Care Home: Ravendale Hall

Similar services:

• Abbey The
• Snydale Care Home
• Hawkhills
• Larchfield Manor
• Beeches The - North Yorkshire County Council
• Staveley Birk Leas Nursing Home
• Carentan House

What the care home does well The majority of the requirements from the last inspection had been met. The experiences of the people were positive in relation to how their care needs were met at the home. People who lived in the home said `I like every thing here` and `I am very happy here, I am well looked and have no complaints`. People were provided with a homely, clean and tidy and well-decorated environment. One person stated that they `couldn`t wish for a more comfortable bed`. The staff were friendly and knew a lot about the people who lived in the home. Staff helped the people who live there in a dignified and respectful manner. Comments from people who lived in the home included `the staff couldn`t be better` and `these are the best staff I have ever known`. The staff working at the home were caring towards people and had good working relationships with them. A welcoming atmosphere was created for family and friends when they visited the home. One relative said that `the care home makes it appear as one big family and I and other family members are always welcomed as friends of the family`.There were a lot of activities on a daily basis at the home. This means that everyone, at some point, were able to join in activities that were of interest to him or her. People were very happy with the activities made available to them. One said `I enjoy the activities and outings at the home`. The home obtained the views of all of the people who lived, worked and visited the home to make sure that it was doing a good job or to decide how it can change things to make it better for everybody. The staff were supported as they were provided with individual time to talk to the manager about how well they were doing, or if they needed more training or support with their work. What has improved since the last inspection? They had improved the way they evaluated the care plans taking into account any incidents or changes over the previous but they had not always updated the care plans where needed following this. They had provided evidence that people or their representative had had the opportunity to see and agree their plan of care so that people were enabled to make decisions about the care they were to receive. They ensured that medications were stored as per instructions on medication advice sheets so that safe storage of medication is maintained in the home. They made sure that they protected people`s rights to refuse medication. They made sure that staff had received training in safeguarding adults to offer protection to people. They had removed the freestanding radiators which were health and safety risk. They had made sure that recruitment processes protect people. They had made sure that people at risk of falls were identified and accident records were completed fully. What the care home could do better: They could provide more information about the services provided and lifestyle that can be expected in the home within the statement of purpose and service users guide. They must make sure that people`s needs are assessed prior to the admission to the home. This is to ensure that the home is able to meet people`s needs. They must make sure that care plans are developed which set how peoples assessed needs are to be met and that when needs change care plans are updated. This is to make sure that the care staff have all the information to enable them to meet people`s needs. They must monitor staff adherence to medication policies and procedures to ensure safe practice. They must make sure that medication records are accurately maintained to ensure a full audit trail. They must minimise the risk of fire in the home by ensuring fire doors are not wedged open, staff training is provided regularly and the fire alarm is tested weekly. They must be more proactive in planning refresher training to make sure that this is kept up to date. They must make sure that accurate records of financial transactions are maintained where the home assists people with their finances. The manager must provide a report into the investigation of the discrepancy identified at the inspection. They must make sure that peoples health and safety is protected when using bedrails by completing full risk assessments. CARE HOMES FOR OLDER PEOPLE Ravendale Hall Ravendale Hall East Ravendale Grimsby North East Lincs DN37 0RX Lead Inspector Mrs Kate Emmerson Unannounced Inspection 21st May 2008 09:30 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 Ravendale Hall DS0000035677.V366711.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. Ravendale Hall DS0000035677.V366711.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ravendale Hall Address Ravendale Hall East Ravendale Grimsby North East Lincs DN37 0RX 01472 823291 01472 823121 cynthiacommons@hotmail.com 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) Cleethorpes Care and Nursing Ltd Julie Hardy Care Home 34 Category(ies) of Dementia (5), Dementia - over 65 years of age registration, with number (5), Old age, not falling within any other of places category (34), Physical disability (6) Ravendale Hall DS0000035677.V366711.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th May 2007 Brief Description of the Service: Ravendale Hall is a 40-bedded care home providing for the needs of older people, those suffering with dementia and also has 6 beds for the physically disabled. The home is situated in a rural position in a small village on the edge of the Wolds, approximately five miles from Grimsby. The building is set in extensive grounds and is in the style of an old manor house, it has maintained much of the character and original features and has had an extension provided in more recent years. The home is spacious and homely, with the accommodation based on two floors, a passenger lift is provided. There is a wide variety of day space, which includes three sitting rooms, two dining rooms and a library all on the ground floor. All the rooms are currently for single occupancy and include en- suite facilities. Many rooms offer views over the surrounding countryside. A large mature garden surrounds the home with seating provided. Ample parking is available. The home and its grounds are very well maintained. The current fee for the services provided at the home is £345 - £385 per week. Ravendale Hall DS0000035677.V366711.