Care Home: Ravensfield

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What the care home does well What has improved since the last inspection? Improvements continue to be made to the decorations and furnishings at the home. This helps to ensure that the home is maintained to a good standard and provides a comfortable and safe environment for the people that live there.The home has also started to carry out nutritional assessments for people living at Ravensfield. This helps to ensure that any problems with eating and drinking are identified at an early stage thus reducing the risks of people suffering from mal-nourishment. What the care home could do better: There are still some improvements that should be made with regard the food. The home should consider looking at the daily menus to ensure that all the options and choices are clearly shown. This mainly relates to sandwich fillings and types of soups that will be served. Some people also said that it would be nice to have more choices at teatime and `not just sandwiches`. Some people would like the private rooms to be bigger with en-suite facilities. This is not possible in the current building but there are plans for the home to re-locate. This would mean that all bedrooms would be bigger with en-suite facilities. Many people thought that the home `could do with more staff` and `speed up the employment process`. It is important that staff are recruited properly and safely. Perhaps a review of the recruitment process would be beneficial but certain processes have to remain in place to help ensure that the safety of people using this service is not compromised. CARE HOMES FOR OLDER PEOPLE Ravensfield High Hill Keswick Cumbria CA12 5NX Lead Inspector Diane Jinks Unannounced Inspection 10th April 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ravensfield DS0000035388.V361895.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. Ravensfield DS0000035388.V361895.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ravensfield Address High Hill Keswick Cumbria CA12 5NX 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) 017687 72490 01768 780978 www.cumbriacare.org.uk Cumbria Care vacant post Care Home 30 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (10), Old age, not falling within any other of places category (30) Ravensfield DS0000035388.V361895.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service must at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The home is registered for a maximum of 30 service users to include: up to 30 service users in the category of OP (old age not falling within any other category) up to 10 service users in the category of DE(E) (Dementia over 65 years of age) 26th April 2007 Date of last inspection Brief Description of the Service: Ravensfield is operated by Cumbria Care, which is an internal business unit of Cumbria County Council. The home provides accommodation and care for up to 30 older adults, 10 whom may have dementia. The home is situated close to the centre of Keswick and the local services and facilities of the town. The home provides accommodation on two floors, and is divided into two units. The main part of the home is for people who are physically frail, and there is a small unit for people with dementia. There is a passenger lift, hand rails and grab rails to assist people in moving around the home. There are three bathrooms in the home, which are equipped to assist people with a disability. All of the bedrooms are for single occupancy, and three have en-suite toilet facilities. There are pleasant garden areas with seating, and a car park. The weekly fees for this home do not exceed £449.00, although there are extra charges for hairdressing, magazines, chiropodists and other personal items that people may wish to have. Ravensfield DS0000035388.V361895.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 3 star. This means the people who use this service experience excellent quality outcomes. The assessment of this service took place over several weeks and included a visit to the home. People using this service, staff, visitors and relatives were asked for their views and opinions about the home, either during the visit or by completing questionnaires. The provider completed an Annual Quality Assurance Assessment, which helped verify information throughout the inspection process. What the service does well: What has improved since the last inspection? Improvements continue to be made to the decorations and furnishings at the home. This helps to ensure that the home is maintained to a good standard and provides a comfortable and safe environment for the people that live there. Ravensfield DS0000035388.V361895.R01.S.doc Version 5.2 Page 6 The home has also started to carry out nutritional assessments for people living at Ravensfield. This helps to ensure that any problems with eating and drinking are identified at an early stage thus reducing the risks of people suffering from mal-nourishment. 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. Ravensfield DS0000035388.V361895.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ravensfield DS0000035388.V361895.