Inspection on 30/01/08 for Ridgeway House

This inspection was carried out on 30th January 2008.

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

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 House 06/02/07

Ridgeway House 17/01/06

Ridgeway House 12/07/05

Ridgeway House 21/10/04

Ridgeway House 22/06/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Ridgeway House Front Street Station Town Wingate Durham TS28 5DP Lead Inspector Mr Stephen Ellis Unannounced Inspection 30th January 2008 2:00 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 DS0000039753.V356867.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 House DS0000039753.V356867.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ridgeway House Address Front Street Station Town Wingate Durham TS28 5DP 01429 836383 01429 837658 ridgewayhouse@schealthcare.co.uk www.southerncrosshealthcare.co.uk Southern Cross Home Properties Limited 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) Care Home 48 Category(ies) of Learning disability (10), Old age, not falling registration, with number within any other category (38) of places Ridgeway House DS0000039753.V356867.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Named Individual: The home may accommodate a named individual as set out in a letter to the registered person dated 1st August 2006, which establishes the basis on which the individual’s needs will be met by the home. Where necessary, the home’s Statement of Purpose shall reflect any changes in service provision required for this arrangement. This condition may not apply to anyone else, other than the named individuals, who fall outside the registered category. 6th February 2007 Date of last inspection Brief Description of the Service: Ridgeway House is registered to accommodate up to 38 older people and 10 people with learning disabilities. It is not registered to accommodate persons who require continuous nursing care. Southern Cross Homes Proprieties Limited provides the home. It occupies a prominent location in Station Town, adjoining the main road, close to local amenities and with views over the surrounding countryside. It is a two-storey building situated in its own private, well-maintained grounds. Personal accommodation, lounge and dining areas for both units are located on both floors. The learning disability unit is separate to the older persons’ accommodation, but located within the main building. It has a separate entrance, but may also be entered from the older persons’ unit. It also has its own lounge, dining and kitchen facilities on each floor. Main service areas for the whole home, such as kitchen and laundry, are located on the ground floor. Residents’ personal rooms are all fairly spacious. Twenty-four bedrooms have en suite toilets and wash hand basins and some have showers within their en suites. The weekly fees vary between £399.50 on the older persons’ unit, and £604 and £1079 on the learning disability unit. The fee covers all accommodation, meals and personal care. Hairdressing, toiletries, newspapers, plus services from private opticians, dentists and chiropodists are not included in the fee. The actual amount people pay will depend upon their individual circumstances. Ridgeway House DS0000039753.V356867.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. We have made this judgment using a range of evidence, including a visit to this service. This unannounced inspection took place over 6.5 hours, over 2 consecutive days. It included a tour of the building, examination of a number of records and discussions with 12 residents, one relative and 10 staff. Comments were also received from 3 service users via questionnaire and from one external, social care professional. What the service does well: Residents and the one relative interviewed said they were satisfied with the care and facilities provided. Typical comments included: “I am well looked after here and the staff are marvellous.” “If I am unwell I don’t have to wait long to see the doctor or the nurse.” “The staff are very kind and helpful and always try to support me in what I want to do.” “The food’s very good and meals are always on time.” “The staff are helpful and kind; I like to spend time in my room watching television or reading; I am very happy here.” “There’s good company here and I particularly like the video nights, painting and the visiting entertainment (about every 8 weeks).” “The staff are friendly and helpful and we get on well together.” Residents said they got on well with the staff and would not hesitate to discuss any concerns or complaints with staff or management. They described a friendly, supportive environment. Service user plans of care and support plans were comprehensive and detailed, with the person centred plans of care (being introduced to the learning disability unit) particularly impressive. The home has lounge and dining areas on each floor, which allow residents to meet in groups of various sizes for a number of social events. There is an activities coordinator and a varied programme of social and recreational activities, involving the local community wherever appropriate. The home also has kitchens/kitchenettes on each unit for light snacks and/or meal preparation/dining. There is a smoking room on the older person unit and a sensory room on the learning disability unit. Half the bedrooms have en suite facilities, including some with showers. The home is generally well equipped Ridgeway House DS0000039753.V356867.R01.S.doc Version 5.2 Page 6 and well maintained. Staffing levels and staff training are good. Over 72 of care staff members have completed National Vocational Qualifications (NVQ) in care, at level 2 or above, which is a good