Inspection on 12/09/07 for Ridgeway Court

This inspection was carried out on 12th September 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ridgeway Court 21/08/06

Ridgeway Court 23/11/05

Ridgeway Court 13/09/04

Ridgeway Court 12/07/04

Ridgeway Court 18/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Ridgeway Court 2 Dudley Road Sedgley Dudley West Midlands DY3 1SX Lead Inspector Ms Linda Elsaleh Key Unannounced Inspection 09:30 12 13 17 September 2007 th th th 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 Ridgeway Court DS0000024970.V346861.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. Ridgeway Court DS0000024970.V346861.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ridgeway Court Address 2 Dudley Road Sedgley Dudley West Midlands DY3 1SX 01902 883130 01902 665680 home@hbhchwm.eclipse.co.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) Midland Property Investment Fund Ltd Iris Worrell Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places Ridgeway Court DS0000024970.V346861.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th March 2007 Brief Description of the Service: Ridgeway (formerly known as The Hollies & Bloomfield) is a Care Home in two adapted properties, which have been linked via a connecting extension. A passenger lift provides access to the first floor. The home is situated on a busy road close to local amenities and Sedgley town. It is on a main bus route and there is plenty of off-road parking at the rear of the building. The home provides 24-hour personal care for up to 39 older people, with general frailty (over the age of 65 years not falling into any other category). Thirty-six of the beds are provided within the two main buildings with a further three beds located in a flat accessed through a separate ramped entrance at the rear of the building. The flat is a semi-independent unit, with any residents accommodated accessing the home in the daytime and having access to staff at night via a call system. The home’s Statement of Purpose includes details of the registered provider, registered manager and staff team. The fee for this service is not included. For further details about current fee levels contact should be made with the home. Ridgeway Court DS0000024970.V346861.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 12th 13th & 17th September 2007. The purpose was to assess the home’s performance against the key standards in the National Minimum Standards for Care Homes for Adults and report on the progress made to address requirements made at the previous inspection. The inspector’s findings are based on the information received by the Commission for Social Care Inspection (CSCI) and examination of relevant records and documents kept at the home. The files of four service users and four staff were examined in detail. The manager was not present during this inspection. Discussions were held with the person in charge, staff and service users and comments about the service were received from six relatives. The manager has been in post since January 2007 and has made progress in addressing the requirements and recommendations made at the previous inspection. An ‘open day’ was held in September to publicise the re-naming of the home. Comments from service users and relatives were generally positive about the service. One relative said, “My relative feels comfortable here. Anything s/he asks for is general done”. What the service does well: The home provides information about the service to prospective service users. Assessments continue to be undertaken to identify their needs and care plans and risk assessments are produced. Regular reviews take place with service users, their relatives and other relevant professionals. Flexible visiting arrangements enables service users to maintain contact with family and friends. Suitable policies and procedures are in place to ensure the health; safety and well-being of service users are protected. Appliances and equipment are regularly serviced. Health care needs are met and arrangements are in place to enable service users to consult with relevant healthcare professionals. The manager is committed to staff training and regularly reviews staffing levels to ensure sufficient numbers of suitably experienced staff are on duty each shift. There are good systems to support service users to express their views about the service. Ridgeway Court DS0000024970.V346861.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Whilst the home is making progress with redecoration and refurbishment, attention needs to be given to addressing the issues identified during this visit and the outstanding environmental issues in a timelier manner. The policy for the Management of Service Users Money and Financial Affairs should include suitable staff guidance for managing personal allowances on behalf of service users. Service users activity records should include how they will be supported to pursue individual interests. A varied four-week menu is provided by the home, however arrangements should be made to provide more fresh meat and vegetables during the week. Risk assessments for staff that commence work prior to full completion of the home’s recruitment process must be available on the employee’s file. Staff should receive regular individual supervision to discuss their performance and training needs. Arrangements should be made for training identified in this report to be provided and training records for staff should be kept up to date. Ridgeway Court DS0000024970.V346861.R01.S.doc Version 5.2 Page 7 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. Ridgeway Court DS0000024970.V346861.