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using this service have their health and social care needs assessed prior to moving into Ravensfield. This helps to make sure that the home will be suitable and able to meet their specific needs appropriately. EVIDENCE: Prospective residents are encouraged to visit the home with their families and friends to see at first hand the facilities available. They are given a tour of the home and the opportunity to of spending a day at the home. This gives people the chance to talk to the people who already live there and experience first hand what life at Ravensfield could be like. All admissions to the home are initially on a six week trial basis. This helps to make sure that the home can meet the needs and expectations of the individual concerned. A sample of four care files was looked at during the visit to the home. All have assessments in place that have been carried out by a social worker or the home. One of the files looked at showed that the person was admitted to the Ravensfield DS0000035388.V361895.R01.S.doc Version 5.2 Page 9 home in an emergency situation. The records show that the home obtained a copy of the care needs assessment on the same day as the admission took place. This helped to ensure that the home would be suitable and able to meet the needs of this person. The home produces information in the form of statement of purpose/service user guide. These documents give information to prospective residents about the home, facilities and services that it can provide. A new manager has recently been appointed at the home and these documents will need to be reviewed and updated to reflect the changes in management. The most recent inspection report is also available in the home. These documents help to inform people when they are making decisions about where to live. Ravensfield DS0000035388.V361895.R01.S.doc Version 5.2 Page 10 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): All of the above standards. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People using this service have detailed plans and records about their care and support needs. This means that the support they receive generally meets their expectations and requirements. EVIDENCE: The sample of care files looked at during our visit generally contained detailed care plans or information relating to the care and support needs of people using this service. The home is hoping to introduce new care plans, which will take a more person centred approach of meeting needs and expectations. One person who had recently been admitted to the home did not have a full plan of how their care needs would be met. However, the records available did contain sufficient information for staff to meet this persons needs appropriately. This included a very detailed health, safety and manual handling assessment. The supervisor was able to give a detailed verbal update; care staff were spoken to and were knowledgeable about the persons needs. This was also reflected in the daily care notes. Ravensfield DS0000035388.V361895.R01.S.doc Version 5.2 Page 11 Care records and assessments demonstrate that people using this service are encouraged to make choices and remain as independent as possible. They show that people have access to health care professionals such as opticians, chiropody, dentist, doctor and community nurses. Some surveys returned by healthcare professionals said; ‘they always seek advice. Residents are always treated as individuals in a holistic manner.’ Nutritional information is gathered and monitored to help ensure that people eat a healthy diet and maintain a healthy body weight. Where necessary advice is obtained from the doctor or dietician and nutritional supplements are supplied. One person is no longer able to access the weighing scales. Records show that advice has been sought for alternative ways of monitoring body weight – measuring arms and/or legs. One member of staff has been allocated this task to help ensure the measurements are consistently taken from the same site each time. Advice has also been sought from the physiotherapist about positioning and manual handling. These measures demonstrate that the service takes the continued health, safety and welfare of people very seriously. People using this service can if they wish, take responsibility for the storage and administration of their own medication. This is only permitted after a thorough risk assessment has taken place. This helps to make sure that medication is managed safely. Some supervisors have received external training to help them carry out blood glucose monitoring tests for people who may have diabetes. Although the district nurse oversees and manages people who may have diabetes, people living at the home are encouraged and supported to be as self managing as possible. We looked at a sample of medication records during our visit to Ravensfield. Medication administration records have been completed and signed accurately. Records include photographs and personal details of each resident, including their name and date of birth. This helps to make sure that medication is administered to the right person. There are arrangements in place to make sure that medicines that may be liable to mis-use are stored and recorded safely. Where medicines may have been stopped suddenly by the doctor this is clearly recorded and there are systems in place to help make sure that people do not continue to receive this medicine. There are protocols included in each person’s medication records to help make sure that medicine prescribed as ‘when required’ or ‘homely’ remedies are administered as the doctor intended and are compatible with other prescribed medication. Supervisors are responsible for the administration of medication and they have undertaken training (both in house and externally) to help ensure that they carry out this process safely. A second person accompanies the supervisor on the medication round. This person acts as a checker. They have also received some basic instruction on the safe administration of medication. Ravensfield DS0000035388.V361895.R01.S.doc Version 5.2 Page 12 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): All of the above standards. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People using this service have access to a wide variety of social and leisure activities, both inside and out of the home. This helps to make sure that they have a stimulating and enjoyable lifestyle. EVIDENCE: The home offers a wide variety of activities that people may choose to take part in if they wish. Activities and events are displayed throughout the home and information is also included in the home’s Newsletter. The Ravensfield newsletter has become very popular with residents submitting entries and articles for the newsletter. The most recent newsletter includes information about the possible re-location of Ravensfield and the consultation meetings that have commenced. People using this service were concerned that the new home may not be as handy for Keswick as the current location. Indications are that the new home will be in Keswick and people are very pleased about this. It will help ensure that the home can continue it’s close links with the local community and stay near their families and friends. Residents meetings are held at the home on a regular basis. The minutes of the meetings are put on display for all residents to read and copies are given Ravensfield DS0000035388.V361895.R01.S.doc Version 5.2 Page 13 out on request. The home has strong links with voluntary organisations are very much part of the local community within Keswick. The home is involved with church groups and three different religious services are held at Ravensfield each month. On the day of this visit to the home one resident was organising a game of prize bingo and was busy letting everyone know where it would be held and the time it would start. Later on staff encouraged and assisted people to attend the bingo session. The daily notes of people living at the home show that their interests and hobbies are recorded and taken seriously. People are encouraged and supported by staff to live an interesting and stimulating lifestyle. Records show that people receive visitors, attend the hairdresser, church services and entertainment both at the home and outside of the home. People are able to have their own daily newspapers or magazines and are helped to go out shopping or for a walk by staff. Care plans show that all aspects of daily living needs are considered, including spirituality and psychological well-being. Some of the comments of people that live at Ravensfield included the following; ‘I join in some things but also like to look on. We have a game of bingo once a week, and also keep fit weekly. We have entertainment in the home and various venues, the Sands Centre, Theatre by the Lake and cruises around Windermere’. Another said ‘we have home entertainment at least twice a month. For any resident’s birthday, a cake is made and entertainment for the day is laid on. Christmas usually lasts all December until the New Year. We get Christmas gifts and at Easter we have an Easter bonnet competition and Easter Eggs.’ The information provided by the home indicates that people have been consulted about the menus and the food at the home. We looked at a sample of the menus and although some changes have been made further work is needed. Menus need to provide sufficient detail for people to help them make an informed choice about the meals and options available to them. The permanent cook at the home has been working as a night care assistant rather than as cook. The home has been covering this task with agency cooks. On the day of this visit there was an agency cook on duty. This is an area that the home could improve upon. Some people commented on the food at the home they said; ‘the meals are most enjoyable. We have a very good cook who will try and make what you want.’ Another person said that ‘A few different choices would be nice for tea, not just sandwiches. Ravensfield DS0000035388.V361895.R01.S.doc Version 5.2 Page 14 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): Standards 16 and 18 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People using this service are protected from harm or abuse by the policies, procedures and staff training that is in place. EVIDENCE: The home has a process in place for people who may wish to raise a concern or complaint. This is on display in the main entrance area of the home. Details of the complaints process are also included in the statement of purpose and service user guide. People completing questionnaires generally knew about the complaint process and all indicated that they know whom to address concerns to if necessary. Staff training includes familiarising themselves with the home’s policies and procedures in relation to complaints and safeguarding adults. Some improvements have been made by the home through discussing the protection of vulnerable adults in staff meetings and during staff supervision. This has helped to raise staff awareness of the subject. The home plans to make further improvements by providing more staff training on the issues surrounding the protection of vulnerable adults. The sample of staff records looked at indicate that this training is already provided to staff at the home. A few months ago, we were told of an incident at the home, which may have put the safety of other people at risk from harm. The person in charge at the home ensured that the matter was