Inspection on 14/09/05 for Ridgeway House

This inspection was carried out on 14th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 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

Ridgeway House 01/04/08

Ridgeway House 02/04/07

Ridgeway House 10/04/06

Ridgeway House 24/05/05

Ridgeway House 18/01/05

Ridgeway House 17/05/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Ridgeway House 2-6 The Avenue Lincoln Lincs LN1 1PB Lead Inspector Mr Doug Tunmore Unannounced Inspection 14th September 2005 10:00 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 House DS0000002548.V249783.R01.S.doc Version 5.0 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 House DS0000002548.V249783.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ridgeway House Address 2-6 The Avenue Lincoln Lincs LN1 1PB 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) 01522 530552 Guardian Care Homes (UK) Limited Mrs D Dunn Care Home 32 Category(ies) of Dementia - over 65 years of age (32), Old age, registration, with number not falling within any other category (32) of places Ridgeway House DS0000002548.V249783.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th May 2005 Brief Description of the Service: Ridgeway House is a care home situated close to the centre of Lincoln and is within easy reach of local facilities, including shops and a post office. It is a converted building with a single storey extension on the ground floor, providing care and accommodation for thirty five people. The home has a refurbishment programme which complies with The Commission For Social Care Inspections standards. The registration is for a care home, providing care for older and for some who have Dementia. The homes statement of purpose states that when people work hard throughout their lives and have committed to helping others, we think they deserve extra cherishing. The home is owned by Guardian Care Homes (UK) Limited and managed by Mrs D. Dunn. Ridgeway House DS0000002548.V249783.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 9.20 am. The main method of inspection used was called case tracking, which involved selecting one resident and tracking the care she receives through the checking of her records, discussion with her, the care staff and observations of care practice. A tour of the home took place with all bedrooms seen apart from those in which residents were resting. What the service does well: What has improved since the last inspection? What they could do better: There are a number of staff vacancies, which have resulted in a number of shifts not being adequately covered by care staff. The home is also without a full time cook with other workers covering this post. Accidents to residents are not recorded as per the homes policies and procedures. The décor of the home needs attention with essential repairs to windows and one bathroom needing to be undertaken. One resident’s shower and a bathroom should not be used Ridgeway House DS0000002548.V249783.R01.S.doc Version 5.0 Page 6 as storage space. A number of bedrooms were found to have strong unpleasant odours. The heating in a number of rooms was on during a bright sunny day making the rooms very hot and uncomfortable. Residents personal wheelchairs are used by any resident a method must be found to identify residents wheelchairs without creating an intuitional practice of written named labels in sight of everybody. The home must check all rooms to ensure appropriate bedding is available and that toothbrushes are fit for their purpose. An immediate requirement was made relating to the home not carrying out Criminal Record Bureau checks on two members of staff before appointing. 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. Ridgeway House DS0000002548.V249783.R01.S.doc Version 5.0 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 Ridgeway House DS0000002548.V249783.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Residents are only admitted after a full care needs assessment has been carried out. EVIDENCE: Files seen showed that one resident who was being case tracked had been written to confirming that the home could meet her needs. The letter informed the prospective resident who her key worker would be and the number of her room. Two care workers spoken to knew about the care needs of residents and were aware of the homes pre-admission assessment procedures. Ridgeway House DS0000002548.V249783.R01.S.doc Version 5.0 Page 9 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): 8,10 Accidents are not recorded appropriately as per the homes policies and practice. Staff have not received appropriate training relating to maintaining the privacy and dignity of residents. EVIDENCE: Daily entries had been made in care plans by care staff, which identified the care given. However, accidents occurring to two individual residents have been recorded differently, with one accident recoded appropriately in the homes accident book, file and body map. The second accident had not recorded a cut to a resident’s head in the homes accident book or on the body map; a record had been made in the residents care plan. One of the two staff seen did not have any knowledge of the homes personal care policy. This policy was seen and found to have only been signed by four members of staff. This policy sets out the guidance for ensuring that a resident’s privacy and dignity are maintained when personal care is being undertaken. One resident said that ‘she (member of staff) baths me, I feel comfortable when I’m bathed and I have one bath a day’. Ridgeway House DS0000002548.V249783.R01.S.doc Version 5.0 Page 10 One District Nurse contacted stated that ‘since the last inspection this home has gone downhill’. Poor communication is still an issue ‘with plans of care not addressed by care staff’. Ridgeway House DS0000002548.V249783.R01.S.doc