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. The inspection was unannounced and took place over one day. The manager and the director of the home were present during the inspection. Whilst at the home, key documents such as care assessments, care plans, daily records and the home’s policies were looked at, and so were some of the rooms and garden. People who live in the home and members of staff were spoken with, along with the director of the service, the area manager, manager and cook. Additional information was provided through four relatives, carers and advocates surveys, and six staff questionnaires. Surveys were provided to the home for the service users and nine were received back. The manager had also provided written information about the service in the form of the annual quality assurance assessment (AQAA). The AQAA is a selfassessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. What the service does well: The majority of the requirements from the last inspection had been met. The experiences of the people were positive in relation to how their care needs were met at the home. People who lived in the home said ‘I like every thing here’ and ‘I am very happy here, I am well looked and have no complaints’. People were provided with a homely, clean and tidy and well-decorated environment. One person stated that they ‘couldn’t wish for a more comfortable bed’. The staff were friendly and knew a lot about the people who lived in the home. Staff helped the people who live there in a dignified and respectful manner. Comments from people who lived in the home included ‘the staff couldn’t be better’ and ‘these are the best staff I have ever known’. The staff working at the home were caring towards people and had good working relationships with them. A welcoming atmosphere was created for family and friends when they visited the home. One relative said that ‘the care home makes it appear as one big family and I and other family members are always welcomed as friends of the family’. Ravendale Hall DS0000035677.V366711.R01.S.doc Version 5.2 Page 6 There were a lot of activities on a daily basis at the home. This means that everyone, at some point, were able to join in activities that were of interest to him or her. People were very happy with the activities made available to them. One said ‘I enjoy the activities and outings at the home’. The home obtained the views of all of the people who lived, worked and visited the home to make sure that it was doing a good job or to decide how it can change things to make it better for everybody. The staff were supported as they were provided with individual time to talk to the manager about how well they were doing, or if they needed more training or support with their work. What has improved since the last inspection? They had improved the way they evaluated the care plans taking into account any incidents or changes over the previous but they had not always updated the care plans where needed following this. They had provided evidence that people or their representative had had the opportunity to see and agree their plan of care so that people were enabled to make decisions about the care they were to receive. They ensured that medications were stored as per instructions on medication advice sheets so that safe storage of medication is maintained in the home. They made sure that they protected people’s rights to refuse medication. They made sure that staff had received training in safeguarding adults to offer protection to people. They had removed the freestanding radiators which were health and safety risk. They had made sure that recruitment processes protect people. They had made sure that people at risk of falls were identified and accident records were completed fully. Ravendale Hall DS0000035677.V366711.R01.S.doc Version 5.2 Page 7 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. Ravendale Hall DS0000035677.V366711.R01.S.doc Version 5.2 Page 8 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 Ravendale Hall DS0000035677.V366711.R01.S.doc Version 5.2 Page 9 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): 1, 3 and 6 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People were provided with basic information to assist them to make an informed choice to live at the home They had usually made sure that people’s needs had been assessed prior to moving into the home. The home does not provide intermediate care dedicated to accommodate people with intensive rehabilitation needs. EVIDENCE: Three care files were examined. The care files contained evidence that people’s needs had been assessed before they were admitted into the home. The assessments were a combination of the home’s pre-admission assessment Ravendale Hall DS0000035677.V366711.R01.S.doc Version 5.2 Page 10 and the care management assessments from the placing authority. The assessments were supported where appropriate with risk assessment. The manager stated that where people were admitted on a rolling respite programme they were reassessed at each admission to ensure that the information was up to date. Staff said that they always received the information about peoples care needs. The Local Authority had raised concerns that the management had moved one person from another home in the company to Ravendale without consultation with them and without assessment. The management acknowledged that this had occurred but that this was in full consultation with the person involved. Approval of the placing Authority should be sought to ensure that the person is appropriately placed for their needs and funding is available. The home had a statement of purpose, service user guide and a brochure that were available to people and their families and friends. Whilst these covered the basic points required to meet the regulations and the standards, the documents a were limited to very basic statements about the service and could be further developed to give information about the life style service users could expect if they lived in the home. The management were in the process of redeveloping the service users guide at this inspection. People indicated in surveys, that they had received enough information about the service before they moved in. Ravendale Hall DS0000035677.V366711.R01.S.doc Version 5.2 Page 11 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 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s health and personal care needs were met at the home, however care plans