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 Ridgeway Court DS0000024970.V346861.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 4 Quality in this outcome area is good. Prospective service users are provided with sufficient information about the home to enable them to make an informed choice about where to live. The home involves prospective service users in the assessment process, identifying how their needs will be met and are provided with written confirmation that the home is able to meet these. A contract/statement of terms and conditions is provided to each service user and is signed by themselves and/or their representatives. This judgement has been made using available evidence including a visit to this service. Ridgeway Court DS0000024970.V346861.R01.S.doc Version 5.2 Page 10 EVIDENCE: The home has recently reviewed its Statement of Purpose and Service User Guide. Seven of the ten people who responded to the CSCI survey stated they had received sufficient information to make an informed choice about where to live. Information is also provided about service users right to access records kept about them by the home. The files examined confirm detailed assessments of prospective service users needs are carried out. The assessments include a personal profile and individual preferences, which are generally well completed. The assessment process includes the involvement of relatives and/or service users representatives, where applicable. Prospective service users are provided with a letter from the home confirming it is able to meet her/his needs. A signed and dated copy of the contract between the home and service user is also available on their files. Ridgeway Court DS0000024970.V346861.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. Service users benefit from having an individual plan of care that identifies their needs and how these will be met. However, training provided for staff responsible for carrying out specific health care monitoring practices should be recorded on their files to demonstrate service users health and well-being is fully protected. The home has satisfactory policies, procedures and practices for dealing with prescribed medication to ensure service users health and wellbeing is protected. The introduction of a homely remedy policy will further protect service users. Service users are treated with respect by the staff and their right to privacy is upheld. This judgement has been made using available evidence including a visit to this service. Ridgeway Court DS0000024970.V346861.R01.S.doc Version 5.2 Page 12 EVIDENCE: The home produces detailed care plans based on the individual’s needs assessment. The plan includes personal, health and social needs and individual preferences. Where applicable, risk assessments are carried out to support service users to live as independent lives as possible in a safe environment. Risk assessments examined include the use of wheelchairs, hoist and bedrails for the less mobile. Daily records are kept of the care provided to each service user. These are monitored in conjunction with the care plan and risk assessments to ensure her/his needs continue to be appropriately met. The plans are amended where applicable. Information is sought from service users and recorded to enable their final wishes to be respected. Throughout this visit the inspector observed staff responding to service users needs in accordance with their care plan and individual wishes. Regular recordings are made of service users blood pressure, pulse and temperature. The senior member of staff on duty stated suitable training had been provided to staff responsible for monitoring these. Staff files do not include reference to the individual’s training and monitoring of their competence in this area. A record is kept of all health care appointments and regular consultations take place with health care specialists. Consultations are carried out in the privacy of the service users own rooms. The home manages medication on behalf of the majority of service users. There are suitable procedures in place for the safe handling of medication that includes ordering; storage; administering and the return of unused prescribed medication to the pharmacist. The names of staff who are responsible for medication is kept at the front of the medication folders, with a sample signature and initial for ease of identification. Since the last report the home has taken action to ensure sufficient numbers of staff trained to administer medication are available during the night time hours. Up to date details of medication prescribed to service users are held in their individual files and in the medication folder. Allergies and medical conditions are clearly stated. Photographs of service users are available on their files and on their medication administration record sheets to assist with identification. Examination of a selection of service users monthly medication administration record sheets found these to be appropriately completed. However, clearer recordings need to be made of medication prescribed or discontinued during the month in order to assist the monitoring and auditing process. The home has suitable systems in place for monitoring and recording the health and wellbeing of service users who manage their own medication. Ridgeway Court DS0000024970.V346861.R01.S.doc