Care Home: Ravensworth Care Home

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What the care home does well Comments received from people who live at the care home included: “It’s nice to live here.” “They take care of people, and tend to their every need with kindness.” “I have lived here about nine years, and found it clean and the food very good. After settling in I have been quite content.” “I am very happy at Ravensworth.” “I am happy here, and there is nothing that could make it better.” In addition comments received via relatives’ surveys included: “They seem to quickly and sympathetically respond to the moods and needs of the residents.” “They are good at providing personal care, the home is clean and fresh, and family are welcome anytime.” “I have found the care and attention given to my father satisfactory.” In addition Ravensworth provide comfortable and homely accommodation, with efforts made to ensure that people’s individual physical needs are met. There are good and imaginative activities arranged for people who live at the care home. What has improved since the last inspection? At the last key inspection in March 2009, seven statutory requirements were made, relating to: Medication administration records, Care plans relating to medication, consultation with the Environmental Health Officer, Replacing of worn chairs, Employing a specific cleaner, rather than having care staff cleaning, Improving the quality assurance system, and providing staff training in Infection Control. These were all found to have been met. In addition, there is an ongoing programme of redecoration, the signs around the building have been improved to provide better help to people who may have dementia, there is a new smoking conservatory, the chairs (identified above) have been replaced, some carpets have been replaced, the outside of the building has been painted, the drive has been repaired, some of the emergency lighting has been replaced. What the care home could do better: One statutory requirements has been made as a result of this key inspection visit, this relates to all staff attending safeguarding adults training. Two good practice recommendations have been made relating to: End of life care plans containing more information, and all staff receiving a minimum of six formal supervision sessions per year.Ravensworth Care HomeDS0000062116.V378644.R01.S.docVersion 5.2 Key inspection report CARE HOMES FOR OLDER PEOPLE Ravensworth Care Home Markham Road Duckmanton Chesterfield Derbyshire S44 5HP Lead Inspector Rob Cooper Key Unannounced Inspection 2nd December 2009 02:41 DS0000062116.V378644.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Ravensworth Care Home DS0000062116.V378644.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Ravensworth Care Home DS0000062116.V378644.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ravensworth Care Home Address Markham Road Duckmanton Chesterfield Derbyshire S44 5HP 01246 823114 Telephone number Fax number Email address 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) maxine_ravensworth_carehome@yahoo.co.uk Ravensworth Care Home Limited Mr Fred Renshaw Miss Maxine Lynette Spray Care Home 26 Category(ies) of Dementia - over 65 years of age (26), Learning registration, with number disability (3), Old age, not falling within any of places other category (3) Ravensworth Care Home DS0000062116.V378644.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered provider may provide the following categories of service only whose primary care needs on admission to the home fall within the following categories Dementia - DE aged 55 years and over, maximum number of places 20, Old Age, not falling within any other category OP, maximum number of places 3, Learning Disability LD, aged 60 and over, maximum number of places 3. The maximum number of service users who can be accommodated is 26. 12th March 2009 2. Date of last inspection Brief Description of the Service: Ravensworth Care Home is registered to provide personal care and accommodation for up to twenty-six older people, including for up to twenty people with dementia, aged fifty-five years and over and three people with learning disabilities aged sixty and over. Total numbers not to exceed twentysix people. The home is located near a main bus route in the village of Duckmanton, approximately seven miles to the north east of Chesterfield, close to local shops and a pub and within sight of the new Junction 29A of the M1 motorway. Accommodation is provided over two levels, with a stair lift to the main stairway and with some environmental aids and equipment to assist people who may have mobility problems. There are eighteen single and four shared rooms. There are also a number of communal bathroom and toilet facilities and well-maintained enclosed gardens to the rear of the property providing level and safe access for people. Car parking spaces are provided. People are provided with care and support from a team of care, support and hotel services staff, led by the registered manager and with a high profile in the home from the registered provider. The fees for this home are £395 per week, and are determined in accordance with peoples individually assessed needs and as per Derbyshire County Council, placing authority rates. They are subject to review from 01 April 2010. Further information about fees charged and what they cover can be obtained directly from the home. Ravensworth Care Home DS0000062116.V378644.