Inspection on 11/12/06 for Ridgeway Manor

This inspection was carried out on 11th December 2006.

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 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 Manor 12/06/08

Ridgeway Manor 26/06/07

Ridgeway Manor 29/08/06

Ridgeway Manor 12/01/06

Ridgeway Manor 23/08/05

Ridgeway Manor 14/09/04

Ridgeway Manor 13/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Ridgeway Manor Ridgeway Manor Barrow Green Road Oxted Surrey RH8 9HE Lead Inspector Denise Debieux Key Unannounced Inspection 11th December 2006 09:50 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 Manor DS0000013764.V323040.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 Manor DS0000013764.V323040.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ridgeway Manor Address Ridgeway Manor Barrow Green Road Oxted Surrey RH8 9HE 01883 717055 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) gratwick@mistral.co.uk CNV Limited Janet Browne Care Home 43 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (10), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (10), Old age, not falling within any other category (32), Physical disability over 65 years of age (1) Ridgeway Manor DS0000013764.V323040.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Of the 43 residents accommodated, up to 10 may fall within the category of either MD(E) or DE(E) One named person may be accomodated within the category of DE Date of last inspection 29th August 2006 Brief Description of the Service: Ridgeway Manor is a spacious listed building situated in a quiet rural area on the outskirts of Oxted. It has an extensive garden accessible to service users and is surrounded by woodlands. The original house has been re-designed and developed to provide accommodation for up to 42 older people. Rooms are mainly for single occupancy, although 3 rooms can be used as doubles. Many rooms have ensuite facilities. Fees range from £490 - £720 per week. This fee does not include newspapers, chiropody, hairdressing, optician, dentist or day centre. This information was provided on 29/11/06. Ridgeway Manor DS0000013764.V323040.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place over 5 hours and was carried out by Denise Débieux and Cathy Clarke, Regulation Inspectors. Ms Janet Browne (Registered Manager) and Ms Claire Davis (Deputy Manager ) were present as the representatives for the establishment. A tour of the premises took place. The lunchtime meal and medication round was observed during this visit. Eight of the forty-one service users and six onduty staff were spoken with during the visit. Six relatives’ survey forms were received prior to the visit. In addition, six service user survey forms and seven care staff survey forms were completed and handed in to the inspectors on the day of this visit. Some of the comments made to the inspectors and made on the survey forms are quoted in this report. The home had completed a pre-inspection questionnaire and service user care plans, staff recruitment and training records, health and safety check lists, menus, policies, procedures, medication records and storage were all sampled. Following the previous inspection the home was asked to provide CSCI with an improvement plan, setting out how and when they planned to meet the requirements made. Information provided in the home’s improvement plan was referred to during the visit and has been included in this report. The inspector would like to thank the service users and staff for their time, assistance and hospitality during this visit and the service users, staff and relatives who participated in the surveys. What the service does well: One service user surveyed commented ‘I am very satisfied with everything.’ Staff surveyed were happy working at the home. When asked what they felt was the best thing about working at the home, replies included: ‘The level of commitment shown by staff and management’, ‘Team work and good communication’, ‘Friendly atmosphere’ and ‘The standard of care given to residents’. The six relatives surveyed all stated that they were happy with the care their relative receives. Additional comments included: ‘Staff and management are very kind and caring. I am very pleased with the care and consideration of everyone concerned – 10 out of 10’ and ‘My family and I are particularly happy with the home in all aspects – care, accommodation, food are all exemplary and staff are eminently approachable in all things.’ Ridgeway Manor DS0000013764.V323040.R01.S.doc Version 5.2 Page 6 All interactions observed between service users and staff were respectful and caring. What has improved since the last inspection? What they could do better: Six requirements have been brought forward from the last inspection as they were not met within the given timescale. The home must ensure that robust staff recruitment is fully implemented and that all required information and documents are obtained prior to employing new staff to ensure that service users are not being placed at unnecessary risk of harm or abuse. The home must make immediate arrangements to ensure that the staff receive all required training appropriate to the work they are to perform and develop and implement a sound induction and ongoing training programme. Staff must be suitably supervised during their induction period. Additional requirements have been made regarding the provision of training in the protection of vulnerable adults; the introduction of choice into the menus; ensuring that the home and grounds are assessed for any improvements necessary to meet the needs of the service users at the home, especially in relation to those with confusion, dementia and mobility or sensory difficulties and the provider must address the lack of an effective quality assurance system at the home. The registered person will be asked to produce an improvement plan showing how these concerns are to be addressed. A copy of this plan must be made available to service users and their representatives. Please contact the provider for advice of actions taken in response to this Ridgeway Manor DS0000013764.V323040.R01.S.doc Version 5.2 Page 7 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 Manor DS0000013764.V323040.