Inspection on 28/11/06 for Ridgeway House

This inspection was carried out on 28th November 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 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 24/02/06

Ridgeway House 30/06/05

Ridgeway House 15/03/05

Ridgeway House 28/07/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Ridgeway House 143 Highridge Green Bishopsworth Bristol BS13 8AB Lead Inspector Paula Cordell Key Unannounced Inspection 28th November 2006 09:30 Ridgeway House DS0000026614.V314028.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ridgeway House DS0000026614.V314028.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ridgeway House DS0000026614.V314028.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ridgeway House Address 143 Highridge Green Bishopsworth Bristol BS13 8AB 0117 9645054 NONE 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) Ms Elaine Leslie Miss Alivia Susan Peacock Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Ridgeway House DS0000026614.V314028.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 7 persons, aged 18 - 64 years, requiring personal care. 24th February 2006 Date of last inspection Brief Description of the Service: Ridgeway House is registered with the Commission for Social Care Inspection (CSCI) to provide accommodation and personal care to seven adults with a learning disability aged between 18-64 years of age. Mrs Elaine Leslie owns the home, with Ms Alivia Peacock as the registered manager. Ridgeway House is situated on the outskirts of Bristol. There are local amenities close by including shops. The home can be accessed by public transport. The home is in keeping with the local neighbourhood. There are seven single bedrooms arranged on the first and second floor. The fees for the home at the time of publishing this report are £950 plus. Ridgeway House DS0000026614.V314028.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced site visit following the visit in February 2006. The purpose of the visit was to monitor the progress to the requirements and recommendations made at that inspection and to review the quality of the care provided to the individuals living in Ridgeway House. There have been no additional visits during this period. The home has been keeping the Commission for Social Care Inspection informed of incidents that affect the wellbeing of the individuals living at the Ridgeway House and the provider has sent monthly appraisals of the service. This information was used to plan the inspection process. The inspection was conducted over a total of 5.5 hours. The inspector had an opportunity to meet with five of the six residents, two members of staff, the home manager and the registered manager. The home presently has a vacancy. The methodology used during this inspection included viewing care records and other relevant documents required of a care home and a tour of the home. The inspector received responses from nine relatives and four visiting professionals to questionnaires sent prior to the inspection. A pre-inspection questionnaire was completed by the registered manager was also received and this information assisted with the planning of the site visit. The inspector would like to take this opportunity to thank the team and the residents for their welcome and their assistance in the inspection process. What the service does well: Staff were respectful, warm, good humoured and sensitive towards the residents within a relaxed homely environment. Staff provide a standard of care, which is individualised, and person centred and work hard to ensure that residents needs and wishes are met. Relationships between staff and residents are established and effective methods of communication both verbal and non-verbal have been developed. The activities provide a regular, varied and stimulating programme to suit individual preferences. The home has built up good relationships with other professionals complimenting the skills of the care staff and the management of the home. Ridgeway House DS0000026614.V314028.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ridgeway House DS0000026614.V314028.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ridgeway House DS0000026614.V314028.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs are assessed to ensure that the home is suitable to meet the individual requirements. Prospective residents have available to them clear information about the service provided at Ridgeway House. EVIDENCE: A copy of the statement of purpose and the service user guide was submitted to the Commission for Social Care Inspection prior to the site visit and it was noted that this has been amended to reflect the changes in management and will be discussed later in this report. These documents were accessible to residents and were written in plain English and contained symbols and photographs and clearly described the service that was available. This is good practice. Ridgeway House DS0000026614.V314028.R01.S.doc Version 5.2 Page 9 The inspector saw many examples of the staff team demonstrating the capacity to meet the residents’ specialised needs. This evidence was gathered through discussion, observation, reading care files, professional and relative feedback. Ridgeway House is registered to accommodate and provide personal care for younger adults with a learning disability. It was evident from care records, discussions with staff and residents that several individuals also have complex physical, psychological and communication needs. There was evidence that the Community Learning Disability Team including the consultant psychiatrist and a behaviour team was supporting the home, staff and the individuals. This is seen as good practice and demonstrated a multi-disciplinary approach to the care of the individuals. Professionals commended the home on the person centred approach and the commitment to support the individuals living at Ridgeway House. Resident’s need assessments and care plans are written from a “person centred prospective” involving the individual and where relevant relatives. Assessment information had been regularly reviewed and updated which shows staff closely monitor residents changing needs. Training will be discussed later. However, it was evident that the training was planned around the care needs of the individuals living in the home. The home manager and the registered manager clearly had a good understanding of the process of assessment prior to a resident moving to the home. The home was in the process of filling a vacancy that the home has