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 was an unannounced visit as part of the key inspection process – so that no one at Ravensworth knew that the inspection visit was going to take place. The visit took approximately five hours through the middle of the day, with one inspector present. In preparing for this inspection, the information that the Commission holds about this care home was reviewed, this included looking at the last inspection report, the inspection record, considering any complaints or concerns that have been made about the service, and reviewing any notifications made relating to incidents that affect the well being of people living at Ravensworth. The methods used during this key inspection and visit were to visit the care home, where a method called case tracking was used; this involved identifying four people who live there and looking at their individual files and making a judgement about the quality of care they are receiving, and if their needs are being met. This was followed by a partial tour of Ravensworth, looking at the activities on offer, and talking to three residents, two relatives and three members of staff about the quality of the service, and their experiences of living and working at the care home. We also sent out an Annual Quality Assurance Assessment (known as an AQAA), which allowed Ravensworth to carry out a self-assessment; and provide a range of information relating to their service. Information provided, helped to form the judgements in this report. We also sent out five surveys asking for views and information to people who live at the home, five to relatives and five to staff. Of these, all of the surveys were returned, which also helped with the judgements that we made. The registered manager Maxine Spray provided much of the information during this key inspection visit. On the day of this inspection there were twenty-two people living at Ravensworth. People who might want to live at Ravensworth can obtain information about the home direct from them, and this would include seeing previous inspection reports prepared by the Care Quality Commission. Ravensworth Care Home DS0000062116.V378644.R01.S.doc Version 5.2 Page 6 What the service does well: Comments received from people who live at the care home included: “It’s nice to live here.” “They take care of people, and tend to their every need with kindness.” “I have lived here about nine years, and found it clean and the food very good. After settling in I have been quite content.” “I am very happy at Ravensworth.” “I am happy here, and there is nothing that could make it better.” In addition comments received via relatives’ surveys included: “They seem to quickly and sympathetically respond to the moods and needs of the residents.” “They are good at providing personal care, the home is clean and fresh, and family are welcome anytime.” “I have found the care and attention given to my father satisfactory.” In addition Ravensworth provide comfortable and homely accommodation, with efforts made to ensure that people’s individual physical needs are met. There are good and imaginative activities arranged for people who live at the care home. What has improved since the last inspection? What they could do better: One statutory requirements has been made as a result of this key inspection visit, this relates to all staff attending safeguarding adults training. Two good practice recommendations have been made relating to: End of life care plans containing more information, and all staff receiving a minimum of six formal supervision sessions per year. Ravensworth Care Home DS0000062116.V378644.R01.S.doc Version 5.2 Page 7 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Ravensworth Care Home DS0000062116.V378644.R01.S.doc Version 5.3 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 Ravensworth Care Home DS0000062116.V378644.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12&3 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have access to detailed information about the services on offer. There are contracts or a service agreement in place and people receive a comprehensive assessment of their needs, which means an informed decision about whether the home can meet those needs can be made. EVIDENCE: Both the statement of purpose and service user guide were seen during the inspection visit. Both documents are presented in a combined format, and contained a great deal of useful information about the care home, and the service it provides. Discussions with the manager indicated that information would be available in alternative formats (large print and audio tape) if Ravensworth Care Home DS0000062116.V378644.R01.S.doc Version 5.3 Page 10 required, but so far the need has not arisen. Signed sheets in individual’s care files showed that they had been given a copy of the service user guide, and copies were seen in some bedrooms. As part of the case tracking process four people who live at the care home were identified, and their files were seen, each one contained an agreement from Social Services to fund their placement, including a purchase order from the County Council, and a copy of the terms and conditions of residence. Each of the four files that were seen contained a formal assessment of need. The assessments had all been completed in-house and covered areas such as: the risk of falls, continence, dependency, and nutrition. In some files a FACE assessment (the standard assessment for older people used by Social Services) was seen, but the manager explained that the individual’s Social Worker does not always send them. The evidence showed that the information provided by these assessments had been used to draw up the care plans. In their AQAA they said: “A thourough needs assessment is completed prior to admission, by a suitable person with skills and sensitivity using our own assessment form. We always confirm whether we can meet the needs of a prospective service users assessed needs. We ensure that all new service users receive a comprehensive needs assessment prior to admission. We encourage prospective service users to visit the home prior to admission to get the feel of the place.” Ravensworth does not offer intermediate care, and therefore this National Minimum Standard was not assessed. Ravensworth Care Home DS0000062116.V378644.