Archived: Ravendale Hall

Ravendale Hall is a large converted listed building in its own grounds. The service is provided over two floors and offers communal lounge areas, library, bathroom and toilet facilities, bedrooms, dining area, kitchen, conservatory, passenger lift, staff areas, outside garden space and on-site parking facilities.

At the time of our inspection our records showed that the service had a registered manager in post. We found out during the inspection the registered manager had left their post in February 2016 and their application to cancel their registration had been submitted and was being processed by the CQC. A new manager had been appointed in February 2016 and was awaiting the outcome of their application to become the new registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

This inspection took place on 26 April 2016 and was unannounced. The service was last inspected on 16 June 2015 where we found the registered provider was in breach of the legal requirements relating to safe recruitment practices and the management of medicines. At this inspection the registered provider had made improvements and had met the necessary requirements.

The service understood how to keep people safe and there were policies and procedures to guide staff in how to safeguard people from the risk of harm and abuse. Staff understood how to report potential abuse and had received training to reinforce their understanding.

There were sufficient numbers of staff to safely support people. Staff received supervision, observations of practice and annual appraisals to support their practice. We found people received their medicines as prescribed and staff were appropriately trained with the skills to carry out their role effectively.

We found staff had been recruited safely and appropriate checks had been completed prior to them working with vulnerable people. Staff had good knowledge and understanding of the needs of the people they were supporting and people told us staff were considerate and kind.

Staff had received training in legislation such as the Mental Capacity Act 2005, Deprivation of Liberty Safeguards and the Mental Health Act 1983. They were aware of the need to gain consent when delivering care and support and what to do if people lacked capacity to agree to it. When people were assessed by staff as not having the capacity to make their own decisions, meetings were held with relevant others to discuss options and make decisions in the person’s best interest. The acting manager had submitted a number of applications to ensure people were not unlawfully restricted.

People who used the service were provided with a varied diet and spoke highly of the food they received. Staff monitored people’s food and fluid intake and made referrals to healthcare professionals when required. People who lived at the service were supported to access health care and attend appointments when needed to ensure their health and wellbeing was maintained.

The service offered a range of activities and people were encouraged to participate. The registered provider had a complaints procedure which people could use to raise any concerns or issues they had. People who used the service had personalised care plans in place which identified potential risks, likes and dislikes and outcomes. Family and friends were welcome to visit and people living at the service were encouraged to maintain family contact.

People told us the leadership at the service was approachable and supportive and people were encouraged to give their views and opinions of the service. The registered provider promoted an open and transparent organisation and staff were supported through regular supervision, team meetings and annual appraisals. The service had an effective auditing system in place to assess and monitor the quality of the service provided.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, and the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People felt safe because their rights and dignity were respected by the staff. People told us they felt safe.

Members of staff understood the safeguarding systems in place and it was clear that learning occurred following any incidents or accidents.

Members of staff understood the home’s policy on the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards although no applications had been made.

The home had robust risk management processes in place and staff supported people to take positive risks to promote their independence.

People received their medicines as prescribed. Prescribed medicines (including controlled drugs) were stored and administered safely in line with current regulations and guidelines.

Recruitment processes were safe and thorough. People were supported by staff that had been checked with the Disclosure and Barring Service and whose references had been checked before they started work.

The home had a robust training policy which required its staff to achieve nationally recognised qualifications in care. This ensured people were protected from unsafe practices.

Is the service effective?

People were able to express their views about their health. People were involved in the assessment of their needs and care plans reflected their choices and preferences.

Staff supported people to be as independent as possible.

People and their relatives were involved in discussions about their nutrition and hydration needs. People were effectively assessed to identify the risks associated with nutrition and hydration. People’s identified needs were monitored regularly and effectively.

Is the service caring?

We saw people were cared for by staff who showed patience and gave encouragement. People commented, “The staff are very kind, they are a really good team.” A relative said, “I come here almost every day and I think the carers are very good; they are very caring people.”

Staff knew the people they cared for and understood their preferences and personal histories.

Policies and procedures were in place to ensure staff understood how to respect people’s privacy and dignity.

Members of staff had been trained to a nationally recognised standard in equality and diversity.

People and their relatives were encouraged to make their views known about their care and treatment and these views were respected.

The home had involved appropriate professionals in the planning and delivery of care.

Is the service responsive?

People were encouraged to participate in a range of activities regularly. The home had its own minibus that meant activities could be provided outside of the home’s environment.

People had access to activities that were important and relevant to them. The home monitored people’s participation in activities to prevent them from becoming isolated.

Members of staff actively listened and acted on people’s views and decisions. People were given the information at the time they needed it.

People’s capacity to make their own decisions was considered under the Mental Capacity Act (2005).

Concerns and complaints were encouraged. People were made aware of how to complain.

Is the service well led?

There were effective systems in place to continually review safeguarding concerns, accidents and incidents.

The registered manager had robust systems in place to monitor and assess the quality of the service provided to people. Where gaps or shortcomings had been identified the registered manager took swift action to address the issues.

Members of staff were clear about their roles and responsibilities. Staff were motivated, caring, well trained, supported, and open. The registered manager understood their responsibilities and was supported by head office management to deliver what was required.