Care Home: Ravenswood

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What the care home does well A high standard environment consistently well maintained and improved. There is ongoing re-investment and further investment into the home. Good standards of personal and healthcare. Healthcare professionals comment very favourably about the co-operation of staff and a positive and pro-active approach to healthcare matters. All visitors report a friendly and relaxed atmosphere where they are well received and kept informed of their relatives progress and care.Flexible routines accommodate the individual choices and preferences of residents. The two providers have a daily presence in the home, are known to and readily available for residents, visitors and staff. Any complaints are responded to swiftly, investigated thoroughly and outcomes notified in writing. Any shortfalls in the service identified are changed/rectified immediately. The providers are keen to comply with any suggestions or deficiencies identified. What has improved since the last inspection? What the care home could do better: A range of activities is now required to meet the individual recreational and occupational needs of residents, including the increased numbers of people with dementia care needs. A person with experience to lead activities for this specialist group is now needed. Footrests must always be fitted to wheelchairs whilst residents are transported inside and outside the home. Failure to do so could result in serious injury to the person. Medication Administration Records must accurately reflect the current medication to be given with the correct date. At the time of the inspectionMAR sheets carried a date 6 weeks prior to the current date. This presents the potential for serious errors in medication administration. Soap dispensers have been provided in the sluice, kitchen and toilet areas of the home. Disposable towels are to be provided in these areas also to improve infection control. Current multi-use of cotton towels does not ensure good infection control practice. Bedroom doors should not be propped open. Self-closing devices should be provided if residents wish to have their bedroom doors left open. Notifications of all deaths, accidents requiring medical attention and events affecting the lives of residents should be notified to CSCI under Regulation 37. CARE HOMES FOR OLDER PEOPLE Ravenswood 15 The Avenue Kidsgrove Stoke on Trent Staffordshire ST7 1AT Lead Inspector Peter Dawson Unannounced Inspection 26th August 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 Ravenswood DS0000064271.V370323.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. Ravenswood DS0000064271.V370323.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ravenswood Address 15 The Avenue Kidsgrove Stoke on Trent Staffordshire ST7 1AT 01782 783 124 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) Mr Jasbir Singh Johal Mrs Surinder Kaur Johal Rita Lynne Scarlett Care Home 44 Category(ies) of Dementia (44), Mental disorder, excluding registration, with number learning disability or dementia (44), Old age, of places not falling within any other category (44) Ravenswood DS0000064271.V370323.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia DE 44 Old age not falling within any other category (OP) 44 Mental Disorder (MD) 44 The maximum number of service users to be accommodated is 44. 2. Date of last inspection Brief Description of the Service: Ravenswood is a large pleasant, detached property set in secluded gardens of over an acre and very close to Kidsgrove town centre. A new extension was completed and registered in August 2008 and provides an additional 20 places for people with dementia care needs. The building meets all the current National Minimum Standards in providing a high quality environment with excellent facilities. The pre-existing building has also been considerably upgraded. Furniture, fittings and equipment are to a very high standard and it is exceptionally well maintained. The home now provides a specialist service to people with dementia care needs or those having mental health needs and/or physical disabilities. The home is now able to cater for up to 40 people in the above categories of registration. Weekly fees for care at Ravenswood are in the region £330 - £455 Ravenswood DS0000064271.V370323.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 2 stars. This means the people who use this service experience good quality outcomes. This unannounced key inspection was carried out by one inspector on one day from 08:30 – 17:30. The inspection was undertaken using the National Minimum Standards for Older People as the basis for the assessment. A new extension to the home was approved and opened 3 weeks prior to this inspection increasing the number of beds from 24 – 44. There were 36 people in residence at the time of the inspection. An Annual Quality Assurance Assessment (AQAA) was not received prior to the inspection. There was a delay by CSCI in making the request for one. This will be completed and returned to us soon as it is a legal requirement. Most residents were seen and 15 spoken with directly. Residents were positive about the care provided at Ravenswood. There were many positive comments about the newly completed extension and upgrading of the original building. Apart from many residents moving into the new bedrooms there were greater options in the communal areas for dining or using different lounge areas. Four visitors were spoken with during the inspection, some of new residents some of established residents. All expressed satisfaction with the care being provided and enthusiastic about the excellent new extension. One relative had waited several weeks for completion of the building works and said “I am sure that this home is the