achievement. There is a friendly, welcoming atmosphere. Management are keen to receive comments from residents and others about the quality of service provided by the home. The service is well run, with regular quality assurance audits being carried out by senior staff, and the information provided to residents and prospective service users is detailed and explicit. What has improved since the last inspection? What they could do better: The manager is at an advanced stage of submitting her application for registration and, whilst this requirement is overdue, the manager’s previously submitted application was mislaid/lost in transit. The temperature of the medicines room on the older persons’ unit is constantly monitored but is higher than ideal and the home is required to reduce the temperature or move the medicines to a cooler environment. The home is giving this matter its full attention and intends to remedy the situation soon. The commendable person centred planning taking place on the learning disability unit would benefit from being further developed and rolled out for all service users, with especial attention being given to identifying personal dreams and aspirations and working out ways in which some or all of these could be fulfilled. It would be very good if the home could help people achieve some of their personal aspirations. Ideally, the learning disability unit’s team leader post should have some supernumerary time (time not dedicated to caring directly for service users) so that the team leader can carry out other duties, such as developing person centred care plans and supporting and supervising staff. Management would like to achieve accreditation of its induction and foundation training (for staff on the learning disability unit) with the Learning Disability Award Framework (LDAF) and this would be a very good development. Ridgeway House DS0000039753.V356867.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 House DS0000039753.V356867.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 House DS0000039753.V356867.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, and 3. People who use the service experience good quality outcomes in this area. Prospective residents and their representatives have the information needed to choose a home that will meet their needs. They have their needs assessed and a contract which tells them much about the service they will receive. Intermediate care is not provided. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: Residents, staff and one relative, confirmed evidence in case notes that full assessments of needs were carried out prior to admission to the home. Also, the initial period of residence following admission was regarded as a trial period, so that new residents could take time to consider whether they wanted to continue living at the home, or make other arrangements. Family, friends, Social Workers from the Local Authority and/or healthcare professionals from the Primary Care Trust would normally support prospective residents in making these decisions. Most residents felt there was enough information from which to make a choice about being admitted. The home supplies copies of its terms and conditions of residence/contract, statement of purpose and service user’s Ridgeway House DS0000039753.V356867.R01.S.doc Version 5.2 Page 10 guide to help explain its range of services, aims and objectives, and charges. These are helpful documents, providing clear information to service users and their representatives. They can be supplied in a variety of formats, including large print and audio versions. Ridgeway House DS0000039753.V356867.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 and 10. People who use the service experience good quality outcomes in this area. The health and personal care, which a resident receives, is based on their individual needs. The principles of respect, dignity and privacy are put into practice. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: Those residents who were able to respond said that their health and social care needs were well known by staff and were being fully met. Health and social care assessments were being carried out, with input from local doctors, community nurses, specialist advisers and social workers. Several of the residents said that the community nurse or doctor would see them whenever required and they were very satisfied with the quality of service they received, as confirmed by the visiting relative. Residents’ personal, social and health care needs appeared to be well known, understood and respected by the staff team. Residents said that they felt they were treated with respect and sensitivity. Typical comments received from residents included: Ridgeway House DS0000039753.V356867.R01.S.doc Version 5.2 Page 12 “I am well looked after here and the staff are marvellous.” “If I am unwell I don’t have to wait long to see the doctor or the nurse.” “The staff are very kind and helpful and always try to support me in what I want to do.” Service users’ plans of care and associated risk assessments were detailed and comprehensive about service users’ health and social care needs, providing clear guidance to staff. Plans of care were subject to regular review and evaluation, involving service users, relatives, health care professionals and social workers wherever practicable. This was particularly the case on the learning disabilities unit. Their service user plans of care addressed many of the issues involved in person centred planning, focusing on individual needs, interests and aspirations, in a holistic way, looking at the individual in relation to all his/her key relationships/influences. These were accompanied by pictorial