficient bathing and toilet facilities and the home is clean and hygienic. EVIDENCE: The home was safe and well maintained. The lift had developed a fault recently and some service users had been obliged to remain in their rooms all day. Others had descended to the lounge for the morning but were not able to return to their rooms at night. These service users were made comfortable for the night and slept in the lounge. The problem with the lift was rectified the next day. Service users said that whilst they had been inconvenienced, the situation had been fully explained to them and they felt it had been resolved quickly. They praised the energy and cheerfulness of staff who had climbed upstairs on many occasions throughout the day to take meals and drinks to those service users in their rooms and said that staff had made a special effort to chat as they were aware that service users may be feeling a little isolated. Decoration and refurbishment is carried out on a programme agreed with the trustees of the home. The furnishings are good quality with the chairs and the Ravensworth Lodge J53_JO4 S7668 Ravensworth V222776 030505 Stage 4.doc Version 1.30 Page 14 carpet in the upper lounge having been recently replaced. Service users and visitors said the home was ‘beautiful’ and well cared for. The home has two baths and one shower room for the use of all service users. Both baths are assisted and one is a Parker bath. Service users commented that they preferred the Parker bath, as it was easier to climb in and out of. Some service users preferred the shower. They also commented that they were consulted over how often they would like to take a bath and received any help they required with bathing. The grounds were tidy and attractive and the building complies with the local fire and environmental health departments. Service users said they enjoyed using going into the garden and using the summerhouse in good weather. The home was bright, clean and cheerful with no offensive odour. Washing machines met the standard regarding water regulations, and policies and procedures for infection control were seen. Recent residents meeting minutes recorded that some service users had experienced a problem receiving the wrong clothes back from the laundry but all said this had now been resolved. Ravensworth Lodge J53_JO4 S7668 Ravensworth V222776 030505 Stage 4.doc Version 1.30 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) 27,28,29 and 30 There are sufficient staff on duty at all times and staff are well trained, which ensures that service users needs are met in an appropriate way. Staff are recruited according to policy and procedure ensuring those providing care for service users are suitable to be in post. EVIDENCE: Staff rotas were seen. A senior carer and two care assistants are on duty during the day and two night staff are on duty with another on call. Staffing hours remain as they did at the previous inspection and continue to meet the standard. The home was clean and there was evidence through out the day that there were sufficient domestic staff on duty. Almost 50 of staff have achieved NVQ at level 2. Some are awaiting certificates. Staff reported that they had completed an application form when being recruited, had been called for interview and then had references taken up. All had received terms and conditions of service. Staff files confirmed that all required information was present and that a thorough recruitment procedure was in place. Staff receive thorough induction and foundation training, which although does not use the TOPSS format adheres to TOPSS specifications. Service users said they were treated well by staff and they felt they the recruitment system worked because the staffing complement did not change often. Many staff had been at the home for a number of years. Ravensworth Lodge J53_JO4 S7668 Ravensworth V222776 030505 Stage 4.doc Version 1.30 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) 31,33,35,36 and 38 The manager is competent and manages the home well. Service users are consulted over the way they live their lives in the home and their suggestions are acted upon. Service users finances are safeguarded. Staff are appropriately supervised. Service users are safe and their health and safety are promoted. EVIDENCE: The manager has achieved NVQ level 3 in care and has the Registered Managers Award. She is enrolled on a course leading to a qualification to NVQ level 4 standard with Selby College, along with two other senior members of staff. Her manner was professional and competent, despite having several scheduled appointments on the day of this unannounced inspection, which required her to rearrange her plans for the day. Ravensworth Lodge J53_JO4 S7668 Ravensworth V222776 030505 Stage 4.doc Version 1.30 Page 17 The home has developed a quality assurance system, where the views of service users, visitors, thirds parties, health care and other professionals are elicited on a regular basis through questionnaires. The results are fed back through staff and service users meetings but there are no formal published results. It is recommended that the results be published so that current and prospective service users may be assisted to form a view of the home. Service users said they were encouraged to manage their own finances if they had capacity and wished to do so. Secure facilities were seen within rooms for the storage of any valuables. Staff said they received regular supervision and the manager had just finished a series of annual appraisals with all staff. Records were seen on staff files. Staff said they felt well supported and were adjusting to a new management style. Written evidence was seen of all staff training on health and safety. All certificates were seen for the maintenance of electrical systems, gas, fire equipment and alarms. Environmental risk assessments were seen. There had been an incident in recent months when a member of the public had entered the building by deception. The manager had asked staff to be extra vigilant, to ask visitors to sign in and out and to record who they were visiting. CCTV cameras have been fitted to the exterior of the building to assist with security. Service users said they had no concerns over their safety in the home. Ravensworth Lodge J53_JO4 S7668 Ravensworth V222776 030505 Stage 4.doc Version 1.30 Page 18 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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x 3 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 Standard No 16 17 18 Score 3 x 3 2 x 2 x 3 3 x 3 Ravensworth Lodge J53_JO4 S7668 Ravensworth V222776 030505 Stage 4.doc Version 1.30 Page 19 na 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. 2. 3. Refer to Standard 9 31 33 Good Practice Recommendations Staff competence in administering medication should be recorded. (Outstanding recommedation from last inspection) The manager should be qualified to NVQ level 4 in care by 2005 Quality assurance feedback should be published. Ravensworth Lodge J53_JO4 S7668 Ravensworth V222776 030505 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection York Area Office Unit 4, Triune Court Monks Cross York, YO32 9GZ 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 Lodge J53_JO4 S7668 Ravensworth V222776 030505 Stage 4.doc Version 1.30 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. 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. 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