best for my mother, it was worth the wait”. What the service does well: A high standard environment consistently well maintained and improved. There is ongoing re-investment and further investment into the home. Good standards of personal and healthcare. Healthcare professionals comment very favourably about the co-operation of staff and a positive and pro-active approach to healthcare matters. All visitors report a friendly and relaxed atmosphere where they are well received and kept informed of their relatives progress and care. Ravenswood DS0000064271.V370323.R01.S.doc Version 5.2 Page 6 Flexible routines accommodate the individual choices and preferences of residents. The two providers have a daily presence in the home, are known to and readily available for residents, visitors and staff. Any complaints are responded to swiftly, investigated thoroughly and outcomes notified in writing. Any shortfalls in the service identified are changed/rectified immediately. The providers are keen to comply with any suggestions or deficiencies identified. What has improved since the last inspection? What they could do better: A range of activities is now required to meet the individual recreational and occupational needs of residents, including the increased numbers of people with dementia care needs. A person with experience to lead activities for this specialist group is now needed. Footrests must always be fitted to wheelchairs whilst residents are transported inside and outside the home. Failure to do so could result in serious injury to the person. Medication Administration Records must accurately reflect the current medication to be given with the correct date. At the time of the inspection Ravenswood DS0000064271.V370323.R01.S.doc Version 5.2 Page 7 MAR sheets carried a date 6 weeks prior to the current date. This presents the potential for serious errors in medication administration. Soap dispensers have been provided in the sluice, kitchen and toilet areas of the home. Disposable towels are to be provided in these areas also to improve infection control. Current multi-use of cotton towels does not ensure good infection control practice. Bedroom doors should not be propped open. Self-closing devices should be provided if residents wish to have their bedroom doors left open. Notifications of all deaths, accidents requiring medical attention and events affecting the lives of residents should be notified to CSCI under Regulation 37. 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. Ravenswood DS0000064271.V370323.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 Ravenswood DS0000064271.V370323.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): Standards 1 – 5 were inspected on this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Pre admission procedures and assessments were in place to ensure residents are able to make a judgement about the suitability of the home and that their needs could be met. EVIDENCE: A new Statement of Purpose was provided by the service in support of their application for registration of the recently opened extension. As the service develops the document should include the arrangements in place to provide activities for people with dementia care needs. The weekly fees should also be included. Ravenswood DS0000064271.V370323.R01.S.doc Version 5.2 Page 10 There is a copy of the Statement of Purpose/Service Users Guide, including a copy of the complaints procedure, in all bedrooms for resident and visitor reference and use. Pre-admission assessments were evidenced in the records of two recently admitted residents. One had visited the home prior to admission making a decision about its suitability. Relatives of the other person had acted on his behalf but an assessment of the persons needs carried out in his current setting. There were also Care Management Assessments obtained prior to admission. This allowed the both home and resident to make an informed decision about the suitability of the service. Contracts for funded residents are provided by the sponsoring Local Authority. A sample of 3 records of self-funding residents had a copy of a signed contract with the home. This home does not provide intermediate care. Ravenswood DS0000064271.V370323.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): Standards 7 - 10 were inspected on this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Continued improvements in care planning and recording will ensure residents needs are fully met. Improvements in the recording of medication are needed to ensure a safe system is in place to avoid errors and to protect residents EVIDENCE: A sample of 5 care plans were seen including both recently admitted and longterm residents. The format has been changed to include more detailed information giving a clearer picture for carers to identify the actions required to meet individual needs. The change is good, although the providers are presently researching an alternative format in line with their changed objectives of providing a more person-centred delivery of care to people with dementia care needs. Ravenswood DS0000064271.V370323.R01.S.doc Version 5.2 Page 12 Health care records for each person are in place recording diagnosed conditions and interventions by health care professionals. There is a record of visits by healthcare professionals, although in one instance 2 recent visits by the GP were not recorded on the list, although reference was made to those visits in daily notes. A good relationship exists between the local GP practices including District Nurses. A view was sought from two nurses who regularly visit the home, they both said that the approach to healthcare matters was “excellent” they considered Ravenswood to “be one of the best care homes in terms of cooperation and care, they seek advice regularly and