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 & 11 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have their health and personal care given in a professional and caring manner by the staff, which means that individuals are having their care needs met. EVIDENCE: Each of the files that were seen contained a plan of care, which identified personal goals and identified people’s needs and how to meet them. Evidence was seen that care plans were being reviewed regularly, and there were daily entries by care staff, to record progress and any issues relating to individual’s care. Discussions with two members of staff showed that staff had a good understanding of people’s needs, and that the documentation acted as a guide. In their AQAA they said: “Every service user has an individualised plan Ravensworth Care Home DS0000062116.V378644.R01.S.doc Version 5.3 Page 12 developed from their pre-admission needs assessment, and is carried out by a skilled person in care planning. Plans are developed and agreed in partnership with the service user in each case, and with their representatives, or family where appropriate. They are intended to be as holistic as possible, including the service users full range of care and support needs.” All of the files that were seen contained health care plans. The plans included information relating to health care professionals such as visits to the doctor, or by the nurse, and any hospital visits. A mobile optician (Health Call opticians) provides a service to people living at the home, and a local dentist from Staveley provides dental support, with the added bonus that 90 of people can be seen and treated at the care home, which avoids travelling. Three people were asked about seeing the doctor, and they all said that the staff would get them a doctor if they were unwell, and if they needed one. In addition each person living at the home has a monthly physical check, of their basic health, and records relating to these were seen in the files. A local chemist provides Ravensworth with their medication, and they provide good support and advice, with up to three visits to the home a year to check on medication systems and procedures. Records relating to these visits were seen, with the last one dated June 2009. An inspection of the medication systems showed that medication is handled safely, and that clear and accurate records are kept. Administration records were seen and found to be complete. No one living at Ravensworth currently self-medicates. All aspects of the medication procedures that were seen showed a clear audit trail for medication, and indicated that people living at the care home were safe. Discussions with three people who live at Ravensworth, and discussions with three relatives, together with observation of the staff working with people generally showed that the staff treat people with respect and dignity. This included observing staff knocking on people’s doors before entering, and speaking in a respectful manner. Comments received from people who live at the home in the surveys included: “It’s nice to live here.” Comments from relatives included: “Considering no old person wants to be in care, Ravensworth do a very good job.” “They respect the dignity and wishes of the service users.” Each person’s file that was seen had an end of life care plan, covering different aspects of the individual’s wishes at the end of their life, and offering guidance to staff. In some cases the information was a little brief, and this was discussed with the manager, who outlined plans to develop these care plans further. Ravensworth Care Home DS0000062116.V378644.R01.S.doc Version 5.3 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 & 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have a lifestyle that reflects their cultural, social and religious interests, and needs, and there is clear evidence that their social care needs are being met. EVIDENCE: Discussions with three people who live at the care home and the activities coordinator employed there identified that there were plenty of activities arranged, these varied from activities in the home such as bingo and table topped activities (games and puzzles), a session of which was observed, as a group session in the dining room, with plenty of laughter and chat. The activity co-ordinator keeps good records about activities, and what has taken place, and discussions showed that training courses she has attended around chair based activities and exercises to increase independence have been particularly useful. There were also many photographs of activities on display, showing Ravensworth Care Home DS0000062116.V378644.R01.S.doc Version 5.3 Page 14 people involved in a range of different activities. Around the home there were a number of photographs from the past, which are aimed at helping those who’s memories are beginning to fail, among these was a 1935 photograph of Chesterfield FC, while the group activity mentioned earlier had a discussion about the price of milk in days gone by, and free milk that was available in school too. In their AQAA they said: “We encourage service users to become involved in activities and to maintain or even develop new social outlets and contacts. This is an aspect that is included in every plan of care and needs assessment.” Three relatives were spoken with during this inspection visit, they were all positive in their comments, although two said their relative had only recently moved to the care home. All of the relatives said that they were made to feel welcome, and that the staff were friendly and approachable. They praised the building, and the cleanliness, and said that they were more than happy with the care their relative was receiving. In addition comments received via surveys included: “They seem to quickly and sympathetically respond to the moods and needs of the residents.” “They are good at providing personal care, the home is clean and fresh, and family are welcome anytime.” “I have found the care and attention given to my father satisfactory.” Staff were observed to see how well they interacted with the people who live at the care home, and whether choices were being offered. This was positive, with choice offered particularly around drinks and activities. The staff demonstrated how choices were offered and recorded at meal times, and the activity co-ordinator talked about how activities were organised, and choice was offered, including taking feedback from people taking part in activities. The manager said that a meals satisfaction survey had also been circulated to gain people’s views. Discussions with three people indicated that they thought they had control over a lot