Inspection on 31/08/07 for Ridgecott

This inspection was carried out on 31st August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Ridgecott 189 Ridgeway Plympton Plymouth Devon PL7 2HJ Lead Inspector Antonia Reynolds Unannounced Inspection 31st August 2007 13:30 Ridgecott DS0000069613.V344941.R01.S.doc Version 5.2 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 Ridgecott DS0000069613.V344941.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 Adults 18-65. 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. Ridgecott DS0000069613.V344941.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ridgecott Address 189 Ridgeway Plympton Plymouth Devon PL7 2HJ 01752 330495 01752 313329 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) Peninsula Autism Services & Support Limited Joanne Evans Care Home 12 Category(ies) of Learning disability (12), Physical disability (12) registration, with number of places Ridgecott DS0000069613.V344941.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 either gender whose primary care needs on admission to the home are within the following categories: Learning Disability (Code LD) Physical Disability (Code - PD) The maximum number of service users who can be accommodated is 12. New Service 2. Date of last inspection Brief Description of the Service: Ridgecott is a care home providing personal care and accommodation for twelve people with learning disabilities, aged over 18, who may also have associated physical disabilities. The home is owned by Peninsula Autism Services and Support Limited (PASS), which also owns other care homes in Devon and Cornwall. Fee levels vary depending on the individual needs of service users. Information about the home and copies of inspection reports can be obtained from the Registered Manager, Joanne Evans. Ridgecott has been a care home for several years and was purchased by the present owners in February 2007. It is comprised of a two-storey house in Plympton, on the outskirts of Plymouth. The home is within walking distance of local shops, the centre of Plymouth is accessible by public transport, and the home has its own vehicle. All the bedrooms are single and are located on each floor. Four of the bedrooms have en suite toilets with showers. There are also showers/baths and toilets on each floor, close to bedrooms and communal rooms. There is a through lounge/dining room on the ground floor with dividing doors that can be closed if required. The home has a call bell system installed in most of the rooms for service users and/or staff to summon assistance if needed. The home has been partially adapted to accommodate service users with physical difficulties. The home has outdoor space at the front and the back of the property and its own car park. Ridgecott DS0000069613.V344941.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection consisted of one unannounced visit between 1.30pm and 6.20pm on Friday, 31st August 2007. The Deputy Manager, Annette Mitchell, was present throughout the visit and the Registered Manager, Joanne Evans, was present in the home for a short time. A tour of the premises took place and records/documents relating to the care of the service users, staff and the home were inspected. An annual quality assurance assessment had been completed by the Registered Manager, which contained information relevant to the inspection. Eleven service users were spoken with or observed during the inspection. Six staff members were spoken with and observed in the course of their normal duties. Survey forms were received from one service user, six relatives and ten staff members. Three survey forms were sent to health and social care professionals but none were returned. What the service does well: What has improved since the last inspection? What they could do better: Fire safety procedures need to be followed so the fire alarm system is tested more frequently. The frequency and content of staff training may need to be reviewed to comply with fire regulations. With regard to recruitment procedures, where staff members are interviewed in connection with an offence they have committed in the past, the outcome of this interview should be recorded to demonstrate that the home is taking Ridgecott DS0000069613.V344941.R01.S.doc Version 5.2 Page 6 appropriate steps to protect service users. It may also be useful for staff to attend the adult protection training provided by Social Services in Plymouth so that they are fully aware of local procedures. Service user plans should be reviewed and updated to include detailed information about the action that needs to be taken by care staff to ensure that all aspects of service users’ needs are met. Risk assessments should relate to the needs identified on the care plan, such as manual handling, medication, the potential to burn themselves on the radiators and the use of transport. The existing risk assessments should be reviewed, updated and documented individually so that staff are aware of any particular procedures they should follow to keep service users safe. Medication profiles should be reviewed and updated to reflect the changing needs of service users. The use of coded locks on doors to communal rooms, particularly the dining/lounge room, should be reconsidered so that service users can access all of the home all the time. If a risk is identified for a particular service user, alternative ways of managing the risk should be considered that do not impinge on the liberty of others. Consideration should be given to fitting suitable locks to all bedroom doors that are accessible to staff in emergencies. This is to enhance service users’ privacy and so that personal belongings can be kept securely if service users are absent from the home for any reason. 