recently a teaching session was provided by request on catheter care”. One person has been cared for in bed for the past 5 month. An airwave mattress and special positioning bed have been provided. The person returned from hospital with severe pressure damage, District Nurses have visited daily until recently. This person said that she receives “wonderful care” from the staff at Ravenswood “they are really good to me and I have no complaints about them”. There are daily records for all residents. Some improvement could be made in this area. Several records seen did not have a daily entry. The record of a recently admitted resident showed that the GP had been called after aggression by the person and anti-biotics prescribed with the instruction “please observe” – there was no entry the following day. In another record no daily recoding was made in 3 out of 6 days. Residents are weighed regularly and food/fluid input charts established where there are concerns about hydration/well-being. One person had increased in weight by 3 stones over a period and the food/fluid intake still recorded. There are monthly reviews of care plans internally and the home intend to invite relatives/others in future to those reviews. A resident with pressure damage to his heel was seen transferred to a wheelchair and moved within the home without the footrests being put into place. The person was holding his legs above the floor. This is a dangerous practice with obvious risk of injury to the person. Footplates must always be used to ensure safety of the person. The medication system is provided in Monitored Dose form by Lloyds Chemists in Nomad cassettes. Medication Administration Records (MAR sheets) recording the medication being given at this time were out of date. They had been prepared weeks previously and had the original medication and dates 6 weeks previously. Staff were changing the dates and having to check and review weekly any changes made. This provided a recipe for serious error. The pharmacy must provide current MAR sheets to ensure safety of Ravenswood DS0000064271.V370323.R01.S.doc Version 5.2 Page 13 administration. This has been previously discussed with the Pharmacy, but no improvements made. The provider will pursue this matter with the pharmacy as a matter of urgency. Ravenswood DS0000064271.V370323.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): Standars 12 – 15 were inspected on this visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A person-centred approach to activities would provide residents with greater stimulation and improve quality of life. There is high satisfaction with food provision. EVIDENCE: There was evidence of chosen lifestyles being accommodated and individual choices being made. Discussions with residents confirmed this. Breakfast is provided on a staggered basis in the dining room, some rose during the morning up to 11 a.m. one resident chooses to rise later, sometimes in the afternoon and to go to bed very late, following his particular interests and routines. He confirmed that he was able to make his own decisions and that staff respected and accommodated his choices. An Activities Co-ordinator left the home some months ago. A replacement has not yet been found. Meanwhile care staff are engaged in daily activities from a dated programme that has been in operation for sometime with the usual inRavenswood DS0000064271.V370323.R01.S.doc Version 5.2 Page 15 house activities and entertainment aimed at the small or larger group. The recent opening of the new extension, effectively doubling the number of residents and moving towards a specialist service for people with dementia care needs, means that additional activities on a person-centred basis must be provided to meet the particular needs of the resident group. A person to lead activities is needed on more than a part time basis to ensure social and recreational activities are provided for a more diverse group and on a more individual level. Many residents have short concentration spans and 1:1 activities are needed. This is an area that needs considerable improvement with an experienced activities lead who can take the service forward in this specialised area of care. The excellent new environment needs to be complemented by a similar standard of recreation and occupation for residents on a varied, flexible and ongoing basis. National trainers have provided dementia care training for all staff and further training is planned with the same reputable company and their advice will be sought in this area. The home have developed some links with the local community including regular visits from and to local schools. The town centre is only 500 metres from the home and adequate staffing would allow many residents to visit the town. The new building has been registered and fully operational for the past 3 weeks. Several new residents have been admitted and the environmental standards are high. Residents have been transferred also from the former annexe which accommodated 5 residents. Integration of new and former residents and the old and new buildings is underway but in the very early stages. Residents are encouraged to move between or “try” the different settings of old and new. Established residents have been given a choice to have bedrooms in the original or new parts of the home. Some have not adjusted to this fully at this time. Staff are sensitive to the varying needs and feelings and harmonious integration will be achieved soon. The external areas have recently been landscaped following the new-build and the home remains in a secluded, woodland setting only metres from the town centre. All external doors are alarmed and the garden area made secure for those residents able to take advantage of the remaining summer weather. Food provision is good and has vastly improved under the current providers. Menus are compiled involving residents and choices offered at all mealtimes. The kitchen size has more than doubled with the new-build and there is now a choice of 2 dining areas. Each offers a homely, comfortable dining experience with new furniture, high standard linen, cutlery and crockery on well-laid attractive tables with a restaurant-like presentation. All residents spoken with said that food provision was good, there were choices at all mealtimes and “we can have anything we like”. Ravenswood DS0000064271.V370323.