Inspection on 21/08/06 for Ridgegate

This inspection was carried out on 21st August 2006.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ridgegate 13/08/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Ridgegate Ridgegate 88 Doods Road Reigate Surrey RH2 0NR Lead Inspector Helen Dickens Key Unannounced Inspection 21st August 2006 09:45 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.V308856.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.V308856.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 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) ridgegate@sweethaven.biz Governors of Ridgegate Home Mrs Rosemarie Bowering Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Ridgegate DS0000013762.V308856.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th January 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 some 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. A new lift is currently being installed to allow better access to all areas of the home, including the garden. There is car parking to the front of the property and Ridgegate owns its own minibus. Ridgegate DS0000013762.V308856.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 6.75 hours and was the first key inspection to be undertaken in the Commission for Social Care Inspection year April 2006 to June 2007. The inspection was carried out by Mrs. Helen Dickens, Lead Inspector for the service. Mrs. Rosemarie Bowering, the Registered Manager, represented the establishment. The Vice Chair of the Governors of Ridgegate Home, Mrs. Margaret Benson, joined the inspection for part of the morning. A tour of the premises took place which included all the communal areas and several residents bedrooms. The inspector spoke briefly with most residents and interviewed 2 at length. In addition to the manager, two staff were interviewed and a number of documents and files were also examined as part of the inspection process. A pre-inspection questionnaire and 22 returned comment cards from relatives, residents and professionals dealing with the home, were also used in compiling this report. The inspector would like to thank the residents, staff, manager and Vice Chair for their time, assistance and hospitality. What the service does well: What has improved since the last inspection? Ridgegate DS0000013762.V308856.R01.S.doc Version 5.2 Page 6 There are have been a number of improvements since the last inspection, too numerous to mention in detail. All the requirements have been met with the exception of updating recruitment files, which has been partially met. Residents now have a monthly magazine to which they and staff can contribute. The August edition had copies of newspaper cuttings of the cook going to Buckingham Palace with her husband to receive his award for services to the local community. It also covered birthdays, babies born to staff, and anniversaries; achievements of staff on their training courses; and progress with the lift and refurbishment work. There were also puzzles, and a list of the activities for the coming month. The Ridgegate scrap book – a history of the home – has progressed well with input from residents, staff and local people. They are now going to do a feature of all the centenarians who have lived at the home and on the Governors to complete this project. The manager has started monthly inspections of the kitchen and looks for health and safety issues, checks the risk assessments, and the dating of food etc in the fridges. Food diaries are now being kept by care staff for those residents who have particular nutritional needs, such as a poor appetite. The home now has their own vegetable garden run by the cook and assistant cook – they are currently growing leeks, tomatoes, cucumbers, parsley and other herbs; they now also grow their own flowers. Residents helped with potting up and continue to help with watering. Some new furniture and carpets, and a new dishwasher have been purchased; the staff toilet and residents hairdressing salon have also been redecorated. There is now a first aid station on each floor within the home to make access easier if there is an emergency. What they could do better: Progress has been made on the major refurbishment of the lift area but other areas of the home now look worn and in need of repair/redecoration; this has to wait for the lift project to be completed. There were some mixed views from residents on their comment cards regarding food and activities; this was discussed with the manager and she was asked to keep these matters under review. Some comment cards from relatives highlighted that they thought the home was sometimes short of staff; the manager was asked to use the Residential Forum matrix to calculate staff to resident ratios. Ridgegate DS0000013762.V308856.R01.S.doc Version 5.2 Page 7 Stair carpets are becoming worn in places, and the manager must keep these under review to ensure the safety of residents. Some hallways need redecorating and the carpet squares in the basement need to be risk assessed and any remedial action taken to prevent them causing a trip hazard to residents. A toilet roll holder needed repairing. One resident could not reach her bell whilst seated in her bedroom and this was discussed with the manager. 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. Ridgegate DS0000013762.V308856.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ridgegate DS0000013762.V308856.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 No resident moves into this home without having his/her needs assessed and been assured that these will be met. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three resident’s files were examined and there was a good record of assessments prior to admission. The home does their own initial assessment, which is carried out when they visit the prospective resident prior to moving into Ridgegate. Other assessments from social services, the hospital and other professionals were on file. Assessments clearly set out resident’s health and social care needs, as well as a personal profile including a resident’s background, family connections, and social interests. New residents can come for the day or part of the day for an assessment – and this is offered to all who are not coming as emergency admissions. Ridgegate DS0000013762.V308856.