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. Ridgecott DS0000069613.V344941.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ridgecott DS0000069613.V344941.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2, 3, 4 and 5 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. The home’s admissions procedure should ensure that prospective service users and their relatives/representatives know that the home will meet their needs. EVIDENCE: The Deputy Manager confirmed that no new service users have been admitted to the home since Peninsula Autism Support and Services Limited bought it in February 2007. However there is an admission procedure and assessment process to ensure that the needs of prospective service users are identified. Service users and their relatives/representatives are welcome to visit the home prior to admission to meet other service users, staff and have a look around the home. Discussions with service users and staff, as well as observation, show that staff are aware of the needs of the service users. The Assistant Manager confirmed that all the service users are funded and have contracts agreed by the Local Authority. The statement of terms and conditions of residency for each service user are in the process of being updated. When completed these will be signed by service users or relatives/representatives, depending on the needs of service users. Ridgecott DS0000069613.V344941.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, 8 and 9 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. Service users can be confident that they will be encouraged and supported to make choices and decisions about their lifestyles. Care plans and risk assessments do not always reflect the complex needs of the service users. EVIDENCE: Discussions with service users and the staff team confirmed that personal care is maintained; service users can bathe/shower when they choose to and are encouraged to be as independent and make as many choices as possible. Service users said they are involved in the day-to-day running of the home and that independence is promoted. Three service users’ files were inspected and these contained care plans and risk assessments relating to health and personal care needs. The Deputy Manager confirmed that person centred planning is being introduced into the home. However care plans did not contain enough detail about how service users’ needs should be met by the staff team. One care plan had not been Ridgecott DS0000069613.V344941.R01.S.doc Version 5.2 Page 10 reviewed since 25th May 2006. One care plan referred to a risk assessment being updated on 3rd August 2007 but this assessment could not be found on the day of inspection. Whilst individual risk assessments for service users had been carried out, these had not been updated or reviewed since 2003. Also, these were all recorded together in one document and not individually. A discussion took place about the importance of carrying out risk assessments related to the use of transport by service users when they go out to ensure that staff are aware of any particular procedures they should follow. With regard to service users’ money, the Deputy Manager confirmed that they all have individual accounts managed by the organisation (Peninsula Autism Support and Services Limited). If service users need money, the Head Office of PASS is contacted, and money is transferred into a local account, specifically for the purpose of holding this money. The home then administers this spending money on behalf of the service users. The records of three service users were checked and found to be correct. The Deputy Manager said that, wherever possible, service users are supported and enabled to administer their own finances. Service users are expected to make a contribution towards the cost of the home’s transport, which is twenty-six pence per mile. If more than one service user goes out in the home’s vehicle, the mileage is divided by the number of service users and they are charged accordingly. Ridgecott DS0000069613.V344941.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 11, 12, 13, 14, 15, 16 and 17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. Service users can feel confident that they will have opportunities for personal development, various activities are available to fulfil their aspirations, and independence and choice are promoted. EVIDENCE: Discussions with service users and staff, as well as pre-inspection documentation provided by the home, confirmed that all the service users are encouraged and supported to participate in a range of voluntary work, leisure, and educational opportunities. Service users confirmed that they use the local amenities, such as shops, pubs, the youth club and the swimming pool. Where possible service users are involved in daily routines and domestic activities in the home, including cleaning and tidying their own rooms and doing their own laundry. Service users said that they visit their families and family members visit them on a regular basis. Some service users spend weekends with their families. Feedback from relatives showed that they are always welcomed. Ridgecott DS0000069613.V344941.R01.S.doc Version 5.2 Page 12 One relative said that Ridgecott is “very much an ‘open house’ where I am made to feel welcome at any time I might visit”. The Deputy Manager and staff were knowledgeable about the personalities of each person in the home and the