illustrations in three of the person centred plans that had been completed. It would be very good if the home could develop its person centred planning further and roll it out for all service users, and help people achieve some of their personal hopes, dreams or aspirations wherever possible. Staff training, such as National Vocational Qualifications (NVQ) in health and social care at level 2 or above, has included the important issues of privacy and dignity and over 72 of permanent care staff have achieved these important qualifications. There are good arrangements for the safe administration of medicines. All senior care staff members responsible for the administration of medicine have completed Safe Handling of Medicines courses. There is good support from a local Pharmacist who supplies most medication in blister packs known as a Monitored Dosage System. There are good storage systems (including daily temperature monitoring). The room temperature of the medicines room on the older persons’ unit is higher than ideal and management are taking steps to reduce the temperature, either by installing a cooling device or by changing the room. Senior members of staff check all medication when it is received into the home. Medication is kept securely in lockable cabinets and trolleys. Residents may attend to their own medication but in practice most prefer to delegate this responsibility to staff. Unwanted medicines are returned promptly to the Pharmacist and the home is careful not to stockpile large quantities. The manager and senior members of care staff carry out medicine audits routinely. It is commendable that a photograph of the service user is kept next to their Medicine Administration Record, along with their name, date of birth and room number, to aid identification. Ridgeway House DS0000039753.V356867.R01.S.doc Version 5.2 Page 13 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 and 15. People who use the service experience good quality outcomes in this area. Residents are able to choose their lifestyle, social activity and keep in contact with family and friends. Social, cultural and recreational activities meet residents’ expectations. Residents receive a healthy, varied diet according to their assessed requirement and choice. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: Those residents who were capable either said, or indicated, that they enjoyed living at the home and got on well with the staff. All described the staff as being friendly and caring. Typical comments included: “The food’s very good and meals are always on time.” “The staff are helpful and kind; I like to spend time in my room watching television or reading; I am very happy here.” “There’s good company here and I particularly like the video nights, painting and the visiting entertainment (about every 8 weeks).” An activities organiser coordinates a varied programme of social and recreational activities, taking into account people’s hobbies, interests and preferences. The home involves people from the local community in social events, including pie and peas suppers and themed celebrations such as Easter, Halloween and Valentine’s Day. There is a monthly newsletter and a Ridgeway House DS0000039753.V356867.R01.S.doc Version 5.2 Page 14 weekly trolley shop. On the learning disabilities unit, social, educational and recreational activities take place according to the assessed needs and interests of individual service users, including baking, music, television, car washing, craft and artwork plus outings to local places of interest. There is also a sensory room, which is popular with some residents who enjoy the music and light displays. Residents confirmed that they could choose how they spent their time in the home and were free not to join in activities and social events if they did not wish to. Residents and staff said that relatives and friends may visit at any reasonable time and are always made welcome. Most residents said they liked the meals at the home. There was a good choice of menu and residents’ dietary needs and preferences were catered for wherever possible, following individual nutritional assessments. Meals are served in attractive settings and staff were observed to give assistance where needed. The home regularly reviews its menus for nutritional value and satisfaction, trying to maintain quality and choice for all service users. Ridgeway House DS0000039753.V356867.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience good quality outcomes in this area. Residents have access to a robust, effective complaints procedure and are protected from abuse. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: All residents and one relative who commented said that they were confident about approaching staff and management about any concerns or complaints they might have. They described the staff and management as being very approachable, helpful and friendly. A written complaints procedure is provided in the statement of purpose and service user’s guide, and the manager has an ‘open door’ policy, welcoming contact from service users and their representatives. Staff and management are aware of the need to safeguard adults from abuse or neglect and all have undergone recent training in these issues. Staff confirmed they are aware of the home’s ‘whistle blowing’ policy and confident to speak out about any suspected abuse or neglect. There have been several ‘safeguarding adults’ referrals concerning service users on the Learning Disability Unit over the past year. These have all been reported promptly and dealt with effectively, involving safeguarding staff from the Local Authority. The Local Authority confirmed that it was satisfied with the actions