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 Manor DS0000013764.V323040.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): 3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Pre admission assessments are carried for new service users prior to them moving to the home. The home is working towards ensuring that all identified needs are incorporated into the service users’ individual care plans to ensure that their needs will be met. The home does not offer intermediate care. EVIDENCE: Four care plans were sampled in depth, two of which were for the most recent admissions to the home. Pre-admission assessments had been completed for three of the service users. The forth pre-admission assessment could not be located although the manager and deputy remembered that they had both visited the service user together and completed the assessment. Not all needs identified on the pre-admission assessments had been included in the care plans sampled. However, the home is still in the process of updating the care plans for all service users, using a new documentation system and the Ridgeway Manor DS0000013764.V323040.R01.S.doc Version 5.2 Page 10 requirement made at the previous inspection is still within the agreed timescale. Of the six service users surveyed, two said that they always receive the care and support they need and four answered ‘usually’. All relatives who returned survey forms stated that they were satisfied with the overall care provided by the home. New regulations came into force earlier this year and were discussed during this visit. These regulations require that additional information be included in the service users’ guide and that all service users be given a full breakdown of their fees. Although not assessed during this inspection, the manager advised the inspectors that she has been working on revising the service users’ guide. Ridgeway Manor DS0000013764.V323040.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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home needs to ensure that all service users have an up to date, individual care plan that details the care required to fully meet all aspects of their health, personal and social care needs. Policies, procedures and practices are in place to ensure the safe administration of medication. Service users feel they are treated with respect and the majority of service users feel that their right to privacy is upheld. EVIDENCE: At the previous inspection a requirement was made regarding care plans. The provider’s improvement plan, received on the 10th October 06, stated that new care plans were being introduced and that the process was expected to be completed by the 31st December 2006. During this visit four care plans were sampled and it was seen that work had begun on transferring all care plans onto a new documentation system, the new care plans had been signed by the staff member completing them. Ridgeway Manor DS0000013764.V323040.R01.S.doc Version 5.2 Page 12 However, in the care plans sampled, not all needs identified on assessment had been included in the care plans, where needs were not included the reason was not explained. The care plans did not contain goals or objectives for each identified need; specific staff actions to meet each need were not included; service user’s preferences in the way they would like their care delivered were not incorporated into the care plans; where risk assessments highlighted a concern, there were no care plans detailing measures to minimise the risk; newly identified needs had not been incorporated into the care plans; daily notes did not evidence that service users’ needs were being met and three of the four care plans had not been signed by the service user or their representative to signify their involvement or agreement. The need to audit the care plans to ensure they meet the standards and the requirement made at the last inspection was discussed and the previous requirement has been brought forward to this report with the timescale amended to correspond with the provider’s improvement plan. The files sampled showed that service users had been supplied with any equipment identified. (E.g. pressure relieving mattresses). This was a requirement at the last inspection which has now been met. The medication administration record (MAR) sheets, medication blister packs and medication storage were all sampled and were found to be in good order. The lunchtime medication round was observed and seen to be in line with the home’s policies and procedures. The inspector was advised that, following the previous inspection, all staff responsible for the administration of medication had attended a training session and that weekly audits of the MAR sheets will be carried out by senior staff. The previous requirement has now been met. During the tour of the home, staff were observed to always knock before entering the service users’ bedrooms. All interactions observed between service users and staff were seen to be respectful and caring. Of the six service users surveyed, three stated that they felt their privacy was always respected, two answered ‘usually’ and one answered ‘sometimes’. One service user added the comment ‘Oh yes.’ Ridgeway Manor DS0000013764.V323040.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Contacts with family and friends are encouraged. The plan to appoint an activities co-ordinator is a positive step towards ensuring that activities provided will be developed to meet the preferences, expectations and needs of all service users. However, the current limited activities and lack of choice of menu is limiting service users’ opportunities to exercise choice and control over their lives. EVIDENCE: During the last inspection, the manager discussed how the home had recognised that they needed to improve their activity provision and had recently employed an experienced activity co-ordinator who was expected to start work in September. During this visit the inspector was advised that the new coordinator had started but had unfortunately left after one day. However, the home re-advertised and are in the process of interviewing people for the vacant role of activity coordinator. Of the six service users surveyed, one felt there were usually activities they could take part in and three answered ‘sometimes’, two people left this section blank. One service user commented that ‘I’m not interested’ and another that ‘nothing happens’. Ridgeway Manor DS0000013764.V323040.R01.S.doc Version 5.2 Page 14 The inspector was advised that activities at the home include a church group; pianist; Caterham Day Centre; Oxted Work Centre; arranged entertainment and carers’ activities. At the last inspection concerns were raised regarding the menu provision at the home and a requirement was made. These concerns were that the service users were not offered a choice of hot meal at lunchtime, with just one main dish on the menu each day and that, on three evenings a week, the supper consisted of sandwiches. This potentially meant that, on occasions where service users opted for a sandwich at lunchtime, and the evening meal was soup and sandwiches, the service user would not have had a hot meal all day. The provider’s improvement plan, received on the 10th October 06, stated that the menus were being reviewed and would include a choice of two hot meals each lunchtime by the 30th November 06. During this visit the menus for four weeks were sampled and demonstrated that the proposed improvement to the menus had yet to be implemented. The inspectors were shown a copy of a new, draft menu, which did include a choice at lunchtime, but has yet to be put in place. The manager stated that these new menus will be implemented by the 20th December. The concerns from the last inspection remain the same and the current menu provision is not acceptable. The requirement made at the last inspection has been carried forward, the timescale has been extended for a limited period until the 31st December 06 and the provider must now take steps to ensure that this requirement is met without further delay. Of the six service users surveyed, two stated that they always liked the meals at the home, two answered ‘sometimes’, one answered ‘never’ and one person left this section blank. One service user added that the food was ‘not bad at all’ and another that there was ‘not much of a choice’. Ridgeway Manor DS0000013764.V323040.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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has a simple, clear and accessible complaints procedure which includes timescales for the process. The policies and procedures in place to protect service users from harm or abuse need to be reviewed in line with the Surrey Multi-agency Procedure and the Department of Health ‘No Secrets’ guidelines. Current recruitment practices, lack of comprehensive care planning and the need to improve staff supervision and staff training is placing the service users at possible risk of harm and abuse. EVIDENCE: The home has a complaint’s procedure in place that is available to all service users and their relatives. Since the last inspection the home have amended their procedure to state that CSCI can be contacted at any time. Of the six service users surveyed, two answered that they always knew who to speak to if they were not happy and two answered ‘usually’. One service user answered ‘not sure’ and one person left this section blank. The home now have a copy of the latest Surrey Multi-agency Procedure for the Protection of Vulnerable Adults and staff surveyed all said they were aware of the adult protection procedures at the home, all stated that they would report any suspected abuse or report of abuse to the senior staff or manager. The home has a policy on the prevention of abuse but this is not in line with the Department of Health ‘No Secrets’ guidelines, as reported at the last Ridgeway Manor DS0000013764.V323040.R01.S.doc Version 5.2 Page 16 inspection. The recommendation made at the previous inspection has therefore been brought forward to this report. At present the home does not provide specific training on the protection of vulnerable adults. The manager has reserved a place on the Surrey Multiagency procedure training course in early January 2007. The home’s improvement plan states that this training will then be cascaded down to all staff. The two deputies were originally also booked on this course but their places have now been cancelled due to oversubscription. The