of things in their lives, and were quite satisfied with the control they had. On the day of this inspection visit there was a good choice of meal on offer including a vegetarian option if required. Discussions with the cook showed that there was a basic two week menu, which was what people who live at the home said they liked, and this menu changed at different seasons of the year, to provide food choices appropriate to the weather, and the season. Information related to people’s likes and dislikes was seen in the kitchen. All of the people spoken with said good things about the food with comments such as: “The food is very nice, I’m very satisfied.” “There’s always a choice, if you don’t like something, they’ll get you something else.” “It’s very good, no problems with the food at all.” Ravensworth Care Home DS0000062116.V378644.R01.S.doc Version 5.3 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are safe, as a result of the policies, procedures and systems that are in place. People living at the care home and their relatives are confident that their complaints will be taken seriously and dealt with. EVIDENCE: Ravensworth has not received any complaints since the last key inspection in March 2009. The home’s complaints procedure, is on display in the foyer, and throughout the home and also forms part of the service user guide. Discussions with three people who live at the home indicated that they knew who to complain to, and how to complain, although none of them had ever needed to. Discussions with three relatives about the complaints procedure identified that they would speak to the manager, and they felt confident that she would deal with the complaint, although so far, this had not been necessary. In their AQAA they said: “The home has put in place a clear straight forward complaints procedure, which gives details of who will deal with any complaint, the time scale for a response (with an assurance that they Ravensworth Care Home DS0000062116.V378644.R01.S.doc Version 5.3 Page 16 will be responded to within a maximum of 28 days), details of the local CQC office and how a complaint will be dealt with. All our residents are aware of the complaints procedure. Full details are explained to new service users upon admission, and are included in the homes service user guide with a complaints procedure available in main entrance.” A review of the staff training records in relation to safeguarding adults, showed that only eight out of twenty-three care staff had undertaken this training in the last twelve months. The training is aimed at raising staff awareness of abuse, and issues around abuse and through raising those issues, offering people greater protection against abusive practice, while also making sure that the staff understand the correct policy and procedure to follow if abusive practice is found. Three members of staff were asked about safeguarding adults training and they said they were aware of the issues, and had undertaken this training. Ravensworth have not had made any safeguarding adults referrals since the last key inspection. Ravensworth Care Home DS0000062116.V378644.R01.S.doc Version 5.3 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a safe, clean, well maintained and comfortable home, with their personal possessions around them; this means that people are living in ‘homely’ surroundings that meet their needs. EVIDENCE: A partial tour of Ravensworth showed that it was comfortable and well maintained, with good quality fixtures and fittings. The home had been decorated ready for Christmas and this included a Santa’s grotto and tableaux. Two people who live at the home, passed comment on the decorations, Ravensworth Care Home DS0000062116.V378644.R01.S.doc Version 5.3 Page 18 saying: “How Christmassy they make it feel.” And “isn’t it pretty?” Discussions with three people who live at the care home showed that they thought that it was comfortable and meets their needs. Several bedrooms were seen, and these were well personalised, and homely, all of the people who were spoken with said they felt they had everything they needed, and that they thought their bedrooms were comfortable and the home was well equipped. In their AQAA they said: “In this home we place a very strong emphasis upon quality of life and upon safety, and we are confident that the home provides a comfortable, homely, safe secure environment for our service users to live in and enjoy their surroundings. Communal space is available for all service users access. The home is made safe and secure with alarms and locked doors in place to meet service users individual needs, in a comfortable and homely way. Service users have the use of a large accessible garden. A nurse call system is fitted in every service users room, and each room is centrally heated. Adapted equipment is provided within the home for the service users with limited mobility, for example: grab rails, hoists and rotundas to name a few. The building fully complies with the requirements of the local fire service, the environment department, and relevant Health and Safety.” Staff were seen cleaning in different parts of Ravensworth during this inspection visit, and discussions with cleaning staff showed that there are systems in place for cleaning, and that the care home has a good supply of cleaning materials. The building was found to be clean, and smelt fresh. In relation to cleaning they said in their AQAA: “The home is cleaned on a daily basis with no offensive odours present. Policy and procedures are evident to prevent cross infection/contamination in accordance with the infection control team.” Ravensworth Care Home DS0000062116.V378644.R01.S.doc Version 5.3 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 & 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff have been recruited professionally, and have been trained to do their jobs, which means that the people who live at the care home are safe, and have staff who are able to meet their needs. EVIDENCE: The staffing rota was reviewed and this showed that there are enough staff currently employed to meet people’s needs. Three members of staff were asked about staffing