Inspection on 13/08/08 for Ridgegate

This inspection was carried out on 13th August 2008.

CSCI found this care home to be providing an Excellent service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ridgegate 21/08/06

Ridgegate 12/01/06

Ridgegate 16/08/05

Ridgegate 23/08/04

Ridgegate 07/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Ridgegate Ridgegate 88 Doods Road Reigate Surrey RH2 0NR Lead Inspector Jo Griffiths Unannounced Inspection 13th August 2008 09:30 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 Ridgegate DS0000013762.V369617.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. Ridgegate DS0000013762.V369617.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ridgegate Address Ridgegate 88 Doods Road Reigate Surrey RH2 0NR 01737 242926 01737 222461 office@ridgegatehome.org.uk 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) Governors of Ridgegate Home Mrs Rosemarie Bowering Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Ridgegate DS0000013762.V369617.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only – (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP) The maximum number of service users to be accommodated is 25. Date of last inspection 21st August 2006 Brief Description of the Service: Ridgegate is a large house in a pleasant residential area in Reigate, Surrey. It is run by The Governors of Ridgegate Home and is registered with the Charity Commission. The accommodation is arranged on four floors, reached by a staircase or the lift. Residents all have single rooms, and most have ensuite facilities. There is a large comfortably furnished lounge on the ground floor, and two smaller lounge areas (one containing a small library) are available for residents to use. The kitchen and dining room are on the lower ground floor. There is a ramp to the front of the property and to the large rear garden for wheelchair access. There is car parking to the front of the property and Ridgegate owns its own minibus. The care home provides residential accommodation and care to 25 older people. An information pack about the service can be obtained from the manager of the home. The current fees range from £400 - £650 per week depending on the size of room accommodated. Ridgegate DS0000013762.V369617.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 Star. This means the people who use this service experience excellent quality outcomes. This was a key inspection of Ridgegate carried out by Jo Griffiths, Regulatory Inspector, on 13th August 2008. Prior to the inspection visit the Manager completed an Annual Quality Assurance Assessment (AQAA) for the service and sent this to the Commission as requested. As part of this inspection an ‘expert by experience’ was used. An ‘expert by experience’ is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. The ‘expert by experience’ spoke with 6 people that use the service and 2 visitors to the home. They also spent time observing the activities in the home and had a meal with the residents. 8 people that use the service completed a survey about the quality of their care and returned this to the Commission. The inspector and the ‘expert by experience’ had a look around the home. The inspector looked at some of the records and care plans and spoke with the Manager about changes that had been made since the last key inspection. Some of the staff members were spoken with as part of the inspection. What the service does well: People looking to move to the home are given all the information they need about the service. Everyone has a care plan and the residents of the home feel their needs are met very well. There is a varied activities programme with something for people to do each day. People that live in the home say that they feel safe and secure. The staff that support them treat them with respect and support them in the way they prefer. The staff are trained and the majority have their NVQ award. The Manager is qualified and experienced and makes sure that the residents views are listened to and taken seriously. The home regularly asks people how they can improve the service. Ridgegate DS0000013762.V369617.R01.S.doc Version 5.2 Page 6 The home itself is clean and comfortable with lots of communal areas for socialising and a large, beautiful garden with a summerhouse. The residents of the home enjoy the meals and have lots of choice of what they have. Feedback from the residents and relatives of residents was very positive about the service. Comments included; ‘They look after us very well’ ‘It is a home from home’ ‘Brilliant, the staff are very nice and kind, the meals are very good’ ‘You would have to go a long way to find a home as good as this’ ‘Ridgegate has got better and better’ What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ridgegate DS0000013762.V369617.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ridgegate DS0000013762.V369617.