requirement made at the previous inspection, that all staff must receive training in the protection of vulnerable adults, has been brought forward to this report. The original timescale of the 29th November 06 has not been met. It is important that all staff receive this training and that it is included in the home’s induction for new staff. The timescale for the requirement has been extended to the 31st January 2007 and the provider must now take steps to see that all staff have received protection of vulnerable adult training by this date. (It should be noted that the requirement does not state that this training for staff must be training in the Surrey Multi-agency procedure.) Care planning is addressed in the ‘Health and Personal Care’ section of this report and staff recruitment, supervision and training is addressed in the ‘Staffing’ section of this report. Of the six service users surveyed, five said that they felt safe at the home and one answered ‘some of the time, not all of the time.’ Ridgeway Manor DS0000013764.V323040.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, 22 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The location and the layout of the home provide the service users with a homely environment in which to live. The registered person needs to arrange for an environmental assessment to ensure that the premises are able to meet the needs of all service users accommodated at the home, particularly those with confusion, dementia or mobility/sensory problems. The home was clean and warm on the day of this visit but action must be taken to ensure that the kitchen is kept clean and hygienic at all times. EVIDENCE: During this visit the home was toured. Personal bedrooms were bright and many had been personalised with the service users’ own belongings. The grounds are extensive and provide a pleasant outlook from the bedrooms, with seating areas provided for the warmer weather. There were numerous communal rooms and all were seen to be cheerfully decorated. Ridgeway Manor DS0000013764.V323040.R01.S.doc Version 5.2 Page 18 Of the six service users surveyed, four said that the home was always fresh and clean and two answered ‘usually’. At the last inspection it was noted that one of the communal lounges on the ground floor is mostly for the service users that need a higher degree of supervision or assistance. Many of the carpets in this area are highly patterned, and there are many doors coming off of the corridors and out of the communal lounge. This can be confusing for those with dementia or mobility/sensory problems. A recommendation was made that the home commission an environmental assessment from someone with specialist knowledge of adaptations that can be made to the environment that are known to help people with dementia and/or mobility and sensory problems. Also at the last inspection it was noted that this room opens directly onto the grounds via two double patio doors and the inspector was advised that these doors are generally kept shut as it would not be safe for the ambulant service users with confusion or dementia to have open access to the grounds. The home offers accommodation for up to ten service users with dementia and due to the open and extensive nature of the grounds and gardens, there are no parts of the grounds that these service users can enter without a substantial risk to their safety unless they are closely supervised. A recommendation was made that the home explore ways that a safe area could be provided. To date, neither of these two recommendations have been followed up and they have now been brought forward and incorporated into a requirement that an assessment of the premises be carried out. The home employs two laundry assistants, who ensure that a laundry service is provided seven days a week. The laundry is located in the basement and was seen to be well equipped. Hand washing facilities are located throughout the home. During the tour of the home, areas of concern were noted in the kitchen and adjoining kitchen assistant’s area. This is covered in more detail in the ‘Management and Administration’ section of this report. In order for standard 26 to be fully met, the home need to ensure that all staff have received training and updates in the control of infection. Ridgeway Manor DS0000013764.V323040.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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff are provided in sufficient numbers to meet the needs of the service users at the home. Over 50 of staff are now qualified to a minimum of NVQ level 2 in care. Some action has been taken to improve the staff recruitment and training procedures but further work needs to be done in both these areas to ensure that the service users’ safety is protected. EVIDENCE: The staff rota evidenced that staff are provided in sufficient numbers to meet the needs of the service users at the home. Of the six service users surveyed, two stated that staff are always available when needed, two answered ‘usually’ and two answered ‘sometimes’. One service user commented that ‘sometimes they are busy elsewhere’. The home has now achieved 50 of care staff qualified to National Vocational Qualification (NVQ) level 2 in care. The inspector was advised that, of the twenty-five care staff, nine have achieved NVQ level 2, three have achieved NVQ level 3 and one holds NVQ level 4 (Registered Manager’s Award). In addition to this there are now three members of staff studying for NVQ level 4 and five studying for NVQ level 2. During this visit the files of four recently recruited members