reported and dealt with appropriately and that other residents were safeguarded. Ravensfield DS0000035388.V361895.R01.S.doc Version 5.2 Page 15 Staff training records show that staff are provided with training to raise their awareness of adult abuse and the action they should take if they suspect someone is being abused. The home has a copy of the local authority’s multidisciplinary guidelines to help ensure that any concerns are reported and dealt with appropriately. Some comments received via a questionnaire indicated that there were on occasions issues with the attitude of some night staff. Staff supervision records also allude to this. Issues had come up during a review meeting, which indicated that night staff were at times rude. This concern has been discussed in general terms with staff during supervision sessions. This will help ensure that the staff concerned improve their care practices. Ravensfield DS0000035388.V361895.R01.S.doc Version 5.2 Page 16 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): Standards 19, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable, warm and homely environment for the people that use this service. EVIDENCE: The home recognises that they are ‘not up to our full compliment of domestic staff’ and that improvements could be made. The home has struggled to recruit new domestic assistants and care staff are assisting with some of the domestic tasks to help ensure that the home is clean and maintained to a high standard. People living at the home say that the home is generally kept clean and tidy and this was the case on the day of our visit. However, there was a noticeable odour in one room and a nearby corridor. This was discussed with the manager for urgent attention. There is a maintenance programme in place at the home. Some of the carpets have been replaced and some of the rooms redecorated. Some new furniture for five of the bedrooms is currently on order and the home is soon to have Ravensfield DS0000035388.V361895.R01.S.doc Version 5.2 Page 17 new curtains and other soft furnishings. All parts of the home are re-decorated as part of the rolling programme for the maintenance and upkeep of the home. The accommodation at the home is laid out on two floors. People using this service have their own private bedroom. They are able to personalise these rooms with some of their own possessions such as small items of furniture, pictures, photographs, ornaments, TV’s and radios. There are communal bathrooms, toilets and lounge/dining areas throughout the home. These were kept clean and tidy and bathrooms were warm, cosy and homely. Throughout the home there are hand rails, emergency call bells and other equipment designed to help people keep as much independence as possible and assist them with their mobility in safety. A passenger lift is available for people living in the first floor. There is a designated room for people who wish to smoke. The laundry at the home is kept in a clean and tidy condition. Personal protective clothing is available for staff to wear and this helps to reduce any risk of cross infection. Outside the home there is a small car parking area and secure gardens. People living at the home are able to access the gardens in summer. There is also a greenhouse at the home. Some of the people living at the home are keen gardeners and are able to continue to pursue this hobby at Ravensfield. Ravensfield DS0000035388.V361895.R01.S.doc Version 5.2 Page 18 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): All of the above standards. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using this service generally receive their support from regular staff that have received appropriate training. This means that their care and support needs are usually met by staff who take a consistent and understanding approach to their care needs. EVIDENCE: The home has robust policies and procedures regarding the recruitment and selection of care staff. A sample of staff recruitment files was looked at during our visit to Ravensfield. Prospective staff complete application forms, references are checked and Criminal Record Bureau checks (CRB) are obtained before staff work at the home. New employees complete a 5 day induction training programme, which covers topics including health and safety, manual handling, basic first aid awareness and adult protection. Training records also show that staff complete further training including specialist training such as dementia awareness, stroke awareness, diabetes, medication administration, infection control and food hygiene. Over half the staff employed at the home have gained or are working towards a National Vocational Qualification in Care. Staff training helps to make sure that people using this service are supported safely and by competent and knowledgeable care workers. Comments received from a health and social care professional said that staff would benefit from more Ravensfield DS0000035388.V361895.R01.S.doc Version 5.2 Page 19 training in manual handling techniques, specific diets and continence management. Manual handling training records show that the 5 day induction training provides a full days training but further training and updates tend to be done in house and as and when required. The supervisor said that one of the community nurses is scheduled to attend the next staff meeting to talk about diabetes awareness. Supervisors at the home undertake other training so that they can carry out risk assessments and train staff to use safe manual handling techniques. Some are also NVQ assessors, have undertaken