activities that they enjoy. Good communication was observed between service users and staff who used total communication methods, including finger spelling and makaton, as well as words. Various pictures and symbols are also used in the home to facilitate communication between service users and staff. The home has a designated activities coordinator and all the service users have individualised activities, taking place through support from the home. The home is continually looking and developing new activities for each person to maintain their presence in the community and to enhance their quality of life. The home has a pet rabbit and all the service users are encouraged to be involved in his care. The Deputy Manager was not sure what is happening about holidays for service users in the future, although they have been away in the past. The home owns a minibus, with a tail lift for those service users who use wheelchairs, to transport service users to appointments and social events. Service users are asked to make a voluntary contribution of twenty-six pence per mile towards the cost of transport. Service users are also supported to use public transport if they are able to. A written menu was available, which showed that service users are offered a varied selection of meals. Discussions with the staff team indicated that they are well aware of the likes and dislikes of each person and are always willing to offer alternatives to the menu. Observation of the evening meal in the home confirmed that staff support and encourage service users to make choices and enjoy their meal in a relaxed, unrushed and sociable atmosphere. Service users said that they liked the food provided in the home and can choose what they want to eat. Ridgecott DS0000069613.V344941.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. Service users can be confident that personal support is provided in the way, and at the time, that they want and need. Health care needs are monitored and advice is sought when necessary. EVIDENCE: Service user plans provide information about personal, emotional and health care needs, although some need to be updated with more detail (see Standard 6). Where possible, service users sign their care plans to show that they have been consulted and know what information they contain. Where service users have complex needs, the management and staff team work hard at meeting those needs with support from local health and social care professionals. The home keeps daily records to monitor an individual’s progress. External professional advice and guidance is sought when necessary from local health care professionals or social services and visits to the doctor, dentist and other health appointments are recorded in individual files. Through observation it is clear that timings are flexible and the choice of the service user. Ridgecott DS0000069613.V344941.R01.S.doc Version 5.2 Page 14 Medication is stored securely, records pertaining to its administration are up to date and the administration practices described by a staff member were satisfactory. The medication profile for one service user was out of date as it said that rectal diazepam was prescribed, although staff confirmed that this is no longer the case and it did not appear on the medication administration records. Ridgecott DS0000069613.V344941.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. Service users can be confident that any concerns or complaints will be listened to and addressed. EVIDENCE: The home has a complaints procedure but there have been no complaints since the change of ownership in February 2007. Service users are aware of how and to whom they can make a complaint and feel free to do so. Discussion with the service users, staff and the Deputy Manager, demonstrated that the open culture of the home and the recognition of service users’ rights ensure that service users are protected from harm. The Deputy Manager and the staff confirmed that all staff are expected to attend in-house training relating to the protection of vulnerable adults. The home has a copy of the Local Authority’s Alerter’s Guidance available for staff with a procedure for notifying any alleged incidents of abuse or concern. Ridgecott DS0000069613.V344941.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 25, 26, 27, 28, 29 and 30 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. Service users live in a clean, safe, comfortable and well-furnished home, although access to the lounge/dining room is restricted at night. EVIDENCE: The home is comfortable, safe and clean with a good standard of décor and furnishings. A designated staff member is responsible for maintenance and he confirmed that repairs, maintenance and redecoration are ongoing projects. There is a lounge/dining room on the ground floor and this is a popular place for service users to congregate and talk to each other and the staff. There is a coded lock fitted to the door into the dining room from the corridor where there are three bedrooms. The staff said that this had been fitted because of the specific needs of one service user. However this also means that the other two service users are denied access to the dining/lounge room at night. A discussion took place about alternative methods of monitoring service users (where necessary) to alert staff without encroaching on the rights of others to use the communal rooms at night should they wish to. A coded lock is also Ridgecott DS0000069613.V344941.R01.S.doc Version 5.2 Page 17 fitted to the kitchen and the staff said this is only locked at night for health and safety reasons. Each