did not always reflect peoples needs. There were some practice issues in regard to practice with the medication, which may put people at risk. People felt they were treated with respect. EVIDENCE: Three care files of people living at the home were examined. Observation showed that staff had paid attention to detail when assisting people with personal care. People said that staff had assisted them with cleaning their glasses, dressing their hair and shaving. Ravendale Hall DS0000035677.V366711.R01.S.doc Version 5.2 Page 12 There had been improvement in the level of detail recorded in care plans, diary records, evaluations and records of professional healthcare visits. However care plans had not been developed for all needs identified in assessment. For example one person had been assessed as at high risk of pressure sore development and although equipment had been obtained to minimise risk there was no care plan to identify the care required. District nurse instructions although recorded were not always entered into the care plan, this means that over time the information/care instructions could go unnoticed and may put people at risk of needs not being met. For example in one case the instruction for a person’s foot to be elevated had not been included in the care plan. The care plans and risk assessments had been signed by either the person or their representatives to acknowledge their involvement in the development of the plan and their agreement to it. Evidence from staff training records and staff discussion indicated that staff who administered medication had received accredited medication training and policies and procedures were available to staff. However there were some issues in relation to handling medication and medication records, which may put people at risk. The medication records did not always reflect the prescription on the medication boxes and although the staff could explain the changes i.e. changes to medication after an admission to hospital there was a lack of documentation to support this. Where records had been hand transcribed there was no indication that these had been double-checked against the prescription to ensure the correct details had been recorded. A staff member was observed dispensing the medication and then giving this to another carer to give to the resident who was in their bedroom. This is not safe practice and increases the risk of error, for example the medication being given to the wrong person. This practise was also in conflict with the homes policy and procedures and the staff member was aware of this. It was also observed that medication in one case was not given at times on the medication records as the person preferred to get up late. The records were not accurate in that they were signed that they had given medication at 8am when fact this had been given at 11am. One person was prescribed medication on as required basis to control aggressive behaviour, there was no management plan to give specific instructions to staff on the use of this medication and staff were not trained to make decisions in regard to administering as required medication to modify Ravendale Hall DS0000035677.V366711.R01.S.doc Version 5.2 Page 13 behaviour. This may lead to inappropriate or inconsistent use of this medication. People confirmed that they were always treated with dignity and respect and the staff used their preferred term of address, knocking on their doors before they entered and when providing personal care. This was also observed to happen on the inspector’s tour of the premises. People were very well groomed and all the people spoken with said they were very happy. Ravendale Hall DS0000035677.V366711.R01.S.doc Version 5.2 Page 14 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 and 15 People who use the service experience good quality outcomes in this area This judgement has been made using available evidence including a visit to this service. People provided with the opportunity to become involved in a range of different activities at the home and in the community. However there were some extra charges that had not been agreed with the placing authorities for one activity and this might put undue financial burden on people and the home may be in breach of contract. Visitors were made to feel welcome in the home. People were provided with good quality, varied meals that were appropriate to their needs. EVIDENCE: People were provided with the opportunity to become involved in varied activities arranged through the activity co-ordinator. The activity co-ordinator worked very hard to maintain the level of activities that were made available to people living in the home. Records and a plan of activities held in the home were available. Ravendale Hall DS0000035677.V366711.R01.S.doc Version 5.2 Page 15 One person stated that they ‘went to the pub, had bus trips and played bingo’ and another said ‘there’s plenty to do’. On the day of the inspection there was a trip to a luncheon club and all were asked if they wanted to go. The home hired a bus suitable for peoples needs as required. People were very happy with the activities made available to them. One said ‘I enjoy the activities and outings at the home’. Visitors stated in surveys that they were always made to feel welcome when they visited the home. One relative stated that ‘the care home makes it appear as one big family and I and other family members are always welcomed as friends of the family’. Local community activities and events were publicised on the homes notice board. A relative said ‘the activities and outings are very good’. The home had arranged for an external agency to come to the home to provide motivational group activities. If people in the home wished to attend they were being to cover the costs. The manager was advised that activities were part of the care plan and that this formed part of the contract with the funding agencies. Extra charges for activities in the home should therefore be agreed with the agency funding individual’s placements in the home. There was no evidence that this had been done. The home provided a varied three-week rotating menu and choices were available at all meal times. People had had input into the development of the menus and annual survey of this area had been completed completed. People spoken with all said that the quality of the meals was ‘very good’ and one person said that ‘you can have what you want for breakfast, eggs, toast, cornflakes, just tell the cook, there are no problems