taken by management at the home in response to the incidents, including the suspension and dismissal of staff where appropriate. All staff members have had enhanced Criminal Records Bureau (CRB) checks and Protection of Vulnerable Adults (POVA) checks carried out as required by Ridgeway House DS0000039753.V356867.R01.S.doc Version 5.2 Page 16 law. Also, two references are obtained in respect of each new employee, with special attention given to the last employment. This is to try to ensure that unsuitable people are not employed to care for vulnerable adults. Staff confirmed that new staff members go through full induction and foundation training so that they have the right knowledge and skills to do their jobs competently. The home’s manager and team leader from the Learning Disability Unit are implementing an improved recruitment and appointment strategy, so that even greater care is taken to employ the right staff to work with vulnerable adults. The Local Authority Financial Protection Team is involved in overseeing some residents’ finances, which enhances the home’s own policies and procedures concerning financial protection of service users’ monies. Ridgeway House DS0000039753.V356867.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use the service experience good quality outcomes in this area. The physical design and layout of the home enables residents to live in a safe, well-maintained and comfortable environment, which encourages independence. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The home was found to be clean in all the areas inspected. Domestic staff members are employed in sufficient numbers for the needs of the home. Since the last inspection, a housekeeper has been employed to coordinate the carrying out of domestic duties. Also, the manager and/or key members of staff carry out weekly ‘attention to detail’ audits, trying to ensure high standards are maintained. Most staff members have completed training in health and safety, fire safety, food hygiene and infection control. Bathrooms and toilets have liquid soap and paper towels in wall mounted containers, to help prevent cross infection. All residents have their own personal towels and flannels, which they keep in their rooms. Most residents said they were pleased with the premises, finding them comfortable, clean and homely as well as practical. The home is well maintained, with repairs and servicing being Ridgeway House DS0000039753.V356867.R01.S.doc Version 5.2 Page 18 carried out according to schedule and generally in a timely manner, including inputs from the home’s maintenance officer. Ridgeway House DS0000039753.V356867.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. Staff in the home are trained, skilled and in sufficient numbers to fulfil the aims of the home and meet the changing needs of residents. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: On the day of inspection, there were 23 residents being accommodated on the older persons’ unit and 8 people on the learning disabilities unit. A good rapport was observed between residents and staff on both units. Most residents said they got on well with staff and felt there were sufficient numbers of staff to meet their needs. This view was reflected in staff comments and in comments received from one relative. Typical comments included: “The staff are marvellous.” “The staff are friendly and helpful and we get on well together.” During the day on the learning disabilities unit (8am to 8 pm) there is one senior support worker plus 4 support workers on duty (2 on each floor and one ‘floating’ between floors). At night, there are 3 support workers (one on each floor and one ‘floating’ between floors). This high standard is determined by the assessed needs of the individual service users concerned. However, there have been occasions when this level has slipped due to staff sickness. The home’s manager and the team leader for the unit are taking action to try to ensure that such absences reduce in frequency and new staff are carefully recruited to provide a consistent, reliable service. Ridgeway House DS0000039753.V356867.R01.S.doc Version 5.2 Page 20 On the older persons’ unit, there is one senior care assistant or deputy manager and 3 care assistants on duty during the day (8 am to 9 pm). At night, there is one senior care assistant and 2 care assistants on the older persons’ unit. The manager is full time, Monday to Friday. The home also employs a full time administrator, housekeeper and a full time maintenance officer. There are dedicated catering and domestic staff, deployed in sufficient numbers for the needs of the home. A comprehensive staff training and development programme is in operation, including Protection of Vulnerable Adults, Safe Handling of Medicines, Dementia Awareness, Infection Control, Palliative Care, Challenging Behaviour, Fire Safety, First Aid, Moving and Handling and Food Hygiene. Staff across the home confirmed that they had undergone induction and foundation training and felt confident and competent in their work. Management would like to achieve accreditation of such training (for staff on the learning disability unit) with the Learning Disability Award Framework (LDAF) and this would be a very good development. Over 72 of permanent care staff have completed National Vocational Qualifications (NVQ) in care at either level 2 or 3, which is a good standard. Ridgeway House DS0000039753.V356867.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38. People who use the service experience good quality outcomes in this area. The management and administration of the home is based on openness and respect, has effective quality assurance systems developed by an experienced and competent manager. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The home’s manager, Julie Bennett, is an experienced, qualified nurse and manager of care homes and is competent in her role. She is in the latter stages of applying for registration with the regulator and hopes to complete her Registered Manager’s Award by July 2008. There are good management arrangements in this home, with effective supervision and support of staff, including the subdivision of staff into teams, a key worker system for each resident, and senior staff heading up each shift. Ridgeway House DS0000039753.V356867.R01.S.doc Version 5.2 Page 22 For example, the small learning disabilities unit continues to be well run by a team leader and dedicated staff under the supervision of the home’s manager. Ideally, this team leader post should have some supernumerary time (time not dedicated to caring directly for service users), so that the team leader can carry out other duties, such as developing person centred care plans and supporting and supervising staff. Staff confirmed that they participate in regular supervision sessions, as recorded in individual staff files. The manager has planned a full programme of staff supervision sessions for 2008. Good accounting procedures are followed, with receipts and signatures obtained for all financial transactions involving residents’ personal monies, in which the home is involved, wherever practicable. Relatives continue to be involved in looking after the personal monies of many residents. In those situations where the home looks after residents’ monies, such as personal allowances, clear individual records are maintained and subjected to regular audits. The home’s administrator plays a key role in this process. For some residents, the Local Authority Financial Protection Team is involved, to ensure their personal monies and financial interests are safeguarded. Their involvement augments the home’s policies and procedures on safeguarding residents’ monies, which are generally sound and effective. Service users have ready access to monies looked after for them, either by the home or the Financial Protection Team. Comments received from staff and management confirmed that there are good health and safety policies and practices that promote the health, safety and welfare of residents and staff. All staff members do refresher training in Health and Safety, such as moving and handling, fire safety and food hygiene. Health and Safety issues are also discussed at regular staff meetings, in weekly company briefings and in staff supervision sessions. Residents, one relative who was questioned and staff all felt the home was safe and run in the best interests of residents. For example, there are annual surveys of residents’ satisfaction carried out and the findings are reported within the home. The registered provider’s representative visits the home frequently to check on the welfare of residents and the progress of the home and to make a report. Management routinely invite comments and suggestions for improvements from residents, staff and visitors to the home. It also carries out weekly quality audits and monthly surgeries, where the manager is available outside of office hours, so that anyone can raise any issues of concern. The manager also has an ‘open door’ policy, whereby service users and their representatives are welcome to speak with her about any matter at their convenience. Ridgeway House DS0000039753.V356867.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 4 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 Ridgeway House DS0000039753.V356867.R01.S.doc Version 5.2 Page 24 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 OP9 Regulation 13 (2) Requirement Timescale for action 31/03/08 2 OP31 8,9 and 10 The temperature of the medicines room on the older persons’ unit is constantly monitored but is higher than ideal and the home is required to reduce the temperature or move the medicines to a cooler environment. The home is giving this matter its full attention and intends to remedy the situation soon. The new manager must apply for 31/03/08 registration with the Commission for Social Care Inspection. The manager is at an advanced stage of submitting her application for registration and, whilst this requirement is overdue, the manager’s previously submitted application was mislaid/lost in transit. Previous timescale of 01/06/07 was missed. Ridgeway House DS0000039753.V356867.R01.S.doc Version 5.2 Page 25 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 YA18 OP7 Good Practice Recommendations The commendable person centred planning taking place on the learning disability unit would benefit from being further developed and rolled out for all service users, with especial attention being given to identifying personal dreams and aspirations and working out ways in which some or all of these could be fulfilled. It would be very good if the home could help people achieve some of their personal aspirations. Ideally, the learning disability unit’s team leader post should have some supernumerary time (time not dedicated to caring directly for service users) so that the team leader can carry out other duties, such as developing person centred care plans and supporting and supervising staff. Management would like to achieve accreditation of its induction and foundation training (for staff on the learning disability unit) with the Learning Disability Award Framework (LDAF) and this would be a very good development. 2 YA33 3 YA35 Ridgeway House DS0000039753.V356867.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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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