Version 5.0 Page 11 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): 15 The home offers a set menu, which is chosen by residents and accommodates individual preferences. EVIDENCE: The inspector sampled the choice of meals on offer and found that the dishes prepared were hot and very tasty. A resident commented that ‘all the meals her are good’. Menus were inspected and found to offer choices for all mealtimes. The homes new admission assessment, undertaken with prospective residents prior to admission, included residents’ dietary needs and likes and dislikes. This information is also available to the cook for her information. The cook was seen and confirmed that she is temporary until a full time cook can be appointed. She also commented that other staff also help out and that an agency cook attends the home four days a week. Ridgeway House DS0000002548.V249783.R01.S.doc Version 5.0 Page 12 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): These key outcomes were assessed at the last inspection. EVIDENCE: Ridgeway House DS0000002548.V249783.R01.S.doc Version 5.0 Page 13 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): 19,21,24 & 26 Residents do not live in a well-maintained environment. The homes cleaning programme is not effective in addressing unpleasant odours in the home. Residents privacy and safety is not maintained. Residents rooms are not comfortable and do not have appropriate provision. EVIDENCE: A tour of the environment found that there were enough toilets, bathrooms and walk-in showers for the needs of residents. Hot running water is available at an appropriate temperature in those domestic outlets, which were tested by the inspector on the day of the inspection. The homes annual development plans was seen and did not record what improvements had been undertaken or what improvements had been planned for the coming year. No record was available in response to the homes last inspection reports requirements relating to the fabric of the home. A tour of the home found that aids and adaptations are available in bathroom/toilets. Residents personal wheelchairs are used by any resident a Ridgeway House DS0000002548.V249783.R01.S.doc Version 5.0 Page 14 method must be found to identify residents wheelchairs/seats without creating an intuitional practice of written named labels in sight. One bathroom with a hoist was being used to store furniture and a resident’s en-suite shower was used to store boxes of catheters. Another bathroom had its waterproof floor covering falling off the skirting board area on one side of the room. Wooden window frames were seen to be rotting in the main part of the building. Not all bedrooms have been fitted with user-friendly locks and the homes planned installation of locks has not been undertaken. One District Nurse contacted stated that one resident appears to have ‘been locked in his room and due to the lock not working I prop the door open with a chair so I can get dressings from my car’. The home was made aware of this situation and are to take appropriate action. One bedroom did not have sheets on the bed, which was covered with a Duvet. In one bedroom a toothbrush was seen to be matted with old toothpaste. Five bedrooms were found to have strong unpleasant odours. The acting manager commented ‘that this was disgusting’. Seven other rooms were found to be extremely hot with the radiators in operation on a very warm day. The acting manager stated that the home employs two domestic workers who in total work 58 hours per week. Two visitors seen stated that ‘the bedding in the home is always clean’ ‘but the toilets leave a bit to be desired’. Ridgeway House DS0000002548.V249783.R01.S.doc Version 5.0 Page 15 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): 27,29 & 30 Residents are not protected by the homes recruitment process. Not all shifts are covered by adequate staff numbers. Staff are not trained to carryout their jobs. EVIDENCE: Inspection of the files evidenced that two care workers had been employed without having the appropriate POVA First/CRB checks (Protection of Vulnerable Adults checks and Criminal Record Bureau checks) being undertaken. Not all personnel files have a current photograph. Staff interviewed and records evidenced that these staff were working unsupervised with residents. An immediate requirement was made regarding the above and The Commission has sent a letter to the providers. None of care workers have been given The General Social Care Council Codes of Practice, which sets out their responsibilities as care workers looking after vulnerable adults. The homes training record was seen and found not to be up to date. The training record also identified those workers one a senior care worker who had not undertaking statutory training in 2004 or 2005. The acting manager confirmed that the training file is not up to date and certain staff have not Ridgeway House DS0000002548.V249783.R01.S.doc Version 5.0 Page 16 undertaken training. The acting care manager has NVQ 2 & 3 and one care worker has NVQ level 2 (National Vocational Qualifications) five workers are currently undertaking NVQ level 2 training and a further worker has started NVQ level three training. Two carers stated that they had undertaken dementia training, safe handling of medication, fire procedures and manual handling, food hygiene and adult protection. Both workers demonstrated a clear understanding of their role and responsibilities. Neither worker had undertaken NVQ training. The homes rota was seen and it was found that out of fourteen days, on eight occasions, there was a member of staff short on a shift usually the afternoon shift. The acting manager confirmed that that there are staffing shortages and agencies workers are used when required. Two visitors seen confirmed that there is not always enough