with cooking alternatives if you don’t like what’s on the menu, they are pretty flexible’. Another said the meals ‘couldn’t be better’. One person who had had a lay in and came down late in the morning was still offered a choice of breakfast. Aids were provided to encourage people to maintain independence where possible and staff assisted where required in a sensitive and discreet manner. Ravendale Hall DS0000035677.V366711.R01.S.doc Version 5.2 Page 16 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 and 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There were improvements in both areas assessed and people were very positive about the service they received. EVIDENCE: The home had appropriate policies and procedures for dealing with complaints and for the protection of vulnerable adults. The complaint procedure was made available to people in information provided and was also displayed in the home. The manager had opened a book for people to record minor concerns but there were none recorded. The information provided by the manager prior to the inspection indicated that the home had received no complaints since the last inspection. The Commission had not received any complaints about the service since the last inspection. Information on surveys indicated that people who lived in the home and their relatives knew how to make a complaint. People expressed satisfaction with the care relieved one said ‘I am very happy here, I am well Ravendale Hall DS0000035677.V366711.R01.S.doc Version 5.2 Page 17 cared for I have no complaints’ and another said ‘I like everything here’. A relative said they had had a ‘good response when concerns were raised’. There was improvement in the provision of staff training since the last inspection and all but three care staff had attended Local Authority safeguarding training in September 2007. Training for these staff had been booked. There had been no allegations of abuse since the last inspection. Recruitment practices had improved since the last inspection and all checks had been competed prior to staff commencing employment. Ravendale Hall DS0000035677.V366711.R01.S.doc Version 5.2 Page 18 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. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home was very clean and tidy and suitable for peoples needs and people were happy living there. The management had not prevented fire doors being propped open; this would increase the risk of spread of fire in the home. EVIDENCE: The inspector made a partial tour of the premises of the home. The home was exceptionally clean and tidy and free from any offensive smells. It was well decorated and maintained and furniture and fittings were very good quality. Ravendale Hall DS0000035677.V366711.R01.S.doc Version 5.2 Page 19 The home had a clear maintenance and renewal plan and equipment used at the home had up to date maintenance and service records. The grounds of the home were large and very well maintained and people stated they had a lot of pleasure from walking and sitting in the grounds. The heating and lighting in the home were domestic in character. Regular random checks were made on the hot water outlets to maintain the health and safety of the service users. Hot water temperatures were maintained close to 43° C. One person had wedged their door open with a walking frame. This would increase the risk of spread of fire in the home. (See standard 38) People who lived in the home were happy with the service provided, one said ‘we have a good cleaner and a good laundry service, the laundry lady always matches my socks for me’. Another person said ‘I couldn’t wish for a more comfortable bed’ and another said ‘this is a very nice place’. Ravendale Hall DS0000035677.V366711.R01.S.doc Version 5.2 Page 20 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 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staffing levels were appropriately maintained so that people’s needs could be met. The manager did not forward plan refresher training in a proactive way leading to some training becoming out of date. This may put people at risk. Recruitment practices had improved and all checks were now completed. EVIDENCE: The manager of the home stated she used the uses the Residential Forum guidance to determine the number of staff that were required for each shift at the home. All of the people spoken with said that there was always enough’ staff available to meet their needs and comments included ‘staff are very nice, we are well looked after and they are very kind’ and ‘the staff couldn’t be better’. Three staff personnel files were checked and showed that the staff had received appropriate security vetting before they had been allowed access to any of the people living in the home. Ravendale Hall DS0000035677.V366711.R01.S.doc Version 5.2 Page 21 The information provided by the manager prior to the inspection indicated that management and care staff showed a good commitment to NVQ training. Although the home had not maintained the required 50 of staff with NVQ level 2 or above with only seven of seventeen staff having achieved the award there were nine staff in training. The manager kept an overview of the staff training to assist her in the planning of training in the home. However although records showed that the staff had received training in mandatory areas some of these were a little out of date; there was evidence courses had been booked to address this. For example one staff member had not completed safeguarding training since 2004 but a course was booked for this and in another case moving and handling training in was due in April but this had not been completed. A visitor to the home stated ‘the staff appear to be able to cope with difficult residents in a professional manner and deal with emergencies speedily’ and another said ‘my relative needs the assistance with all movement and I have been very impressed with the care given at these times’. Staff interviews and personnel files provided evidence that they are receiving the recommended minimum of six formal recorded supervision periods per year. Staff interviewed and staff questionnaires provided evidence that they were happy working at the home and with the support that they received to carry out their tasks. There was evidence that the staff had completed induction to the home and care workers role to skills for care standards. Ravendale Hall DS0000035677.V366711.R01.S.doc Version 5.2 Page 22 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, 