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 and 5 (standard 6 is not applicable for this care home) People that use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People looking to move to the home are provided with the information they need to make an informed decision. They have the opportunity to assess the service before moving in and have an assessment of their needs to ensure they can be met. EVIDENCE: The Service User Guide is presented as an information pack and includes all the information people need to know about the home before they move in. This is sent to people when they make an enquiry about the home, or if they prefer, when they move into the home. The guide includes an A-Z of information about the services and facilities provided. There is a clear complaints procedure as part of the pack. The fees charged and additional costs are stated within the pack. Ridgegate has its own website and brochure with current photographs of the home. Ridgegate DS0000013762.V369617.R01.S.doc Version 5.2 Page 9 Before a person moves to the home the Manager carries out an assessment of their needs to ensure the service is able to provide the support they need. The person is included in this process and asked their views of the service they wish to receive. The assessment is further updated once they move into the home. The home is able to meet the needs of people from a variety of cultural backgrounds and can cater for people with mobility difficulties and other disabilities. People planning to move to the home are encouraged to visit for a trial period or at least to visit during the day and for meals. The Manager said that most people take up this opportunity and it gives them reassurance about the service and relieves anxiety. This is also an opportunity for them to talk with residents of the home about the care that is provided. There is a 6-week trial period for new residents when they move in so that they can decide if they wish to stay permanently. One person living in the home told the ‘expert by experience’ that ‘you would have to go a long way to find a home as good as this’ Ridgegate DS0000013762.V369617.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 People that use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents have a care plan that ensures their holistic needs are met. They have their health and personal care needs met in the way they prefer and their privacy and dignity is respected and maintained. People are supported to manage their medication safely. EVIDENCE: Each person has a care plan that has been written following an assessment of their needs. The residents have been involved in drawing up their plan and have signed to agree them. The plans cover the support needs of individuals in a number of areas including health, personal care, risks, nutrition, social activities, relationships and emotional well being. The Manager has recently introduced a new assessment that can be used to establish a person’s mental capacity. Advice has been sought from the local ‘Independent Mental Capacity Advisor’ who also provided staff with some training in this area. The care plans Ridgegate DS0000013762.V369617.R01.S.doc Version 5.2 Page 11 are reviewed monthly with the resident and are updated as needed or every six months following a formal review meeting. The records that are maintained in relation to the care plan are very detailed with regard to people’s health needs and well being. The records could be further developed to ensure there is recorded evidence that people’s social needs are being met by the home. Residents are supported to visit the GP as they need to or arrangements can be made for the GP to visit the home. There are regular visits from the district nurse. A chiropody service is provided in the home and support can be provided to access additional health services such as physiotherapy. Feedback from residents in the surveys showed that they are happy with the way their health needs are met. Personal care is provided in the privacy of people’s own bedrooms or within one of the bathrooms. New baths have been fitted since the last inspection to aid people with mobility difficulties. Again feedback from the residents in the surveys showed they are happy with the personal care they receive. Those spoken with on the day of the inspection confirmed they are usually supported to have a bath once per week. Whilst this may seem infrequent the residents said that this is what they prefer and that they felt they could have a bath more frequently if they requested it. There is a hairdresser that visits the home weekly. There is an in-house shop two mornings a week where residents can buy toiletries and other small items. The feedback from residents in surveys and the discussions with residents during the visit showed that they feel staff treat them well and in a respectful way. The ‘expert by experience’ observed, throughout the visit, that staff spoke to people in a respectful manner and did not rush them. Staff were observed to knock on people’s bedroom doors before entering. The medication is stored securely in the home and is only administered by staff that have been trained and assessed as competent to do so. The Boots MDS system is used and an annual audit of the storage is undertaken by Boots the Chemist. People can choose to manage their own medication if they wish to. An assessment of their needs is completed to ensure they will be able to manage their medication safely and to ensure they are provided with the support they need. Two people currently manage their own medicines. They are provided with lockable cabinets for this and are required to sign to say they have received their medication supply each week. The Manager makes regular checks with the individuals to ensure they continue to manage this well. The records of medication administered were checked and had been completed accurately and fully. Ridgegate DS0000013762.V369617.