Version 5.2 Page 13 At present the home does not provide service users with over the counter medication. However, it is in the process of consulting with GPs and developing a homely remedies policy and procedure for use in the future. Care plans are formerly reviewed on a regular basis and the records show service users, relatives/representatives and relevant professionals are involved in this process. Comments were received from service users, prior to this visit, about inadequate staffing levels. Examination of the staffing rotas demonstrated the home has responded to these comments by increasing staffing levels during the morning. Ridgeway Court DS0000024970.V346861.R01.S.doc Version 5.2 Page 14 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): 12, 13, 14 & 15 Quality in this outcome area is adequate. The home provides a varied programme of group activities. However, service users would benefit from support to pursue individual interests. Service users are encouraged to maintain contact with family and friends through the home’s open visiting policy, the welcome provided to visitors and, where applicable, relatives involvement in the care planning process. Staff respect service users right to make their own choices and are encourages them to express their views. Meals are provided in pleasing surroundings. However, the home needs to review its catering arrangements to ensure meals are provided that meet service users preferences. This judgement has been made using available evidence including a visit to this service. Ridgeway Court DS0000024970.V346861.R01.S.doc Version 5.2 Page 15 EVIDENCE: There is a designated activity co-ordinator who is responsible for the home’s activity programme. The programme includes regular bingo sessions, film shows and movement to music sessions. The activities folder shows the home is pro-active in identifying new activities and hiring professional entertainers. Service users spoke enthusiastically about the recent ‘open day’ arranged by the home. This included a steel band, celebrity guest and organist. Records are kept of service users participation in activities and these are used to revise the programme, where necessary, to ensure activities meet the changing interests of the group. As previously stated part of the assessment process includes identifying service users personal interests. The Statement of Purpose states the home “will include appropriate activities for those people who would prefer not to participate in groups”. The inspector was informed discussions between service users and their key workers includes encouraging service users to identify activities/hobbies they are interested in and to identify how service users can be best supported to pursue these. However, there is little evidence to show this takes place. Two service users confirmed they are, on occasions, assisted to pursue individual interests. A request made by a service user at her/his review for support to visit the local village and shops was agreed. However, this has not been recorded on their individual activity programme. There was no evidence to show the home has made arrangements to meet the service user’s request. Some service users prefer to observe rather than participate in activities or spend time in their bedrooms. The majority of bedrooms have personal items belonging to service users and small pieces of furniture they brought with them. The home keeps an inventory of the personal possessions of individuals. Examination of inventories for a selection of service users found hearing aids for two service users had been omitted. This is an outstanding requirement from previous inspections and was brought to the attention of the senior member of staff on duty. The home operates an open visiting policy to enable service users to receive visitors at the time they choose throughout the day. The files examined have a format for recording contact between service users and their relatives and friends. This is not being completed. However, the Visitors Book and other information, such as daily recordings, reviews and discussions held with service users confirm relatives are regular visitors to the home. Relatives stated staff made them welcome and felt they were kept appropriately informed about their relative’s care needs. Ridgeway Court DS0000024970.V346861.R01.S.doc Version 5.2 Page 16 Care plans contain information about service users dietary needs and preferences. Service users are offered a choice of meals from a wellpresented menu. Drinks and snacks are provided regularly throughout the day and, at the service user’s request. A record is kept of meals taken by individuals. Health care professionals are consulted about any dietary concerns. The inspector joined service users for their midday meal. The atmosphere in the dining room was friendly, tables appropriately laid and staff were attentive to the needs of individuals. Some service users chose to take their midday meal in their bedrooms. The menu provided an option of beef casserole or fish and a choice of dessert. The fish was served with parsley sauce and both meals were accompanied by mash potatoes and mixed vegetables. Unfortunately the vegetables were watery and overcooked. Comments were received from service users about the meals. The majority were positive about the varied menu, but stated they would prefer more fresh vegetables. The following comments were made by service users “meals were well presented, but are let down by the quality of