some management training and training in the safe administration of medication. Completed surveys from people who live at the home, their relatives and staff working at the home indicate that there may not always be a sufficient number of staff available. Although all shifts have usually been covered this has been dependent on staff working extra hours or on some occasions the home using agency staff. There are several staff vacancies at the home including night staff, domestic and kitchen staff. There are some new staff waiting to commence work at Ravensfield. Again many comments were made about the length of time it takes to obtain the results of necessary checks in order for staff to start work at the home. Staff at the home take great pride in their work. During out visit to the home staff were observed working with the people that use this service. They were friendly and kind and this helps to create the homely and family style atmosphere at Ravensfield. People were seen to be encouraged and supported in joining in activities. Another person needed assistance with eating and drinking and this was provided with sensitivity. Staff are very attentive to the needs of people living at the home. Some of the comments from people who live or visit Ravensfield include the following: • ‘ The staff are very kind and helpful always.’ • ‘ At the time of writing, we are short staffed due to illness, staff retiring or carers finding the same work closer to home. Those who are left are giving 110 .’ • ‘The residents are very lucky and privileged to have such dedicated staff, nothing is too much trouble.’ Not all comments received were positive. One person said that sometimes carers are called away during a caring process and that a different person comes to finish off the tasks. This is very tiring and upsetting for an older person and we told the manager about these comments. Ravensfield DS0000035388.V361895.R01.S.doc Version 5.2 Page 20 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): Standards 31, 33, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health, safety and welfare of people using this service is taken very seriously. This helps to make sure that the home is run in the best interests of the people who live there. EVIDENCE: The home has been without a registered manager for some time. However, staff at the home have worked hard to help ensure that the interim management arrangements have worked well and have not compromised the standard of care and service experienced by the people that live at Ravensfield. One of the supervisors completed the Annual Quality Assurance Assessment that we ask providers to return to us each year. The document was completed Ravensfield DS0000035388.V361895.R01.S.doc Version 5.2 Page 21 with good detailed information and addressed all areas required. The service has identified areas where they do well, what improvements they have made and where further improvements could be made. A new manager has recently been appointed to the home. The new manager is experienced in managing care services, particularly for older adults. She has undertaken various training courses to help improve her skills or keep them up to date. She has a Diploma in residential and day care and the registered managers award. She has undertaken training in relevant subjects such as first aid, medication administration, staff recruitment and selection. The samples of records and documentation looked at during our assessment of this service were found to have been completed satisfactorily and were generally in good order and up to date. Care records contain detailed information about risk assessments and safe procedures for staff to follow. Staff supervision and appraisal has been undertaken at frequent intervals and there is evidence to show that staff training and development has continued as required. The information supplied by the home shows that policies and procedures are regularly reviewed and that safety checks and servicing takes place at least annually or sooner if required. Ravensfield DS0000035388.V361895.R01.S.doc Version 5.2 Page 22 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 Ravensfield DS0000035388.V361895.R01.S.doc Version 5.2 Page 23 CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 4 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 3 X X X X X 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 3 X 3 Ravensfield DS0000035388.V361895.R01.S.doc Version 5.2 Page 24 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, Domiciliary Care Regulations 2002 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP31 Regulation 9 Requirement The home must have a suitably qualified and competent manager who is registered with the Commission for Social Care Inspection. Timescale for action 31/07/08 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 It is recommended that the Statement of Purpose and Service User Guide be reviewed and updated in order to accurately reflect the recent changes to the management structure at the home. It is recommended that the weekly menus at the home be reviewed to include detailed information about the choices available at each mealtime. For example the type of fillings for sandwiches, jacket potatoes or omelettes and the type of soup that will be served. Consideration should be given to the views and opinions of people using this service. 2 OP15 Ravensfield DS0000035388.V361895.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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. 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