staff on duty ‘afternoon are worst’. Care staff stated that there is not always enough staff on duty to cover shifts. There are three waking night staff who use a night check list to record any assistance given to residents during the night. Ridgeway House DS0000002548.V249783.R01.S.doc Version 5.0 Page 17 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): 33,35,36 & 38 Residents’ health and general welfare and safety are promoted. The home ensures that the residents have the opportunity to voice their views and opinions. Residents financial interests are safeguarded. Care staff are not appropriately supervised. EVIDENCE: The home only deals with personal allowances of residents, which are kept at the home. All other monies relating to funding are paid into the homes bank account on a standing order by relatives. Residents’ personal allowances were seen and it was found that an accurate record is kept. A visitor commented that her sister dealt with their mother’s monies. Ridgeway House DS0000002548.V249783.R01.S.doc Version 5.0 Page 18 There are a range of policies and procedures available in the home relating to fire safety and fire risk assessments. There was also evidence that fire alarm, fire drills and emergency lighting checks have been undertaken. Care staff also receive fire training as part of the homes initial training. The Fire officer inspected this home on the 7/06/05 and made a number of requirements, which the home are addressing. The Environmental Health Officer visited on the 04/04/05 and found the hygiene standards in the kitchen to be good. Supervision of care staff is not undertaken on a regular basis. Care workers files showed that supervision has been undertaken on one care worker and the second only had supervision on the 29/02/05. Also not all workers have had their annual appraisals. One carer mentioned that supervision is undertaken with the care manager or the deputy manager on a monthly basis. Certificates were available showing that the shaft lift, bath hoists, gas boilers and portable electrical equipment had been serviced. All wheelchairs seen on the day of the inspection had footplates, which were in use. Ridgeway House DS0000002548.V249783.R01.S.doc Version 5.0 Page 19 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 x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 2 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x 2 x 2 x x 2 x 2 STAFFING Standard No Score 27 2 28 x 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 3 x 3 2 x 3 Ridgeway House DS0000002548.V249783.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? 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 OP8 Regulation 13(b) Requirement The home must ensure that residents both receive the necessary treatment from health care professional and that good communication is maintained.(Timescale of 17/07/05 not met) The home must record all those accidents to residents in line with the homes policies and procedures. (Timescale of 17/05/04 not met) The home must inform all staff of the homes intimate care policies through the induction process.(Timescale of 15/07/05 not met). The home must be kept in a good state of repair externally and internally. The home must provide suitable storage space for the purpose of the care home and residents. The home must undertake a regular audit of the environment and address any malfunction of facilities ( (Timesscale of 25/05/04 not met) The home must make proper DS0000002548.V249783.R01.S.doc Timescale for action 15/12/05 1 OP8 17(a) 15/12/05 2 OP10 12(4)(a) 15/12/05 3 4 5 OP19 OP19 OP19 23(b) 23(l)(m) 16(2) 15/12/05 15/12/05 15/12/05 6 OP21 12(a) 15/12/05 Page 21 Ridgeway House Version 5.0 7 OP21 23(2)(p) 8 OP22 23(n) 9 OP24 12(4)(a) 10 11 12 OP24 OP26 OP27 16(2)(c ) 16(2)(k) 18(a) 13 OP29 19(1)(a) 14 OP30 18(c )(i) 15 OP30 18(c ) 16 OP36 18(2) provision for the health and welfare of residents by ensuring that tooth brushes are suitable for their purpose. The home must provide heating suitable for residents in all parts of the home. ( Timescale of 15/07/05 not met). The home must ensure that wheelchairs owned by residents are made avaialble for their sole use with any propad cushions as required. The home must fit user friendly locks to residents doors. (Timescale of 16/09/04 not met). The home must provide appropriate bed linen for residents. The registred person must keep the care home free from offensive odours. The home must ensure that at all times suitably qualified, competent and experinced persons are working at the home in such numbers as are appropraite for the health and welfare of residents. The registered person shall not employ a person to work at the care home unless the person is fit to work at the care home. The home must ensure that the persons employed by the registered person to work at the acre home receive- training appropriate to the work they are to perform. The home must provide up to date evidence that training is undertaken by all care staff in the home. The home must ensure that persons working at the home are appropriately supervised. DS0000002548.V249783.R01.S.doc 15/05/06 15/12/05 15/12/05 15/12/05 15/12/05 15/12/05 14/09/05 15/12/05 15/12/05 15/12/05 Ridgeway House Version 5.0 Page 22 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 OP28 OP29 Good Practice Recommendations A minimum ratio of 50 trained staff members to NVQ level two excluding the registered manager should be available in the home by 2005. The home should furnish all staff with the General Social Care Councils Conduct of Practice for their information. Ridgeway House DS0000002548.V249783.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 Ridgeway House DS0000002548.V249783.R01.S.doc Version 5.0 Page 24 - 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. 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