the ingredients used”, “I would enjoy the meals more if fresh vegetables were provided instead of frozen” and “I would like more homemade meals”. The catering staff confirmed the majority of vegetables and meat are purchased frozen. This was raised with the senior on duty. The minutes of service users meetings shows food is an item that is regularly discussed. The home is being pro-active in addressing some of the issues. Arrangements have been made for catering staff to attend a healthy eating programme and all staff hold a Basic Food Hygiene certificate. The inspector observed fresh fruit being served peeled and sliced. Staff reported this has encouraged service users to eat more fruit. The kitchen appeared clean and orderly. Suitable records are kept of food, refrigerator and freezer temperatures. Cleaning schedules are in place and all equipment was reported to be in working order. Ridgeway Court DS0000024970.V346861.R01.S.doc Version 5.2 Page 17 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): 16 & 18 Quality in this outcome area is good. Service users and their relatives and friends are familiar with the home’s complaints procedure and confident their concerns will be listened to and acted on by the home. The home has suitable procedures and provides training for staff to ensure service users are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information provided by the manager states the home has not received any complaints during the last twelve months. The Commission for Social Care Inspection (CSCI) has not received any complaints about this service. Details of the home’s complaints procedure is included in the Statement of Purpose and Service User Guide. A comments book is available in the hall for use by service users and visitors. Seven out of ten people surveyed stated they were familiar with the home’s complaints procedure. Regular meetings are held for service users to enable them express their views about the service. The home needs to ensure action taken to address any issues raised are recorded and reported back to service users. Ridgeway Court DS0000024970.V346861.R01.S.doc Version 5.2 Page 18 Since the last inspection the home reports no adult protection concerns have been identified and none have been reported to the Commission for Social Care Inspection (CSCI). Staff have received training in abuse awareness and have signed the home’s and local authority’s Safeguarding Vulnerable Adults policy to indicate they have read and understood the contents. Training for staff in non-physical interventions and restraint remains an outstanding requirement. The home currently manages the personal allowance on behalf of 13 service users and keeps appropriate records of all transactions. Ridgeway Court DS0000024970.V346861.R01.S.doc Version 5.2 Page 19 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): 19, 21, 24 & 26 Quality in this outcome area is adequate. The home is working to provide service users with a well-maintained and safe environment in which to live. Service users are benefiting from the redecoration and refurbishment being carried out in the home. However, bathing facilities need to be reviewed to ensure the needs and preferences of service users are being fully met. Service users live in a clean and hygienic environment and are protected by good infection control procedures and practices. This judgement has been made using available evidence including a visit to this service. Ridgeway Court DS0000024970.V346861.R01.S.doc Version 5.2 Page 20 EVIDENCE: Ridgeway is two-storey property with off-road parking to the rear of the building. Service users bedrooms are situated on both floors and a passenger lift provides access to the first floor. The communal rooms are located on the ground floor and consist of two lounges, two dining rooms, a quiet room and an activity area. Other facilities include a kitchen and laundry room. A service user stated, “the home has just been decorated and cleaners come in every day”. A tour of the premises found the building to be clean and tidy. The home is making progress with its internal re-decoration and refurbishment of communal rooms and bedrooms. Bedrooms viewed by the inspector were clean and tidy with service users personal possessions on display. One service user stated s/he had not been provided with a key to her/his bedroom door. A copy of information on service users files about facilities provided by the home does not include details for the provision of keys to her/his bedroom door and lockable facility. This was brought to the attention of the senior member of staff on duty. She stated a key would be provided to the service user and the provision of keys would be added to the information about the home’s facilities. The minutes of service users meetings include comments about bedrooms being “too hot”. The home needs to make arrangements to regularly monitor temperatures and ensure these are suitably maintained for the comfort of service users. The inspector observed carpets being steam cleaned in some bedrooms as part of the home’s practice for managing malodour. Bathing and toilet facilities are available on both floors. The toilets and bathrooms situated on the ground floor are fitted with aids and adaptations such as grab rails and bath chairs. Minutes of service users meetings show they have raised issues about the bathing facilities. Discussions held with service users and staff confirmed toilet and bathing facilities on the first floor require