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 People that use the service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are provided with a range of activities within the home and the community that meets their needs and preferences. They are supported to maintain contact with family and friends and to exercise control over their own lives. EVIDENCE: The ‘expert by experience’ spent time talking with the residents of the home about the activities that are available and the meals that are provided. There is a monthly activity programme for the home with a planned activity taking place in the communal areas each day. Residents are given a copy of the schedule for the forthcoming month and can choose which activities they wish to participate in. There is a section at the bottom of the schedule for residents’ comments and suggestions about future activities they would like to see. The range of activities provided include, name that tune, spelling game, general knowledge quiz, beauty sessions, bingo, music and movement, hangman, singing, guitar and keyboard player and flower arranging. Residents Ridgegate DS0000013762.V369617.R01.S.doc Version 5.2 Page 13 are also encouraged to get involved in tending to the vegetables and flowers in the garden. The feedback from residents in the surveys and on the day of the visit showed that the majority enjoy the activities provided and everyone knew that they could make suggestions for other activities. An example was seen where someone had recently requested classic story sessions and this has been arranged for the following month. Outings are arranged for day trips out and visits to places of interest. The Manager said that these are not always successful, as the residents will often decide they do not wish to go on the day. The home has a minibus to enable residents to go out when they wish and most people go out on occasions with their family members. Activities are arranged in the home seasonally and there is always an annual garden party and a Christmas party. Everyone has a celebration of their birthday if they wish to. There are photos around the home of residents enjoying activities within the home and some people showed the inspector the crafts and flower arranging they had completed. There is a library area on the ground floor and the books are renewed by the visiting library every 12 weeks. A large number of the books are large print. The area has comfortable seating and a water dispenser. Residents may benefit if reading lights were to be added to this area. Residents can have a newspaper of their choice delivered daily at an additional cost. There is a newsletter produced for the residents every two months. This contains stories, news and quizzes. Visitors are welcome at any reasonable time and arrangements can be made for residents to see their visitors in private in their rooms or in one of the lounges. Two visitors were spoken with during the inspection and both gave very positive feedback about the home. Comments included ‘It is a home from home’ and ‘Ridgegate has got better and better’. Residents are encouraged to stay in contact with their family and friends and can use the payphone in the quiet lounge to make personal calls. There is a post box in the home for outgoing mail. The home has a four-week menu that is updated seasonally and following any request for new dishes from residents. The menu is varied and balanced and feedback from residents is positive about the quality of the meals. The ‘expert by experience’ joined the residents for the lunchtime roast meal. The experience was relaxed and there were plenty of staff on duty to serve the meals. Where people required assistance they were helped unobtrusively. Alternative meals were available if people did not want the option on the menu and everyone was offered a second helping. When questioned the residents Ridgegate DS0000013762.V369617.R01.S.doc Version 5.2 Page 14 said the hot food was always hot enough. The ‘expert by experience’ commented that the Gammon and vegetables were delicious, but the roast potatoes were a little hard and the gravy a bit tasteless. They commented that the fruit salad was excellent. The catering staff said that people’s individual needs and dietary requirements can be catered for, including cultural and religious needs. Fresh fruit bowls are provided in each persons room weekly and sherry is served in the lounge twice a week. Residents are encouraged to maintain their independence as far as possible and to make their own decisions. There are plenty of options to choose from with regard to meals and residents are consulted on their preference of activities each month. Residents are involved in reviewing their care plan and having a say about how their care is delivered. This includes how they will receive their personal care and which staff will support them. There are four independent advocates involved with the home and information about advocacy was seen in the entrance hall. Ridgegate DS0000013762.V369617.