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Resident’s health and social care needs are set out in their care plans and well met at this home. Medication is well organised and the privacy and dignity of residents is respected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three care plans were examined. These had been generated from comprehensive assessments. They covered all aspects of resident’s health and personal care needs and their social interests. Reviews with social services were on file for those residents funded by social services. All care plans are reviewed twice yearly with the resident and their family, and on a monthly basis with the resident and their key worker. The personal profile for each resident contains information they have given about their origins, family links, activities, and favourite foods etc. They operate a key worker system at this home, which ensures one to one support from the same member of staff on a regular basis. Resident’s are assisted to access local healthcare services and professional advice is sought when necessary. Of those resident’s files examined one had Ridgegate DS0000013762.V308856.R01.S.doc Version 5.2 Page 11 regular input from the district nurse and the resident was spoken to and was pleased with the support offered. Residents are registered with local GPs of their choice and there are records of appointments and treatments on file. The home organises weekly exercise to music to promote healthy physical activity; those residents spoken to comment very positively on these sessions. Medication is well organised at this home – two staff take responsibility for ordering, receiving and monitoring the arrangements for the administration of medication. Of those medication administration records (MARs) examined, there were no unexplained gaps. Two senior care workers monitor MARs for, among other things, any gaps in recording. The storage area was clean and tidy and securely kept. A new room has been fitted out and a trolley is to be purchased for the storage of medication, and advice on this has been sought from the community pharmacist. The last community pharmacist’s report did not highlight any concerns and noted that advice from the previous inspection had been acted upon. Residents were observed to be treated with dignity and respect by staff; staff were seen to knock on doors before entering residents rooms and bathrooms. There are no shared bedrooms at this home. Ridgegate DS0000013762.V308856.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 at least once during a 12-month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Staff work hard to ensure that residents experiences in this home match their expectations and preferences. Family and community contacts are encouraged and residents are helped to exercise choice and control over their lives. Meals are balanced and served in pleasant surroundings. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents at this home are given the opportunity to exercise choice in relation to daily routines such as social activities and mealtimes. The resident’s monthly magazine gives a list of the activities for the coming month and regular weekly features are the music to movement sessions, a church service, video and choc-ices in the lounge on Fridays, the home’s ‘shop’, and the hairdresser. Other activities such as ‘crossword time’, beauty sessions, piano playing and a mini-bus outing also featured on the August activity plan. On the day of the inspection there was a reminiscence session in the afternoon. Bingo is also popular. The Manager arranges the monthly activities plan based on what residents have said on this subject at resident’s meetings. Several comments were made by residents on the pre-inspection comment cards suggesting they only liked the activities ‘sometimes’, and this was highlighted to the manager. Ridgegate DS0000013762.V308856.R01.S.doc Version 5.2 Page 13 Community links are encouraged and residents are registered with local health services, participate in local faith groups, and use local facilities. Relatives are encouraged to visit the home, and the recent anniversary celebrations generated a number of letters of congratulations and positive comments from resident’s friends and relatives. One resident spoken to was particularly pleased with the way the home treated his visitors and he said the staff always brought them a tray of tea and cakes when they arrived. One relative wrote ‘We are always well looked after whenever we visit – such a friendly environment.’ Ridgegate ensures that residents have opportunities to exercise personal autonomy, with support as necessary. Resident’s who need assistance with their finances can deposit small amounts of money with the home and this is then used for personal items such as the hairdresser. All rooms viewed showed evidence of residents bringing their personal possessions with them and some had their own furniture. Residents are offered a varied diet and likes and dislikes are taken into account when menu planning. Residents have the opportunity to have some input into the menus at the resident’s meetings and in addition, the cook has a list of people’s dislikes, e.g. liver and carrots. There is an alternative for residents who do not like the main meal of the day though one resident appeared not to have had all their ‘dislikes’ added to the list and this was discussed with the manager. This resident told the inspector they were ‘finicky’ about their food and generally the cook had managed to accommodate their preferences. Those residents spoken to enjoyed their food at Ridgegate. The dining room is bright and cheerful though the refurbishment work in the home has meant that one wall is boarded up; staff have covered this with a wall hanging depicting palm trees and sunshine as a way to brighten the wall until the refurbishment work is finished. A number of returned comment cards from residents showed that there were some mixed feelings about the food with two saying they liked the food only ‘sometimes’ and one replying they didn’t like the food. This was highlighted to the manager who said she would continue to work with residents on their food choices. Ridgegate DS0000013762.V308856.R01.S.doc Version 5.2 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Complaints are taken seriously at this home and residents protected from abuse. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints log was examined and one complaint had been received and satisfactorily resolved since the last inspection. Residents could raise issues using the complaints box in the hall, using the complaints procedure, speaking with their key worker, or speaking with one of the senior staff or Governors. Comments from residents on the comment cards sent to CSCI were candid and the overall impression was that residents had been empowered to speak up for themselves. The home had also received a number of letters of commendation since the last inspection, particularly about the anniversary celebrations earlier in the year. No protection of vulnerable adult issues had been raised since the last inspection and the home’s in-house policy had now been up-dated as requested at the last inspection. The manager has recently used some ‘Action on Elder Abuse’ publicity material to highlight to residents (at their meeting), that poor treatment of older people is unacceptable and if they have any concerns, they should bring this to the attention of the manager or the Governors of Ridgegate Home. One of these posters has been left on display on the library area notice board downstairs. Ridgegate DS0000013762.V308856.R01.S.doc Version 5.2 Page 15 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 at least once during a 12-month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The home offers a safe environment though the overall look and comfort will be greatly enhanced when the major refurbishment work is complete. The home is clean, pleasant and hygienic. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Maintenance work is ongoing at this home though currently the main focus is on refurbishment in relation to the new lift and the partitioning associated with it. Staff are trying hard to minimise disruption to residents and paying attention to the health and safety aspects in particular. When the work is complete it will make a major difference to the quality of life of residents with a larger modern lift, which will even take residents down to the garden level of the home. However, until this major work is complete, other minor refurbishments cannot go ahead and therefore the comfort of residents and the overall look of the interior of the home continue to be compromised. The manager was asked to keep under review certain areas which show wear and tear or may be hazardous such as some of the stair carpets, and the carpet Ridgegate DS0000013762.V308856.R01.S.doc Version 5.2 Page 16 squares in the basement where residents sit and wait to go up in the old lift. The corridor downstairs needs redecorating but again this will be completed when the lift work is completed. A toilet roll holder was hanging off in one of the bathrooms. The laundry room was clean and tidy; liquid dispensers were being used for washing liquids and there were no other liquids or hazardous substances in the room. The home has a dedicated worker for 19 hours per week for the laundry. There are infection control policies in place including an HIV policy. In addition to their general policy on infection control, the manager gave an example of taking specific advice in relation to one issue following the discharge of a resident back to the home from hospital. Their usual precautions include hand washing, using protective clothing, and having particular regard for open wounds. All hand-washing areas were observed to have soap and paper towel dispensers and hand gel. Hand gel is also available in the reception/entrance for the use of visitors to the home. Ridgegate DS0000013762.V308856.R01.S.doc Version 5.2 Page 17 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 at least once during a 12-month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Resident’s needs are being met and staff training exceeds the National Minimum Standards targets. Recruitment at this home has improved considerably but further work needs to be done. Training and induction for staff are well managed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection there were sufficient care staff on duty to meet resident’s needs and discussion with the manager and examination of rotas showed that there are four staff in the mornings when it is busier, and three on duty in the afternoon – this is in addition to the manager, cleaning staff and the administrative staff. However, 4 comment cards returned from relatives showed that they felt there were not always enough staff on duty. This was discussed with the manager who said that the current staff numbers are high compared with the number of residents – down to only 17 residents (the home is registered to take 25) whilst the refurbishment work has been underway. The manager was asked to carry out the Residential Forum matrix as recommended by the Department of Health and set down in Standard 27. This will confirm whether there are currently sufficient staff, and will be relevant when resident numbers are increased again in the future. The home already exceeded the target percentage of having 50 of care staff trained to NVQ2 level or above by December 2005 and there are good records of staff training and development kept at the home. Ridgegate DS0000013762.V308856.R01.S.doc Version 5.2 Page 18 The home has an equal opportunities policy and recruitment arrangements take diversity issues into account. The home already has older and disabled staff, and currently around 10 of their staff are from minority ethnic backgrounds. Recruitment practices have been overhauled since the previous inspection and as a result all new staff had 2 written references, a full employment history and CRB and POVA check. One staff member whose CRB had been applied for was working under supervision in accordance with the Care Homes Regulations 2001 (as amended). However, further work needs to be done to ensure that all staff files contain the information required in the Regulations and the home must continue to up-date these records in a timely fashion. Arrangements for staff training are good and staff have recently up-dated their first aid training. A number are also studying (by distance learning) manual handling, hazardous substances management and health and safety. All staff receive induction training – in recent years staff had a booklet to work through, purchased from a company specialising in care documentation and policies – these booklets have a good record of staff achievements throughout their induction. The manager was asked to get the information on the Common Induction Standards, which will be mandatory for all care staff from September 06. Ridgegate DS0000013762.V308856.