had for a number of years. It was evident that information about the prospective resident was being sought from relatives, professionals and the prospective resident. This is good practice. The registered manager, the home manager and the provider have met with the individual, relatives and professionals in the prospective residents present home. This has included talking with care staff that are presently supporting the individual. Copies of the placing authorities assessment and care plan had been sought and the home was building on this to develop the home’s assessment and plan of care. The home has an admission policy. Prospective residents are supported to visit the home and the length and frequency of the visits is tailored to the preferences of the individual, in addition a trial period is offered. This is commendable in ensuring that the home is suitable for the individual and that they are compatible with the existing residents. It was evident that the latter was of importance to both the registered manager and the home manager ensuring that individuals remain happy in their home. Ridgeway House DS0000026614.V314028.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be assured that their individual care needs are being met. Residents and, where relevant, relatives are involved in the planning of care. Good consultation processes are in place ensuring residents have some level of involvement in aspects of life in the home, which varies to the ability of the individual. EVIDENCE: Residents care needs were clearly described in the individual’s plan of care. Each resident had three files. These were named personal care needs detailing, “What you need to do to support me”, a health file and an activity file. In addition residents had a diary containing pertinent information about their wellbeing and activities undertaken on a daily basis. Ridgeway House DS0000026614.V314028.R01.S.doc Version 5.2 Page 11 Plans of care were person centred and reflected the preferences and care needs of the individual. Information was informative and useful enabling staff members to provide the appropriate care to support their health and social needs. Plans of care were evidently being routinely reviewed and amended as care needs changed. Residents, Relatives and professionals were involved in the reviews. Where residents are able they had signed the plan of care. Risk assessments were in place for individuals ensuring their safety both in the community and the home for a variety of activities. The registered manager and the home manager stated that resident meetings have recently discontinued. It was felt that they had no value due to the complex communication needs of residents. However resident’s views are sought on a regular basis informally and formally through their care reviews and an annual questionnaire. Ridgeway House DS0000026614.V314028.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy a range of activities and are supported to live a fulfilling life in and out of their home. Residents are supported and encouraged to maintain firm connections with families and friends this is commendable. Residents have available to them a healthy and well balanced diet. EVIDENCE: The atmosphere on the day of the site visit was relaxed. Residents were seen accessing all parts of their home. Whilst the kitchen is locked (documentation was seen supporting this) residents were not excluded from the kitchen when staff were present. Ridgeway House DS0000026614.V314028.R01.S.doc Version 5.2 Page 13 Residents care files included how their were supported with appropriate leisure activities. These were varied to suit the individual and their preferences. The rota provided evidence that additional staff are roistered to enable residents to access activities and the community. Each resident had a structured timetable which included a variety of activities including attendance at day centres, hydrotherapy, dance voice and visiting a local sensory relaxation centre. A resident stated that they go to college twice a week and visit relatives, go for walks and shopping trips. They stated that they liked living in the home. A visiting relative stated that the home is “home from home” and the “care is second to none”. In addition the relative complimented the staff that worked in the home on their motivation and dedication, which they applied to their work. The home has access to transport to enable residents to make full use of the community. Evidence was provided through discussions with staff, the manager and residents that this was on a regular basis and included trips to places of interest, cinema, theatre, meals out and shopping trips to name a few. This was confirmed in daily records. All residents wishing to have an annual holiday have been supported to do so and it was evident that this was tailored to the individual. A further holiday is planned in April next year to Weymouth. In addition weekend breaks and day trips have been organised. Relatives evidently are actively encouraged to participate in the ordinary home principles. One resident stated that their relative visits every Sunday for lunch. Whilst another resident is supported to visit on a weekly basis. The home organises social functions and all relatives are invited to attend. There was good examples seen of correspondence to relatives inviting them to reviews and explaining the changes in the care of the individual and what activities they had undertaken. This is commendable. Questionnaires sent to relatives confirmed that they were made welcome and all comments received were positive. One suggestion was made for the home to reintroduce the “News Letter”. Both the registered manager and the home manager stated that this had been discussed and were looking to reintroduce this in the future. Observation of a mealtime provided evidence that residents were supported in a sensitive and unrushed manner. Staff and residents ate together and conversations were inclusive of all the residents. It was evident that residents were given choice with two different meals being prepared which included a tuna and bean salad or lasagne with salad. All residents appeared to enjoy the meal. Menus seen provided further evidence that meals were varied, healthy and provided an element of choice. Ridgeway House DS0000026614.V314028.R01.S.doc Version 5.2 Page 14 Care files provided evidence that dieticians had been consulted. The home caters for a specialised diet based on the religious beliefs of the individual. Demonstrating that resident’s cultural and diversity needs are being met and taken into consideration. The kitchen was clean, tidy and well equipped. The stores, fridge and freezer had a good supply of food. Records were being maintained demonstrating that good food hygiene principles were being adopted. A quality assurance tool has been obtained as yet has to be implemented. This would be seen as good practice. Ridgeway House DS0000026614.V314028.