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 People that use the service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. People using the service know how to make a complaint if they need to and feel confident they will be listened to. There are suitable policies and practices within the home to ensure people are safeguarded from harm and abuse. EVIDENCE: The complaints procedure for the home is displayed in the entrance hall and is included in the Service User Guide given to every resident of the home when they move in. There is a box to post comments, complaints and compliments in the hallway. Feedback from the residents’ surveys and through discussion with residents on the day showed that they feel confident about making a complaint if they need to and feel they would be listened to and taken seriously. One person said ‘I know I can always ask for help or tell someone I have a concern without feeling uncomfortable.’ There have been no complaints received in the home recently and none received by CSCI in respect of the home. In addition to the formal complaints procedure there are also regular opportunities for residents to comment on the service they receive through their monthly care plan review, the 8-weekly residents meetings and the monthly feedback sheets about activities. The Manager and deputy Manager Ridgegate DS0000013762.V369617.R01.S.doc Version 5.2 Page 16 are available in the home Monday to Friday to discuss any concerns residents may have. There have been a number of letters of compliment about the service with comments including; ‘The family atmosphere which prevails and the help and kindness shown by the staff has helped X feel safe, happy and secure.’ ‘The way the staff work and behave toward the residents is of the very highest quality.’ ‘Everyone is prepared to go the extra mile to make things special’ People that live in the home said that they feel safe and secure and that the staff treat them with respect and kindness. All staff had been trained in Safeguarding adults and update training was being arranged for later this year. Staff spoken with knew the policy and procedure for reporting any suspected incidents of abuse. All staff have a CRB and POVA check before they can begin work in the home. There is an advocate involved with the care home and information is readily available about advocacy services in the entrance hall. Ridgegate DS0000013762.V369617.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21, 22, 23 and 26 People that use the service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is safe, clean and comfortable for the people that live there. Residents’ bedrooms suit their needs and preferences. There are sufficient and suitable bathroom facilities in the home. Residents have access to plenty of comfortable indoor and outdoor communal space. They have the equipment they need to move safely around the home and maximise their independence. EVIDENCE: Many areas of the home have been redecorated since the last inspection. New carpets have been fitted to the communal areas and most bedrooms. New furniture has been purchased for the lounges and a number of bedrooms. Ridgegate DS0000013762.V369617.R01.S.doc Version 5.2 Page 18 There are three lounges in the home, a large main lounge, a quiet lounge and the ‘cosy corner’ with a library area. There is a spacious dining room on the lower level that has plenty of seating for all residents. A new floor has been fitted in the dining room. Since the last inspection a new shaft lift has been fitted, which goes to all floors. It is large enough for staff to travel with residents who are using wheelchairs or frames. The lift reaches all floors including the garden. The rear garden is beautifully maintained with numerous seating areas for residents. There is a new summerhouse with comfortable seating and a greenhouse where vegetables are grown. The garden has a birdbath, bird feeder and a pond. Residents are encouraged to get involved in feeding the birds and tending to the pots and vegetables. One resident commented ‘There is a lovely garden and beautiful summer house’ All residents have a single bedroom and have been supported to furnish this with their personal belongings to make it homely and comfortable for them. Most of the rooms have ensuite facilities and two of the rooms have been recently expanded to include a lounge area. All areas of the home were clean and hygienic. There are three bathrooms, one on each floor, and these have assisted baths to help people with mobility access the facilities comfortably. One resident commented that they would like to see a shower in the home. The Registered Provider should give consideration to this in the future when admitting new residents who may need or prefer a shower. There are plenty of toilets situated around the home. One of the toilets has a folding plastic door and the provider may wish to consider changing this to maximise the privacy for residents. All bedrooms and communal areas in the home have a call bell to summon staff if they are needed. This includes a call point in the summer house. Staff were seen to respond to the call bells quickly during the inspection. Fall sensors have been fitted outside the lift on each floor and some fall sensor mats are used in people’s bedrooms. Walking sticks are provided to assist residents in accessing the garden. All areas of the home and the garden have level access or are accessed by the lift. The home is suitable for people that require support with their mobility. Handrails have been fitted to areas of the home and the summerhouse. One of the Governors of Ridgegate visited the home during the inspection and described the plans for the home for the next year. This will include refitting and modernising the kitchen. Ridgegate DS0000013762.V369617.