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): Standards 16 – 18 were inspected on this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure provides protection for residents. Complaints are acted upon swiftly and positively. EVIDENCE: There is a complaints procedure in place that complies with Regulation 22. All residents have a copy of the procedures given to them with the Statement of Purpose/Service Users Guide. There is also a copy of the procedure in the home for visitors. Three complaints about the service have been received by us since the last key inspection. On related to a resident found wandering in the area near the home. She was returned safely but there had been a breach of security and immediate steps taken to ensure this did not happen again. Another complaint related to allegations about two staff members. This was investigated and not upheld. A third complaint related to medical attention not being sought, staff recruited without police checks and management practices in the home. The first aspect of this complaint was not upheld the remaining two were and appropriate action taken. Ravenswood DS0000064271.V370323.R01.S.doc Version 5.2 Page 17 Staff are aware of the policy/procedure relating to the abuse of residents. All are given a copy of the procedures and sign to confirm that they have read and understood them. There has been staff training in Safeguarding, staff are aware of the broad definitions of abuse. No safeguarding referrals have been made since the last inspection. Ravenswood DS0000064271.V370323.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): Standards 19 – 26. were inspected on this visit. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A high quality environment ensures that residents live in a safe, comfortable setting with excellent facilities. EVIDENCE: The present owners purchased the home 3 years ago and have continued during that time to improve the existing environment with new furniture, equipment and upgrading of the communal and bedroom areas. A new £1m extension was recently completed, approved and registered 3 weeks prior to this inspection. This provides an additional 20 en-suite bedrooms and excellent communal facilities. The building is to a high specification and meets all current National Minimum Standards. Furniture, Ravenswood DS0000064271.V370323.R01.S.doc Version 5.2 Page 19 fittings, equipment and décor are also to a very high standard and provide a comfortable, pleasant, homely environment for residents. Laundry, kitchen and sluicing facilities have been added/extended and vastly improved. There has recently been further upgrading of communal and bedroom areas of the original building. The total presents an excellent facility for up to 39 people. An annexe previously accommodating 5 residents is presently being considered for major upgrading/building work. The home is moving towards specialist care for people with dementia care needs and the new and existing buildings provide a secure and suitable facility for that purpose. Outstanding matters at the point of the recent new registration that have been actioned are: The garden areas to the side of the premises have been made secure with provision of secure gates. The area has been landscaped and will be further developed to provide gardening activities for residents. A certificate has been obtained confirming assessment for the prevention of Legionella. A minimum age of 55 years upon admission for people with Dementia and Mental Health needs has been added to the Statement of Purpose. Matters in process, but not completed at this time include: Appropriate signage suitable for people with dementia care needs is underway and further advice being sought from the Dementia Care Trainers used by the home. Soap dispensers have been fitted as required to the sluice, kitchen, assisted bath/shower rooms and the communal toilets – paper towel dispensers have not yet been fitted and it is important to complete this to ensure good infection control practice. An Activities Co-ordinator has not yet been replaced but the role and hours for this post being reviewed. The Registered Manager has been advised to obtain post qualification in Dementia studies as part of increasing her knowledge around dementia care. The new registration took place only 3 weeks prior to this inspection. The providers are determined to complete all the outstanding matters swiftly that they have given an undertaking to address. Ravenswood DS0000064271.V370323.