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s personal and health care needs are being met. The home has built good relationships with other professionals complimenting the skills of the staff team. Residents are safe guarded by the homes procedures and practices in the administration of medication. EVIDENCE: Residents care files provided evidence that they were referred to appropriate health professionals within a multi disciplinary team. All visits and outcomes to the General Practitioner and any other professionals are recorded to provide a history and quick reference guide. Residents looked well cared for, all had their own distinguished style in dress and hairstyle. Ridgeway House DS0000026614.V314028.R01.S.doc Version 5.2 Page 16 Feedback from professionals was positive stating there was a commitment to ensure that the individuals were supported in a person centred way, and good relationships had been fostered between the care staff and the professional. A consultant psychiatrist complimented the dedication of the staff team in their “good attitude, enthusiasm and motivation to provide person centred care”. Care plans clearly documented the personal and health care needs of the residents. These were being kept under review and demonstrated a person centred planning approach. Each individual had a health action plan that detailed how to ensure an individual’s well-being is maintained. Plans of care included individual assessments for manual handling. Training for staff was in place. There were clear records detailing the personal care support needs of the individual and a daily record of care given. The home has a “Privacy and Dignity” Policy. Staff confirmed the home’s policy that female staff supports female residents where this has been expressed as a choice. Residents are offered a choice of who they would kike to assist them whenever possible. The manager stated that new staff spend a period of supervised practice prior to supporting residents with their intimate care, offering individuals living in the home protection and continuity of care. The home is commended on the assessment and the plans of care that have been developed for monitoring and ensuring an individual is safe during an epileptic seizure. This included ensuring staff were competent to support the individual with annual training, staff that had not received the training were not left unsupervised. Staff training records indicated that staff members had received training in physical and emotional health related issues for example “supporting residents who have epilepsy and this is tailored to the home, supporting residents with challenging behaviour, manual handling and First Aid. Policies and procedures for receiving, storing, administering and disposing of medications were examined and correct. The administration charts were legible and continuity of administration was shown with a signature from the person dispensing. Training was seen for staff who administer medication. A designated person within the team completes routine stock checks. The prescribing general practitioner provides six monthly medication reviews. Ridgeway House DS0000026614.V314028.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be assured that the home will respond appropriately in the event of a complaint or an allegation of abuse. EVIDENCE: The home has a robust complaints procedure in place. Relatives were confident that a complaint would be taken seriously and responded to in an appropriate manner. Information was gained from relatives’ questionnaires. The home has not received a complaint in the last year. Residents concerns are logged in individual care files. The policy and procedure is available for visitors in the home and kept in the conservatory. Due to limited communication skills of those living in the home the staff rely on their expertise and knowledge of the residents to recognise if they are unhappy and may have concerns. It was evident that staff had built good relationships with residents from discussions with the staff, the registered manager and the home manager. The home has procedures for the protection of individuals living in the home including an abuse, bullying, anti-racism, financial, gifts and a whistle blowing policy. Staff were aware of the procedures to safeguard residents. There was a strong awareness of the individuals’ rights. Ridgeway House DS0000026614.V314028.R01.S.doc Version 5.2 Page 18 Staff had a good awareness on abuse and how to respond to an allegation. Staff have attended training with the local authority on “raising awareness on abuse. Finances were checked. These were found to be satisfactory and safeguards were in place to protect the individual’s monies including regular checks, receipts and staff signatures and where possible the residents signature. Resident inventories were in place and the manager stated that these are in the process of being updated to ensure they reflect the current situation with resident’s belongings. Ridgeway House DS0000026614.V314028.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Ridgeway House provides a homely and safe environment ensuring the resident’s needs are met. EVIDENCE: Ridgeway House is in keeping with the local neighbourhood overlooking a green space. The home is partly accessible to individuals in a wheelchair and has two ground floor bedrooms. Stairs accesses the first floor. The home has sufficient communal space for the residents presently occupied. Which is comfortable and fit for purpose. There are two separate seating areas and one doubles up as the dining area. Residents have access to a communal music centre, television and DVD; in addition some of the residents had these in their bedrooms. Ridgeway House DS0000026614.V314028.R01.S.doc Version 5.2 Page 20 The home has three bathrooms, two on the first floor and one on the ground floor and a separate toilet/shower room. The ground floor has been especially adapted to assist residents who have mobility issues with a walk in shower and other equipment to assist with manual handling. Evidence was provided that both the home staff and an external engineer routinely checked this. Clear records were maintained. It was evident that where resident’s needs were changing the home would respond appropriately including seeking the advice of specialist professionals who can advise on further aids and adaptations. The home was well maintained, clean and tidy. The repair book provided evidence that the home responds quickly to repairs. Residents have access to a large outside space, which is secure. Decking has enabled a resident who uses a wheelchair access to the outside space. It was evident from conversations with staff and residents that this space was fully utilised in the summer. Staff were responsible for the keeping the home clean and tidy, residents are also involved with domestic tasks. Ridgeway House DS0000026614.V314028.