attention. Comments from service users included “I have to use the bathing facilities on the ground floor” and “I would like to be able to shower more often”. A bathroom on the first floor has been designated a storeroom and not accessible to service users. Another, although well equipped with a bath chair, walk-in shower, toilet and wash hand basins, is used by the visiting hairdresser and stand free hairdryers and chairs are stored here restricting access. The defective lighting and noise from the extractor fan has still to be addressed. The home needs to ensure bathrooms are available for use by service users. Suitable aids should be fitted in the first floor toilet used by service users. Ridgeway Court DS0000024970.V346861.R01.S.doc Version 5.2 Page 21 Regular monitoring takes place of the home’s infection control practices and training is provided for staff. Written procedures are available in the laundry together with health and safety information, risk assessments and task worksheets. Some remedial work still needs to be carried out in this area. The grounds have a variety of trees and plants. The home has plans for work to be carried out on the garden, perimeter rails and porch. There is a small patio area for service users to sit in fine weather. Some paving stones have become dislodged and need to be re-laid to prevent accidents. Ridgeway Court DS0000024970.V346861.R01.S.doc Version 5.2 Page 22 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): 27, 28, 29 & 30 Quality in this outcome area is good. The staff team is sufficient in numbers and have a good skill mix to meet service users needs. Suitable training is provided to staff to ensure service users are cared for in a safe and appropriate manner. The home has recruitment policy and procedures to protect the welfare of service users. Senior staff should have access to all relevant information about newly appointed workers to ensure service users welfare and best interests are fully protected at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users needs are met by sufficient numbers of staff. The staffing structure consists of a manager, senior care officers and care assistants. The home also employs an activity co-ordinator, ancillary staff and an administrator. Ridgeway Court DS0000024970.V346861.R01.S.doc Version 5.2 Page 23 Examination of the care staff rotas shows a recent increase in the number of staff on duty during the mornings. This was in response to a review of staffing levels carried out by the manager to ensure the changing needs of the service users were being fully met. The selection of staff records examined show training has been provided in Health & Safety, Fire Safety, Basic Food Hygiene, Infection Control, Manual Handling and First Aid. The home has policies and procedures for the recruitment and retention of staff. Three of the four files examined contained application forms, health declarations references and relevant safety checks demonstrating that satisfactory recruitment processes have been completed prior to applicants commencing duty. The fourth file contained all the relevant information including a satisfactory POVA (Protection of Vulnerable Adults) First check. However, a response to the request made for a CRB (Criminal Record Bureau) check had not been received at the time the employee commenced duty. The previous inspection report identified the need for the risk assessment carried out in such instances should be available on the employee’s file. The inspector was informed a risk assessment had been carried out, however a copy was not available on this file. As previously stated staff have attended training courses relating to health & safety issues. Equality and diversity training is being arranged. The manager is introducing new induction and foundation training programmes for staff that meets the Skills for Care specifications. Information provided by the home shows 61 of the care staff team holds the Level 2 National Vocational Qualification (NVQ) or above and 11 are working towards obtaining an NVQ qualification. Ridgeway Court DS0000024970.V346861.R01.S.doc Version 5.2 Page 24 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): 31, 33, 35, 36 & 38 Quality in this outcome area is good. Service users live in a home that is run by an experienced and suitably qualified manager. There are good systems in place for monitoring the service to ensure the home is run in the best interests of service users. The health, safety and welfare of service users are promoted and protected by the home’s policies, procedures and practices. This judgement has been made using available evidence including a visit to this service. Ridgeway Court DS0000024970.V346861.R01.S.doc Version 5.2 Page 25 EVIDENCE: The current manager was appointed by the home on 2nd January 2007. Ms Worrell has been a registered manager at a previous care home for 5 years. She holds the Registered Manager’s Award, Level 4 National Vocational Qualification in Care and other related qualifications. Since taking up her post the manager has made progress in improving the physical environment and developing practice. A representative of the company visits regularly to assess the home’s performance in meeting its Statement of Purpose and aims and objectives. A written report is produced on the findings. Positive comments have been received from service users, staff and visitors about the way the home is managed. Detailed information is available in the home’s quality assurance folder