service user has a single bedroom with space for individual needs and lifestyles, three of which are on the ground floor and nine on the 1st floor. Some bedroom doors are fitted with appropriate locks that can be locked from the inside by service users and locked from the outside by using a key. One service user had her own key and always locked her bedroom door when she was not in the room. The staff have duplicate keys so that they can gain access if an emergency should occur. A discussion took place with the Deputy Manager about fitting locks to all the bedroom doors so that service users can have privacy if they wished to, or the door can be locked to keep their possessions secure, should they be away from the home for any reason. This discussion also included the importance of risk assessing the type of lock, as they have to be compatible with the individual needs of service users. All the bedrooms contain wash hand basins and four of them have en suite toilets with showers. Bedrooms are individually furnished and personalised by or for the service users, depending on their wishes. Service users and the Deputy Manager confirmed that, wherever possible, service users choose the colour and décor of their bedrooms. The home obtains colour charts to assist people with choosing. The type and quantity of furniture varies dependant on the wishes and needs of service users. There is a stair lift for those people who have difficulty in walking or going up stairs. The lounge/dining room is on the ground floor. Service users said that they are responsible for cleaning their own bedrooms if they wish to and the staff clean the communal areas. The home has been adapted, both inside and outside, to accommodate service users with physical disabilities and equipment includes hoists, grab rails, wheelchairs and an external lift to the home’s car park. The shower/bath rooms and toilets are in good condition and discussions with service users, as well as observation, indicated that there are enough facilities to meet the needs of the service users and staff. All shower rooms and toilet doors are fitted with locks that can be opened from the outside by staff in an emergency. The Deputy Manager and staff confirmed that service users use their own en suite facilities for personal care tasks. At the front of the building is a new decking area and at the rear of the building is a large patio with garden furniture, which has been made accessible for all the service users in the home. Laundry and kitchen facilities are satisfactory and discussions with the Deputy Manager and staff confirmed that infection control procedures are in place. Ridgecott DS0000069613.V344941.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 33, 34, 35 and 36 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. Recruitment procedures are robust and service users benefit from a competent, experienced, well-supported and motivated staff team. EVIDENCE: Throughout the inspection staff were observed responding sensitively and respectfully to service users’ requests, and were able to use their knowledge of each individual to encourage choice and independence whenever possible. Staff were friendly, good-natured, courteous and respectful at all times. They interacted well with the service users and were also humorous and fun, which the service users clearly enjoyed. Discussions with service users, the staff on duty and the Deputy Manager confirmed that there are always enough staff on duty to meet the needs of the service users. There are usually three or four staff on duty during the day, as well as the Registered and Deputy Managers, and two staff sleep in at night. Observation showed that the staff members on duty were aware of service users’ needs and how to support them. Service users confirmed that the staff Ridgecott DS0000069613.V344941.R01.S.doc Version 5.2 Page 19 team are very good and it was evident that there was a good rapport between service users and staff. Many staff members have worked in the home for several years and know the service users well. Only four staff members have been recruited since the new owners took over the home in February 2007. The organisation has a robust recruitment procedure and the files of newly recruited staff, as well as information from the Registered Manager, confirmed that all the required documentation is obtained for all new staff members. The Deputy Manager confirmed that, if there is a delay in obtaining written references or a Criminal Records Bureau (CRB), new staff are always supervised and do not carry out personal care tasks until satisfactory checks and references are received. The Deputy Manager also said that, if a staff member has committed an offence in the past, that person is always interviewed about the incident. However, there was no documentation to show that this had taken place. Discussions with staff and the Deputy Manager, as well as documentation, showed that all staff are expected to participate in various courses or training sessions and receive regular supervision. Training includes induction, adult protection, first aid, health and safety, fire safety, medication, food hygiene, National Vocational Qualifications (NVQs) and courses related specifically to working with service users with learning disabilities. These include topics such as working with people with challenging behaviour, epilepsy, dementia and total communication skills. Ridgecott DS0000069613.V344941.