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient and competent staff supports residents. Residents are protected by a thorough recruitment process ensuring their safety. EVIDENCE: Evidence at this inspection was that the home had sufficient staff to meet the care needs of the residents living at Ridgeway House. There was evidence that additional staff were roistered to provide residents opportunities to go out socially. The home employs a minimum of two staff during the day and one waking and one sleep in member of staff cover the nights on a daily basis. Job descriptions were in place to guide staff and have been seen on previous inspections. Additional staff are employed to enable residents to attend regular hydrotherapy sessions twice weekly and other social activities. This is good practice. Ridgeway House DS0000026614.V314028.R01.S.doc Version 5.2 Page 22 The home is using a lot of agency care staff to cover three staff vacancies. It was evident that the home had a core bank of agency staff supporting the home to provide residents with consistency. The manager stated that agency staff always work alongside the care staff employed in the home. This was confirmed in conversation with one of the agency staff who in addition stated that they had worked in the home for the past two years on a regular basis. The manager stated that the home has struggled to recruit to the vacancies but not for the lack of applicants, but the skills and competence of those interviewed which had not met the criteria and standard that is expected when working at Ridgeway House. It was evident that the manager expected a high standard of her workforce ensuring residents care needs are being met. Recruitment information was available for staff case tracked. There were good recruitment procedures in place to ensure the safety and protection of the residents, from initial advert through to interview, and ensuring all documentation is in place prior to commencing in post. Presently the home has achieved 10 of the workforce obtaining an NVQ in care with a further three staff in the process of completing. It was evident that the home was working towards the 50 target. The home manager stated that she was presently completing an NVQ 4 in management and the NVQ assessor’s award. This is good practice. The staff have attended training relevant to the care needs of the residents. Records and conversations with staff confirmed this. The home has good communication systems in place including daily handover records, four to six weekly one to one meetings with staff and the manager and regular team meetings. Staff were seen during the inspection supporting residents in a positive manner. Staff were knowledgeable about their roles as carer and the care needs of the individuals living in the home. Ridgeway House DS0000026614.V314028.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident in the management arrangements in the home. Resident’s safety is assured by the home’s procedures and practices. EVIDENCE: Ms Alivia Peacock is the registered manager. The provider has contacted the Commission for Social Care Inspection (CSCI) about the reduction of hours that the manager is working in the home. The home manager Ms Alison Cooling is in the process of submitting an application for registered manager. If successful the role will be shared between Ms Peacock and Ms Cooling. Ridgeway House DS0000026614.V314028.R01.S.doc Version 5.2 Page 24 It was evident from talking with both the home manager and the registered manager that they both had a clear direction on how the home was going to be managed, with clear lines of accountability being adopted. It was evident that they complimented each other in their skills and background and worked well together. Both the home manager and the registered manager were competent in their roles and demonstrated a commitment to providing person centred care to the individuals in a homely environment. Policies and procedures were in the process of being reviewed and updated in light of changing legislation namely the Health and Safety Policies including risk assessments relating to fire. The registered manager stated that the provider was doing this and using an external company to assist in the process. This will be followed up at the next inspection. Quality assurance was discussed and it was evident that the manager was exploring how this could be further developed. However, annual questionnaires are given to residents and their relatives to appraise the service. From discussions it was evident that suggestions were taken on board. The home has recently installed a suggestions box in the hallway for staff, relatives and residents. This is good practice. Fire Records were examined and found to be in order in relation to the checks on the fire safety equipment and training. Less apparent was the six monthly fire drills. The registered manager stated that the fire brigade recommended that the frequency should be annual so as not to confuse residents with too many fire drills. However it was noted that at least two of the staff have not attended a drill in a twelve-month period. The home manager Ms Cooling stated that this would be addressed within 24 hours and evidence forwarded to the Commission for Inspection that this had been achieved. No requirement was made as this had been completed within the timescale agreed. Ridgeway House DS0000026614.V314028.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 3 X 3 X X 3 X Ridgeway House DS0000026614.V314028.R01.S.doc Version 5.2 Page 26 No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ridgeway House DS0000026614.V314028.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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. 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