36 and 38 People who use the service experience adequate quality outcomes in this area This judgement has been made using available evidence including a visit to this service An experienced registered manager runs the home. People were included in the quality monitoring processes. People’s individual financial interests were generally safeguarded although there was an error found. Deficiencies in the management of health and safety may put people at risk. EVIDENCE: The registered manager stated that she had completed the Registered Managers Award. Ravendale Hall DS0000035677.V366711.R01.S.doc Version 5.2 Page 23 The home had systems to monitor the quality of the care provided in the home. This included surveys and monthly auditing of systems in the home. Records showed that surveys had just been completed. People had not been advised of the findings and action plans had not been developed at the time of the inspection although the manager stated that this would be completed. Records where the home was assisting service users with finances were clearly maintained with receipts held for any transactions. Regular audits by the administrator were completed. Records were checked with cash held and one did not balance by five pounds. The error could not be identified in the inspection and the manager was requested to investigate the discrepancy. There was improved clarity in the record keeping for the resident’s fund, which was managed by the activities coordinator, manager and a relative of a person living in the home. There was evidence that the equipment in the home had been serviced regularly and at appropriate intervals. The handyman completed regular checks of hot water temperatures in the home. In two cases where bedrails were fitted this action was not supported by a risk assessment to determine the need for the device. This not acceptable and may lead to inappropriate or unsafe use of bedrails. The manager stated that the handy man checked bedrails although records recorded the room number only. One fire door was propped open by a persons walking frame. This may increase the risk of the spread of fire in the home. (See standard 19) There was improvement in ensuring that fire drills were completed and recording accidents. Ravendale Hall DS0000035677.V366711.R01.S.doc Version 5.2 Page 24 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 2 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 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 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 2 Ravendale Hall DS0000035677.V366711.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP1 Regulation 14 Requirement Timescale for action 21/05/08 2 OP7 15 3. OP8 1512(1) 4 OP9 13(2) The registered person must make sure that people’s needs are assessed prior to the admission to the home. This is to ensure that the home is able to meet people’s needs. The registered person must 01/08/08 make sure that care plans are developed which set how peoples assessed needs are to be met and that when needs change care plans are updated. This is to make sure that the care staff have all the information to enable them to meet people’s needs. The registered person must 01/08/08 ensure that where care instructions have been made by a visiting health care professional the care plan is updated to reflect these to ensure timely and appropriate care is provided. (The previous timescale of 01/08/07 was not met) The registered person must 14/07/08 make sure that hand transcribed medication administration DS0000035677.V366711.R01.S.doc Version 5.2 Ravendale Hall Page 26 5. OP9 13(2) 6 OP9 13(2) 7 OP9 13(2) 8 OP19 13(4) 23(4) 9 OP30 18(1) instructions are double-checked for accuracy and to minimise the risk of errors. The reasons for any changes to the prescription must be fully documented and signed by the person making the changes. The registered person must ensure medication records are accurately maintained in terms of the times medications are administered. The registered person must make sure when medication is prescribed on an as required basis to modify behaviour a management plan is developed which gives clear instructions on when this medication is to be used and how to monitor its effectiveness. Staff must receive training and evidence competency in assessing when people require this type of medication. This is to ensure a consistent approach in administering medication in these circumstances. The registered person must make sure that staff follow the homes medication policy and procedure in that staff who dispense medication and sign the records also give the medication to the person for whom it is prescribed. This is to minimise the risk of errors. The registered person must ensure that fire doors are not wedged open to minimise the spread of fire in the home. (The previous timescale of 01/08/07 was not met) The registered person must make sure that training is planned so that mandatory training is kept up to date. DS0000035677.V366711.R01.S.doc 21/05/08 14/07/08 21/05/08 21/05/08 01/08/08 Ravendale Hall Version 5.2 Page 27 10 OP35 17(2) 11 OP38 13(4) The registered person must make sure that accurate records of financial transactions are maintained where the home assists people with their finances. The manager must provide a report into the investigation of the discrepancy identified at the inspection. The registered person must ensure risk assessments accurately determine whether a person initially requires bed rail provision and evaluations must determine the continued need for them. Bed rails and protectors must be fitted and checked in line with manufacturers instructions and Medical and Healthcare products Regulatory Agency (MHRA) guidelines. This is to minimise the risk of injury to service users. (The previous timescale of 01/08/07 was not met) 14/07/08 21/05/08 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 OP1 Good Practice Recommendations The registered person should further develop the statement of purpose and service users guide to give information about the life style service users could expect if they lived in the home. The registered person should agree the funding of activities in the home by people living in the home with the placing authority and provide written evidence to this effect. 2 OP12 Ravendale Hall DS0000035677.V366711.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Ravendale Hall DS0000035677.V366711.R01.S.doc Version 5.2 Page 29 - 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!