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 People that use the service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. People that live in the home are supported by sufficient numbers of trained, qualified and competent staff. They are safeguarded by the homes robust procedures for recruiting new staff. EVIDENCE: The rotas show that sufficient numbers of staff are employed to meet the needs of the current group of residents. Observations during the inspection demonstrated that staff have a good understanding of people’s needs and positive and respectful relationships with them. The ‘expert by experience’ commented that staff did not rush people when supporting them with their daily tasks. Comments from residents included; ‘they look after us very well’ ‘the staff are very nice and kind’ The employment records were seen for four staff. These contained evidence that the appropriate pre employment checks had been made to ensure residents are safe in the home. The training files for the four staff members were also seen. All staff have completed the core training courses including Safeguarding adults, health and safety and moving and handling. Some staff Ridgegate DS0000013762.V369617.R01.S.doc Version 5.2 Page 20 had also completed additional training such as dementia and administering medication. The majority of the staff team had recently been involved in a training session on the Mental Capacity Act. All new staff complete the ‘skills for care’ induction workbook. Examples of completed inductions were seen on two staff files. The catering staff confirmed that they have completed training in nutrition to help them plan the menus. Of the 13 care staff employed by the home 11 have completed their NVQ award. This is very positive for residents who can be assured they are supported by qualified staff at all times. Two members of the catering/domestic team have also achieved the award. The home was awarded the ‘Investors In People’ award for the second time in 2007. Ridgegate DS0000013762.V369617.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38 People that use the service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from a home that is run by a competent experienced and qualified Manager. They are consulted on their views of the service constantly and their opinions are listened to and acted upon. Residents’ financial interests are safeguarded by the home. Staff are appropriately supervised and supported in their roles to ensure they provide the best care to residents. The health and welfare of residents and staff are promoted and protected in the home. EVIDENCE: Ridgegate DS0000013762.V369617.R01.S.doc Version 5.2 Page 22 The Manager has completed the NVQ level 4 in care and the Registered Manager Award (RMA). The Manager also completed the NVQ level 5 in management in March 2008. The Manager has many years experience of working with older people and people with disabilities. There have been no changes to the management of the home since the last key inspection. Residents meetings are held every 8 weeks as an opportunity for the people in the home to have a say about how the service is run. The meetings cover activities, meals, environment and any concerns or complaints. Minutes are produced in large print and sent to all residents. People that come to look around the home are asked for feedback. Residents, relatives and other visitors complete surveys annually and the information is collated into a report with an action plan. Examples were seen of the improvement plans that had been completed and the actions that had been ticked off as achieved. Where changes are made as a result of the residents meetings or annual surveys the Manager said that feedback is given to the people in the home. Comments from residents included; ‘Nothing needs improving.’ ‘I can’t see anyway things could be improved’ A monthly quality audit is carried out by a member of the Governors board. The Manager also completes monthly infection control, health and safety and medication audits. There is an audit of the care plans every six months. The audit reports go to the Governors meetings. The home holds money on behalf of some residents. It is stored securely and receipts and a balance sheet are kept. The balance was checked for one person and was correct. All staff have a supervision session every two months and evidence of this was seen on the four staff files inspected. Each staff member also has an annual appraisal of their performance. The Manager makes informal observations of staff practice at regular intervals. Every 2 –3 months there is a staff meeting. The ‘expert by experience’ commented following the inspection that they felt this is a ‘very well run home with a pleasant atmosphere’. Ridgegate DS0000013762.V369617.R01.S.doc Version 5.2 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 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 4 4 3 3 3 X X 4 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 3 X 3 Ridgegate DS0000013762.V369617.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 OP7 OP21 Good Practice Recommendations It is recommended that the provider consider changing the plastic toilet door to provide more privacy for residents. It is recommended that the provider consider ways of recording and monitoring, as part of the care plan records, whether people’s social needs are being met. 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