of staff were sampled. All files had completed application forms, all had valid enhanced Ridgeway Manor DS0000013764.V323040.R01.S.doc Version 5.2 Page 20 Criminal Record Bureau (CRB) certificates which included a check on the POVA list and all contained two references, although one did not have a reference that related to their last place of employment which involved working with vulnerable adults. One file did not have a recent photograph and all application forms had gaps in employment that had not been explored or explained. Reasons for leaving previous employments working with vulnerable adults had not been verified for any of the four staff members. Staff recruitment was a concern at the last inspection and immediate requirements were made at that time. The manager reviewed staff files following the last inspection and made arrangements to obtain missing information, staff without complete documentation were supervised until missing information was received. The provider’s improvement plan, received on the 10th October 06, stated that ‘training will be carried out with the relevant staff’ (regarding staff recruitment) by the 31st October 06. However, recruitment practices since that date are still not compliant with the Care Homes Regulations 2001 and Schedule 2. The previous immediate requirements have been repeated and some recruitment requirements have been brought forward as not met. Staff recruitment practices must now be addressed and monitored to ensure the safety of service users. All staff surveyed confirmed that they have now received a copy of the General Social Care Council (GSCC) code of conduct and practice. The training records for the same four staff were checked. Two had received manual handling training and only one had received fire safety training, none had completed their in house training in the control of infection, health and safety or basic food hygiene. The home use an external company for staff induction. This involves the staff working through and completing workbooks. The workbooks are then sent to the external company who then return a certificate of completion. However, the manager was not aware that Skills for Care have now produced new induction standards that became mandatory from the 1st October 06 and the home have continued to use the induction standards that have been replaced. Copies of the new induction standards, guidance for managers, guidance for new workers and a copy of the log book and completion certificate were all left at the home on the day of this visit. In addition, no measures have been put in place to provide the required supervision for these members of staff until the completion of their induction training. At the previous inspection it was noted that there was no clear system in place for recording training provided or ensuring that mandatory safe working Ridgeway Manor DS0000013764.V323040.R01.S.doc Version 5.2 Page 21 practice updates are carried out. Since that inspection, training was arranged and provided to staff in basic food hygiene and fire training. The provider’s improvement plan, received on the 10th October 06, stated that outstanding training gaps would be identified by preparing a training matrix and subsequently a plan would be prepared to address any shortfalls by the 30th November 2006. During this visit the training matrix was shown to the inspectors but had not been completed. No training plan was provided to CSCI within the given timescale. None of the previous requirements or recommendation regarding staff training have been fully met and they have been brought forward to this report. An additional requirement has been made regarding staff induction and the manager must ensure that new staff members are appropriately supervised during their induction. The current staff recruitment and training practices at the home are placing service users at risk of potential harm or abuse and must be addressed as a matter of urgency. Requirements have been made. Ridgeway Manor DS0000013764.V323040.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The registered manager is qualified and has the experience to run the home and meet it’s stated purpose, aims and objectives. The home does not have an effective quality assurance and monitoring system in place that is based on seeking the views of the service users. Service users’ financial interests are safeguarded by the financial policies and procedures at the home. Service users’ best interests are not safeguarded by the home’s record keeping practices. Action must be taken to protect and promote the health, safety and welfare of service users and staff. EVIDENCE: Ms Browne has been the manager at the home since January 2005, and was registered by CSCI in August 2006. She has worked in care settings since Ridgeway Manor DS0000013764.V323040.R01.S.doc Version 5.2 Page 23 1983 and has held managerial positions for the past three years. She holds the Registered Manager’s Award and an NVQ 4 in management. At the last inspection the inspector was advised that the home holds residents’ meetings twice a year and service users’ views were sought on an informal basis. However, at that time there was no effective quality assurance and monitoring system in place and there had been no internal quality assurance audit carried out in at least the past twenty months. A requirement was made at that inspection which is still within the timescale set for the 28th February 2007. The provider’s improvement plan, received on the 10th October 06, indicates that this is in hand and will be completed by the 31st January 