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 38 Residents live in a home which is well managed. Quality assurance arrangements are excellent. Resident’s financial interests are safeguarded, and their safety and welfare promoted. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has now finished the Registered Managers Award (RMA). She has had four years senior management experience and is not responsible for any other establishments. The manager has continued to up-date her own training and since arriving at the home, and in addition to the work on her RMA, she has also attended seminars on changes in Care Standards and new fire legislation, and been involved in an in-house training session on protecting vulnerable adults. There are clear lines of accountability within the home and the manager reports to the Governors. Ridgegate DS0000013762.V308856.R01.S.doc Version 5.2 Page 20 There are a number of quality assurance measures in place at this home and the overall systems for quality monitoring are excellent. Care plans are reviewed monthly; the home holds residents meetings 6 times per year; staff and senior care meetings take place regularly, and the Governors hold their own meetings – details of all of these are kept at the home in their quality assurance folder. There are regular audits for example the audit on health and safety of rooms and the kitchen, and care plan audits to ensure they comply with the National Minimum Standards (NMS). The results and recommendations are noted. The manager has also carried out a cost benefit analysis on training expenses to enable them to better plan for training. She asks staff to complete an evaluation form on all the training sessions/courses they attend to monitor the benefits to staff and as part of their Investors in People work. A training and development plan and an annual development plan have been completed. A business development plan has been done for the home and staff views were sought. A self-assessment report on the findings of the above meetings has been done to ensure compliance with NMS. Service users financial interests are safeguarded at this home. Those who do have assistance with their day-to-day expenses (e.g. hairdressing and newspaper payments) have money kept securely in the safe, with a record of any expenditure and receipts. Two were randomly selected and found to be correct. Staff receive regular supervision at this home and records were available to be examined. Care staff have already received 4 or 5 sessions this year and will all have received the recommended 6 sessions by the end of the year. A number of documents relating to health and safety matters were sampled including the monthly fire extinguisher check, a copy of the latest environmental health officer’s report, the legionella safety certificate and a fire safety assessment. The requirement from the previous inspection regarding work recommended by the gas safety inspector has been carried out. Water temperatures at basins accessible to residents are regularly monitored and are within the recommended limits set down in the NMS. The hazardous substances cupboard was securely locked and the domestic staff carried their cleaning materials with them and kept them within sight. There is now a first aid station on every floor. The home also carries out regular health and safety checks in resident’s bedrooms and in the kitchen. The manager was asked to keep under review the stair carpet, which is becoming worn, and the carpet squares in the basement which could be a trip hazard. One resident was not able to reach her bell whilst sitting in her armchair and the manager was asked to review this. A delivery of incontinence pads had been put on an upstairs landing and may have caused a fire hazard; the senior care worker arranged for these to be moved immediately. Ridgegate DS0000013762.V308856.R01.S.doc Version 5.2 Page 21 Ridgegate DS0000013762.V308856.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 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 X X 3 X X 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 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 3 X 2 Ridgegate DS0000013762.V308856.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 OP19 Regulation 23(2)(b) Requirement Timescale for action 21/09/06 2. OP29 19 3. OP38 13(4)(a) (c) The registered person must arrange to rectify/keep under review; • The outstanding decorative work in the downstairs hallway • Replacement/repair of the broken toilet roll holder The home must review its 21/09/06 recruitment records to ensure compliance with Regulation 19 and Schedule 2 (as amended), and Standard 29. (Partially met from 19/01/06) The registered person must, 25/08/06 especially for the duration of the major building work, keep under review areas which show wear and tear or may be hazardous, as discussed on the day of the inspection and outlined in the report and including; • Wear to the stair carpets throughout the home • The potential trip hazard caused by the carpet squares in the basement • The accessibility of the emergency call bell in one resident’s bedroom DS0000013762.V308856.R01.S.doc Version 5.2 Ridgegate Page 24 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 OP12 Good Practice Recommendations The registered person should keep under review the range and type of activities, and the arrangements for meals, as highlighted on some residents comment cards, and as discussed with the manager during the inspection. The registered person should consult the CRB website for details on the recommended arrangements for the storage and destruction of CRB certificates. The registered person should obtain details of the common induction standards, which will be mandatory for all new care staff from September 2006. 2. 3. OP29 OP30 Ridgegate DS0000013762.V308856.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 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 Ridgegate DS0000013762.V308856.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!