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): Standards 27 – 30 were inspected on this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A well trained and committed staff group ensure the safety and protection of residents. Robust recruitment procedures will further ensure protection. EVIDENCE: At the time of this inspection there were 36 people in residence, this included 12 people admitted following the recent opening of the new extension. The staffing numbers have increased to 7 in the daytime during the week and 5 at weekends. During the week this includes the Manager and Providers working in the home. Two additional staff come on duty from 7.0 am to assist night staff who work until 8.0 am. There are 3 waking night staff including a Senior Carer and this is adequate for the current dependency levels of residents. There is a kitchen presence throughout the day until 8pm. Domestic hours have been increased. Presently care staff are carrying out laundry duties but plans to provide a part time laundry assistant are in process. As stated earlier in this report there is no Activities Co-ordinator in post at this time and recruitment is in process. Ravenswood DS0000064271.V370323.R01.S.doc Version 5.2 Page 21 New staff have been appointed to meet the increased numbers required. Some presently involved in induction processes. Staff training is good. All statutory training has been completed for existing staff and additional professional practice training been provided. A national trainer in Dementia Care has provided training for all existing staff over a period of 2 days and further training dates being arranged. Additionally - staff have accessed other local dementia care training courses. A provider has recently completed a Moving & Handling trainers Course – staff can now be trained in-house. NVQ training continues and the home have exceeded the required minimum of 50 of NVQ trained staff. A sample of staff files were inspected. All had required checks and references in place including POVA/CRB checks. A requirement of the last report to ensure POVA/CRB checks for all new staff was not complied with being highlighted in a complaint received. Checks from previous employments had been accepted and were not therefore acceptable. This matter has now been addressed. All required documentation under Regulation 22 was present in the files seen on this inspection. Staff on duty during this inspection showed good engagement with residents and there was a relaxed and friendly dialogue with visitors/relatives. Staff confirmed that they had been offered good training opportunities and were enthusiastic about the new improved environment and change of direction in care for people with dementia care needs. Ravenswood DS0000064271.V370323.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): Standards 31 – 33 and 37 – 38 were inspected on this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management of the home ensure good care and routines for the benefit of residents. Some areas of Health & welfare need action. EVIDENCE: The Registered Manager has completed the Registered Managers Award since the last inspection. She works on the staffing rota hands-on and takes a positive lead in care in the home. She is supported in Management of the home by the two providers who have a daily presence in the home and are readily and easily accessible to residents, visitors and staff. Ravenswood DS0000064271.V370323.R01.S.doc Version 5.2 Page 23 There is a committed staff group who together with managers and providers run the home in the best interests of the residents. The homes motto is “If we have not satisfied the residents or their families then we are not satisfied ourselves” – all seek to achieve this objective. Questionnaires are sent to families/relatives to seek their views about service provision. All are invited to social events in the home and warm, friendly relationships between staff and families were observed during the inspection. There is an ongoing annual development plan with a programme of continued maintenance and improvements. Considerable investment has been made into the home with a recently completed extension to a very high standard. Additional places are being taken swiftly. One requirement and 3 recommendations are made in relation to general management/health & safety: Footrests must be used at all times when wheelchairs are used to transport residents. This will ensure their safety. Provision of disposable towels at hand-washing facilities in the kitchen, bathrooms, toilet and sluice to improve infection control in the home. If bedroom doors are propped open then self-closing devices should be in place to ensure the protection of those residents in the event of fire. Notifications to CSCI of all deaths, accidents and other events affecting the lives of residents must be provided to comply with Regulation 37. This allows ongoing monitoring of significant events in the service. Ravenswood DS0000064271.V370323.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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 4 4 3 4 3 3 4 4 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X X 3 2 Ravenswood DS0000064271.V370323.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 OP9 Regulation 13(2) Requirement Medication Administration Records must accurately reflect the current medication to be given to each resident with the correct date. This will ensure a safe system of medication for residents. Provide a range of activtieis to meet the individual recreational & occupational needs of residents. Footrests must be fitted to wheelchairs at all times when residents are transported in the home. This will ensure their safety. Timescale for action 09/09/08 2 OP12 16(2)(n) 23/09/08 3 OP38 13(4) 23/09/08 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 OP38 Good Practice Recommendations Provide disposable towels in the sluice, kitchen, bathroom and toilet areas. This will improve infection control DS0000064271.V370323.R01.S.doc Version 5.2 Page 26 Ravenswood 2 3 OP38 OP38 practice. Consider self-closing devices to avoid bedroom doors being propped open and protect residents in the event of fire. Notifications of deaths, accident and events affecting the lives of residents must be notified to CSCI under Regulation 37. Ravenswood DS0000064271.V370323.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands Office West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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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