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. The management approach is open and inclusive, providing clear leadership and guidance, although fire safety procedures are not being followed. EVIDENCE: The Registered Manager, Joanne Evans, has been managing this home since February 2007 but has worked in the home for many years. She has completed a level 4 National Vocational Qualification (NVQ) in Care and is undertaking the Registered Manager’s Award, thereby demonstrating that she keeps herself up to date with current good practice in social care. The Registered Manager is supported by the company’s senior management team who visit the home on a regular basis. Discussions with the service users and staff confirmed that the ethos of the home is very good because the management approach is open and inclusive. Ridgecott DS0000069613.V344941.R01.S.doc Version 5.2 Page 21 Discussions with staff, as well as training records, confirmed that all staff are expected to attend training in health and safety, emergency first aid, food hygiene and fire safety. However the required frequency of fire safety training was not clear and staff were not sure how often they had received training. The fire logbook showed that the fire alarm system was tested monthly until 23/3/07, but only once since then. The organisation’s fire safety policy says that weekly testing should take place of the fire alarm system. Documentation in the home showed that health and safety checks and tests have taken place such as servicing and checks/tests of the gas and electrical supply, as well as maintenance to the lifts and hoists. Portable electrical appliances have been checked for safety. The Deputy Manager confirmed that all the hot water for baths/showers is regulated and checked by staff to ensure that service users are protected from scalding. Risk assessments have been carried out with each service user in relation to manual handling and the potential to burn themselves on the radiators. However these have not been documented individually or reviewed recently (see Standard 9). The quality of care provided is continually being monitored and reviewed by the Registered Manager as she spends a great deal of time at the home talking with service users, their relatives/representatives and staff. Service users and staff confirmed that they are consulted and included in all decisions regarding the running of the home. Pre-inspection documentation confirmed that a quality assurance system is being put into place and the Deputy Manager said that, as part of this, a relatives forum is being set up where they will be able to make suggestions to improve the service provided. Ridgecott DS0000069613.V344941.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 Adults 18-65 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 X 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Ridgecott DS0000069613.V344941.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/A 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 YA42 Regulation 23(4) Requirement The fire alarm system must be tested in accordance with the organisation’s fire risk assessment. The Registered Manager must ensure that all other fire safety procedures, including the frequency and content of staff training, comply with fire regulations. Timescale for action 21/10/07 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 YA6 Good Practice Recommendations Care plans should be reviewed and updated to include detailed information about the action that needs to be taken by care staff to ensure that all aspects of service users’ needs are met. Risk assessments should be reviewed and updated to include all aspects of potential risk to service users, including manual handling, medication and the use of transport. These should all be documented individually and kept on service users’ personal files so that staff are aware of any particular procedures they should follow to DS0000069613.V344941.R01.S.doc Version 5.2 Page 24 2. YA9 Ridgecott 3. 4. 5. YA20 YA23 YA24 6. YA26 7. YA34 8. YA42 keep service users safe. Medication profiles should be reviewed and updated to reflect the changing needs of service users. Staff should attend the adult protection training provided by Social Services so that they are fully aware of local procedures. The use of coded locks on doors to communal rooms, particularly the dining/lounge room, should be reconsidered so that service users can access all of the home all the time. If a risk is identified for a particular service user the Registered Manager should consider alternative ways of managing the risk that does not impinge on the liberty of others. Consideration should be given to fitting locks to all bedroom doors that are suited to service users’ capabilities and accessible to staff in emergencies. This is to enhance service users’ privacy and so that personal belongings can be kept securely if service users are absent from the home for any reason. When staff are interviewed by the Registered Manager in connection with any offence they may have committed in the past, the outcome of this interview should be recorded to demonstrate that the home is taking appropriate steps to protect service users. Risk assessments that have been carried out with each service user in relation to manual handling and the potential to burn themselves on the radiators should be reviewed, updated and documented individually. This is to ensure that satisfactory precautions are in place to reduce the risk and that staff are aware of any particular procedures they should follow. Ridgecott DS0000069613.V344941.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ridgecott DS0000069613.V344941.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!