demonstrating regular monitoring of the service is taking place. This includes environmental audits, recording processes and staff practices. The views of service users and other stakeholders are also sought. The quality assurance process needs to be developed further to include a system for reporting back findings and publishing the home’s plans for the future development of the service. As previously stated the home manages the personal allowance for some service users. The records kept for three service users were examined and found to be satisfactory. Suitable arrangements are in place to ensure monies and valuables placed with the home for safekeeping are securely stored. The policy for the Management of Service Users Money and Financial Affairs has recently been reviewed. However, it does not contain sufficient guidance for personal allowances managed by the home on behalf of service users. The staff team meet on a regular basis to discuss practice issues and records are kept of these meetings. However, the files examined show arrangements need to be made to ensure regular individual supervision is held with each member of staff to discuss their performance and training needs. Training in safe working practices is provided to staff. Fire safety checks and drills are held regularly. There are good infection control procedures and the relevant agencies are informed of any event that affects the well being of service users. However, staff must be mindful of ensuring storage cupboards are kept locked. The door to the bathroom used as a store cupboard was seen left ajar. The senior member of staff on duty stated she would remind staff of the importance of keeping the door locked. Examination of the records kept by the home show regular checks and services are carried out on appliances and equipment. During this visit general maintenance was observed being carried out on wheelchairs. Ridgeway Court DS0000024970.V346861.R01.S.doc Version 5.2 Page 26 Service users who were spoken to said staff always make sure footplates are in the correct position. Ridgeway Court DS0000024970.V346861.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 3 Ridgeway Court DS0000024970.V346861.R01.S.doc Version 5.2 Page 28 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 Requirement The uneven paving slabs on the patio must be made safe to prevent accidents The defective light and extractor fan in a first floor bathroom must be rectified. (Previous timescale for action, 01/05/06, not met) Suitable aids to support service users should be fitted in the first floor toilet A copy of the risk assessment for employees commencing duties on a POVA First check must be made available. (Previous timescale for action, 01/04/07, not met) Timescale for action 31/01/08 2. OP21 23 31/01/08 3. OP21 23 31/01/08 4. OP29 19 31/01/08 Ridgeway Court DS0000024970.V346861.R01.S.doc Version 5.2 Page 29 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 OP7 Good Practice Recommendations The records of staff responsible for monitoring service users blood pressure, pulse and temperature should include details of the training and assessment of their competence to demonstrate service users health is fully safeguarded. Arrangements should be made to support service users to pursue their individual interests. Items such as hearing aids should be included on service users individual inventory of their possessions. Meals should include more fresh meat and vegetables as request by service users. The home’s response to issues raised by service users should be recorded and reported back to them. Awareness/training for non-physical intervention/restraint should be provided to staff from an accredited trainer. Bathing facilities should be made kept accessible for use by service users and arrangements made to meet their bathing preferences. The defective double glazed window in the shared bedroom and on the landing should be addressed. Service users should be offered the key to their bedroom to support them to maintain their independence and protect their right to privacy. The temperature in bedrooms should be regularly monitored to ensure the service users comfort. The laundry walls and floor should have an easy to clean surface and the sink re-coated or replaced. A copy of qualifications, public insurance liability and safety checks should be available for inspection on the hairdresser and chiropodist’s file. A system for reporting back to service users and stakeholders the home’s findings on its performance should be implemented. DS0000024970.V346861.R01.S.doc Version 5.2 Page 30 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. OP12 OP14 OP15 OP16 OP18 OP21 OP24 OP24 OP25 OP26 OP29 OP33 Ridgeway Court 14. 15. OP35 OP36 The home’s plans for the development of the service should be published and made available to all interested parties. Suitable written guidance for personal allowances managed by the home on behalf of service users should be available to staff. Each member of staff should receive planned supervision on a regular basis to discuss their performance and training needs. Ridgeway Court DS0000024970.V346861.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Halesowen Local Office West Point Mucklow Trading Estate Mucklow Hill Halesowen B62 8DA 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 Ridgeway Court DS0000024970.V346861.R01.S.doc Version 5.2 Page 32 - 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. 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