levels, and they all said that they thought there were enough staff, and said that when there were shortages through sickness for example there were systems in place to bring in extra staff to cover. The rota showed that there are three carers on shift through the day, with two waking night staff each night. In addition following a requirement made at the last key inspection, a cleaner has been employed. The care industry considers National Vocational Qualifications (NVQ) to level II in care to be the basic qualification for staff working in residential care. A review of the staff training records showed that currently there are twentyRavensworth Care Home DS0000062116.V378644.R01.S.doc Version 5.3 Page 20 three care staff currently working at Ravensworth, of whom there are ten staff with NVQ level II, and three working towards their NVQ level II qualification. The files of six members of staff were seen, to check that they contained all of the information that would show that staff at Ravensworth had been recruited in a safe manner – namely that applicants had filled out an application form, provided two written references and had had a Criminal Records Bureau check. The documentation showed that the care home’s recruitment policy and procedure had worked to protect the people living there. Discussions with three members of staff about their recruitment showed that they had gone through all of the pre-employment checks, and had not started working until those checks had been completed. In their AQAA the care home said: “We have in place a range of recruitment policies and procedures which ensure that new employees have POVA and CRB checks and that we obtain two written references for them. We operate an equal opportunities policy and make every effort to recruit from all cutures and backgrounds. Our aim is that we recruit the best people to do the job.” The staff training records showed that Ravensworth does have a training plan in place for its staff. The training records were seen and these showed that staff were receiving the training to help them to do their jobs, including the mandatory training in areas such as fires safety, moving & handling, and health & safety. Discussions with three staff members provided evidence of the training courses staff had attended, and copies of certificates were seen on file. Ravensworth Care Home DS0000062116.V378644.R01.S.doc Version 5.3 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 36 & 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This is a safe, well-managed care home with good systems for ensuring its quality in place, which means that people living at the home have their needs met. EVIDENCE: Maxine Spray is the Registered Manager. She is suitably qualified and experienced with a National Vocational Qualification (NVQ) level IV in management, and the Registered Manager’s Award, and she has been judged Ravensworth Care Home DS0000062116.V378644.R01.S.doc Version 5.3 Page 22 by the Care Quality Commission to be a fit person to run a care home. Maxine has been the registered manager at Ravensworth for seven years. A new quality assurance system which is tied to the current National Minimum Standards is being implemented, and copies of documentation and improvement plans were seen. In addition questionnaires are sent out, to be filled in by people who live at the care home, relatives and visitors. Copies of these questionnaires were seen, and the latest batch, has recently been sent out, and should be returned shortly. Ravensworth hold meetings for the people who live there, although the manager said they have only recently started. Regulation 26 visits (these are monthly audits by a representative of the owners’ management team) are taking place, with copies of reports seen; these are also part of the home’s quality assurance system. No money is held on people’s behalf. Cash is either handled by the individual, and they have secure storage for this, or by their families, or in some cases money is administered by Derbyshire County Council on the individual’s behalf. Ravensworth has a formal staff supervision system in place, in which staff receive supervision with the manager. This is usually in a one to one meeting. Formal supervision offers staff support and guidance in carrying out their work, and is seen as an essential management tool in residential care. Documentation was seen, relating to individual’s supervision, but this did not evidence that the National Minimum Standard of six formal supervisions sessions per year was being met. Three members of staff were asked about formal supervision, and they all said they felt well supported. A range of different health & safety records were seen, including the fire safety records, water temperature checks and the Control of Substances Hazardous to Health (COSHH) records, all were found to be correct and up-to-date, which shows that people are living and working in a safe environment. Ravensworth Care Home DS0000062116.V378644.R01.S.doc Version 5.3 Page 23 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Ravensworth Care Home DS0000062116.V378644.R01.S.doc Version 5.3 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, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP18 Regulation Requirement Timescale for action 30/06/10 Regulation All members of staff must 18 c undertake safeguarding adults training, and have this training updated a minimum of once every two years. This is to ensure that people living at the home are safe. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP11 OP36 Good Practice Recommendations Care plans relating to the end of life, should include the individual’s wishes, and as much information as possible to aid staff in ensuring that those wishes are met. All members of staff should receive a minimum of six formal supervision sessions per year, with records kept of the sessions, and available for inspection. Ravensworth Care Home DS0000062116.V378644.R01.S.doc Version 5.3 Page 25 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.eastmidlands@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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