2007. Service users are provided with lockable storage in their rooms for the safekeeping of any small items of value. Personal money is held on account for service users, with individual records held for each service user and receipts kept of any transactions. These records and receipts were sampled at the last inspection and found to be well maintained. Since the last inspection the home have appointed an administrative assistant and been provided with a new computer system with internet access. Hopefully, these measures will provide additional support to the manager in working towards meeting the National Minimum Standards for older people and the requirements made in this report. During the tour of the home, areas of concern were noted in the kitchen and adjoining kitchen assistant’s area: • opened food was stored in the refrigerator without being dated or labelled; • the floors needed cleaning; • the wall tiles under the sink and dishwasher, and the water pipes in the same area were greasy and needed cleaning; • a stainless steel floor cabinet was being used for storing crockery. This cabinet is situated near to the door with people walking back and forth past it. One door was missing and the other door did not close properly, the unit also was in need of cleaning.; • the wash hand basin was sticky to the touch, particularly underneath. • extractor fans in the kitchen had a build up of grease on the vents and needed cleaning. • the two fire doors leading out of these kitchen areas were wedged open. • both of these fire doors were ill fitting and did not close properly. The labelling of food and cleaning practices in the kitchen were concerns at the last inspection. On that occasion the chef had just returned from two weeks annual leave and the inspector was advised that it was the replacement staff that had not followed the correct procedures. On the day of this visit the inspector was advised that it was the chef’s first day back from a week’s Ridgeway Manor DS0000013764.V323040.R01.S.doc Version 5.2 Page 24 annual leave and the inspector was advised that it was the same problem with replacement staff. An immediate requirement was left at the home that arrangements must be made for the kitchen to be thoroughly ‘deep’ cleaned. The home also now needs to introduce a rigorous and ongoing cleaning routine for the kitchen and kitchen assistant’s area and ensure that the routine is followed at all times, including times when the chef is on annual leave or days off. An immediate requirement was also left that the fire doors must not be wedged open. The provider must also make arrangements for these doors to be made good or replaced to ensure that they comply with current fire legislation. The need for the staff to receive training and updates in safe working practices and induction training that is compliant with Skills for Care specifications, is addressed earlier in the ‘Staffing’ section of this report. Ridgeway Manor DS0000013764.V323040.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 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X X 2 X X X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 X 1 1 Ridgeway Manor DS0000013764.V323040.R01.S.doc Version 5.2 Page 26 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 OP3 OP7 OP8 Regulation 14(2)(a) (b) 15(1) 15(2) (a-d) 16(2)(m) (n) Requirement The registered person must review all care plans and ensure that each service user has an individual plan of care that includes the following: • A comprehensive assessment of needs covering all areas of health, personal and social care (activity) needs; • Risk assessments, to include: prevention of falls, use of bed rails, nutrition, risk of pressure sore development, moving and handling; • Details of all individual needs identified, including social care needs; • Goal/objective for each need; • Actions to be taken to ensure the goals are met and to include the service users’ preferences; • Daily report writing to evidence that identified needs and goals are being met; • Newly identified needs or problems must be promptly added to the care plan; • Signature of service user/representative to signify DS0000013764.V323040.R01.S.doc Timescale for action 31/12/06 Ridgeway Manor Version 5.2 Page 27 2 OP15 16(2)(i) 3 OP18 13(6) 4 OP22 23(2)(a) 23(2)(f) 23(2)(o) their involvement and agreement with the plan; • Date and signature of staff member(s); • A review of care plans and risk assessments must take place at least once a month. (Brought forward as still within timescale) The registered person must 31/12/06 ensure that service users are provided with a varied and nutritious diet; that service users are offered a choice of meals; and that service users are provided with at least one hot meal a day. (Timescale of 30/11/06 not met) The registered person must 31/01/07 ensure that all staff receive training in the protection of vulnerable adults. (Timescale of 29/11/06 not met) The registered person must 31/03/07 ensure that the physical design and layout of the premises; the size and layout of the rooms and areas of the external grounds are suitable for, and safe for use by the service users accommodated at the home. Arrangements must be made for an assessment to be carried out of the premises and facilities, by a suitably qualified person(s), including an occupational therapist, with specialist knowledge of the client group catered for at the home. (including people with confusion, dementia and/or mobility and sensory problems.) A copy of the assessment report, and an improvement plan resulting from any recommendations made, must DS0000013764.V323040.R01.S.doc Version 5.2 Page 28 Ridgeway Manor 5 OP29 6 OP29 7 OP29 8 OP29 be provided to the CSCI, Eashing office. 19(1)(b) The registered person must not Schedule2 employ a person to work at the care home unless he/she is fit to work at the care home and the registered person has obtained the information and documents specified in paragraphs 1-9 of Schedule 2 of The Care Homes Regulations 2001 (as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004). (Timescale of 29/08/06 not met) 19(1)(b) The registered person must Schedule2 check all staff files and make arrangements to obtain the information and documents specified in paragraphs 1-9 of Schedule 2 of The Care Homes Regulations 2001 (as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004) retrospectively for all staff employed since 29th August 2006. 18(3) The registered person must (a-b) ensure that any staff that do not have all the required checks and 19(1)(b) documentation in place, are Schedule2 closely supervised until all requirements of Regulation 19 and the amended Schedule 2 of the Care Homes Regulations 2001 are fully met. 18(1) The registered person must (c)(i) ensure that all staff responsible for staff recruitment are aware 19(1)(a-c) of, and understand, the Schedule2 requirements of The Care Homes Regulations 2001 and Schedule 2 (as amended by The Care Standards Act 2000 DS0000013764.V323040.R01.S.doc 11/12/06 18/12/06 11/12/06 11/12/06 Ridgeway Manor Version 5.2 Page 29 9 OP30 10 OP30 11 OP30 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004). This must take place before any further recruitment of staff. (Timescale of 29/08/06 not met) 18(1)(a-c) The registered person must 11/12/06 ensure that all staff receive training appropriate to the work they are to perform. Where employees have not received appropriate training the registered person must limit their involvement in the work activities until such time as they have received the relevant training. (This includes all mandatory safe working practices). (Timescale of 29/08/06 not met) 18(1)(a-c) The registered person must draw 18/01/07 up a training plan to address the gaps in staff training and ensure staff are competent to provide care to service users. A written plan must be submitted to the CSCI, Eashing office in respect of this requirement. (Timescale of 29/09/06 not met) 18(2) The registered person must 11/12/06 (a)(b) ensure that, for the duration of a new care worker’s induction training, • A member of staff (‘the staff member’), who is appropriately qualified and experienced, is appointed to supervise the new worker; • As far as is practicable, ‘the staff member’ is on duty at the same time as the new worker; • The new worker does not escort any service user away from the care home premises unless accompanied by ‘the DS0000013764.V323040.R01.S.doc Version 5.2 Page 30 Ridgeway Manor 12 OP33 24(1) 24(5) 13 OP26 OP38 14 OP38 12(1)(a) 13(3) 16(j) 23(2)(d) 12(1)(a) 13(3) 16(j) 23(2)(d) 15 OP38 12(1)(a) 13(3) 16 OP38 23(4A)(b) 17 OP38 23(4A)(b) staff member.’ The registered person must establish and maintain a system for evaluating the quality of the services provided at the home. This system must include consultation with the service users and their representatives. (Brought forward as still within timescale) The registered person must make arrangements for the kitchen and kitchen assistant’s area to be deep cleaned. The registered person must introduce a rigorous and ongoing cleaning routine for the kitchen and kitchen assistant’s area and ensure that the routine is followed at all times, including times when the chef is on annual leave or days off. The registered person must ensure that all food is stored and correctly labelled in line with the current food safety legislation and guidelines. The registered person must ensure that the fire doors leading from the kitchen and adjoining kitchen assistant’s area are not wedged open. (Reference The Regulatory Reform (Fire Safety) Order 2005.) The registered person must ensure that any fire safety equipment and devices provided in respect of the premises are subject to a suitable system of maintenance and are maintained in an efficient state, in efficient working order and in good repair. (With particular reference to the fire doors leading from the kitchen and adjoining kitchen assistant’s area.) (Reference The DS0000013764.V323040.R01.S.doc 28/02/07 15/12/06 11/01/07 11/12/06 11/12/06 11/12/06 Ridgeway Manor Version 5.2 Page 31 Regulatory Reform (Fire Safety) Order 2005.) 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 OP18 Good Practice Recommendations It is recommended that the home revise their policy on the prevention of abuse to reflect the Surrey Multi-agency Procedure for the Protection of Vulnerable Adults. (Brought forward from inspection of 29/08/06) It is recommended that the registered person develop and maintain a training log for all staff showing dates that training has been undertaken; topic of training and dates when next updates are due (where appropriate). This log should include all mandatory safe working practices and protection of vulnerable adults training plus additional training required to meet the specific needs of the service users accommodated at the home. (Brought forward from inspection of 29/08/06) 2 OP30 Ridgeway Manor DS0000013764.V323040.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ridgeway Manor DS0000013764.V323040.R01.S.doc Version 5.2 Page 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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