CARE HOMES FOR OLDER PEOPLE
Ridgeway Manor Ridgeway Manor Barrow Green Road Oxted Surrey RH8 9HE Lead Inspector
Graham Cheney Unannounced Inspection 12th January 2006 10:30 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.V277856.R01.S.doc Version 5.1 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.V277856.R01.S.doc Version 5.1 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) CNV Limited Alicia May Martin Care Home 43 Category(ies) of Dementia - over 65 years of age (10), Mental registration, with number Disorder, excluding learning disability or of places 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.V277856.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: 65 Years and over. Of the 43 residents accommodated, up to 10 may fall within the category of either MD(E) or DE(E) 23rd August 2005 Date of last inspection 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 a good standard of accommodation for older people. Rooms are mainly for single occupancy, although 3 rooms can be used as doubles. At the time of the inspection two of the double rooms were being used as singles, reducing total occupancy to 41 places. Many rooms have en-suite facilities. Ridgeway Manor DS0000013764.V277856.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the second inspection of Ridgeway Manor Hall in the CSCI year 2005/2006. In order to get an overall picture of how the home has been operating it is recommended that both reports are accessed. It was an unannounced inspection, which meant that residents and staff did not know in advance that it was to take place. The inspector spent time with the home manager and deputy manager to start with, to get an update on developments within the home and its operation. Then had a tour of the premises and taking the opportunity to talk with residents before lunch. The rest of the time was taken up looking at care plans, medication, staffing arrangements, other documents and records. Residents and staff made the inspector very welcome and were happy to talk about life at Ridgeway Manor, providing a very positive view of the home. What the service does well:
The home provides a high standard of accommodation, with an ongoing programme of redecoration and exterior refurbishment underway. All of the residents who spoke to the inspector were happy with the service provided. They said that they found the staff kind and helpful, although some residents said that staff seemed very busy and on occasions a little difficult to understand. The manager recognised that the spoken English of some agency staff was sometimes limited, but the home was generally well staffed; with agency generally used only for sickness cover. Residents said that they enjoyed the food and some explained that they were offered an alternative if they did not like the main meal. As on the last inspection most of the residents felt in control of their lives, but some found it difficult having reduced mobility and therefore being more reliant on others for support and going out. Some residents said they were happy with the level of activities in the home, others said they would like more things to do. All of the residents who spoke to the inspector said they liked their rooms and especially having their own toilet. Some rooms were also fitted with an ensuite bath, however indications were that these were not commonly used as the majority of residents needed the assistance of a hoist to get in and out of the bath.
Ridgeway Manor DS0000013764.V277856.R01.S.doc Version 5.1 Page 6 The manager stated that there had been some staff turnover, since the last inspection, however they had been successful in recruiting to the vacant posts. Staff roters indicated that staffing levels were six care staff on for the morning shift and five for the afternoon and evening, with three waking night staff. The home’s management team consisting of the manager and two deputies supported these staff and a senior care on duty at all times. At the time of the inspection the home had four vacancies and management staff considered that the current staffing level was appropriate to meeting the level of assessed need in the home. What has improved since the last inspection? What they could do better:
As stated above the administration and recording of medication was sound, however it was found that the administration of Temazepam the previous night
Ridgeway Manor DS0000013764.V277856.R01.S.doc Version 5.1 Page 7 had not been recorded in the home’s controlled drug register. The home’s medication administration record sheets had been accurately completed providing a clear audit trail and as this appeared to be an isolated situation a requirement was made rather than a more serious course of action. A review of staff files and discussion with the manager indicated that there had been progress made in attaining the required recruitment documentation including CRB (criminal record bureau) and POVA (Protection of Vulnerable Adults) checks. However there were still some shortcomings and an ongoing requirement was made, this is detailed in the body of this report. The carpet in room 5 was observed to be in a poor condition and rucking up in places, it was recommended that this be replaced. Despite having now been in post for several months the manager has failed to submit an application to become registered with CSCI. This is legally required and must be actioned promptly. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ridgeway Manor DS0000013764.V277856.R01.S.doc Version 5.1 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.V277856.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed on this occasion. EVIDENCE: Ridgeway Manor DS0000013764.V277856.R01.S.doc Version 5.1 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 The general practice of administration recording and storage of medication was evidenced to be in line with good practice, with the previous requirements having been met, however there were shortcomings in the use of the home’s controlled drugs register. The standard was not therefore met. EVIDENCE: As stated above the administration and recording of medication was generally sound, however it was found that the administration of Temazepam the previous night had not been recorded in the home’s controlled drug register. The home’s medication administration record sheets had been accurately completed providing a clear audit trail and as this appeared to be an isolated situation a requirement was made rather than a more serious course of action. Requirements from the previous inspection had all been met, as follows: • • There was evidence that medication was now being checked on receipt. No gaps were found in the medication administered record sheet. Ridgeway Manor DS0000013764.V277856.R01.S.doc Version 5.1 Page 11 • Staff had stopped the practice of writing room numbers in large print over the pharmacist label, which provides the legal authority and instruction on how to administer. Ridgeway Manor DS0000013764.V277856.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14, 15 The evidence gathered indicated that these standards were fully met and therefore the home was supporting residents to maintain control and autonomy over their lives as far as they were able. Based on the positive comments from residents catering standards were being met. EVIDENCE: All of the residents who spoke to the inspector were happy with the service provided. They said that they found the staff kind and helpful, although some residents said that staff seemed very busy and on occasions a little difficult to understand. The manager recognised that the spoken English of some agency staff was sometimes limited, but the home was generally well staffed; with agency generally used only for sickness cover. As on the last inspection most of the residents felt in control of their lives, but some found it difficult having reduced mobility and therefore being more reliant on others for support and going out. Some residents said they were happy with the level of activities in the home, others said they would like more things to do. Residents said that they enjoyed the food and some explained that they were offered an alternative if they did not like the main meal.
Ridgeway Manor DS0000013764.V277856.R01.S.doc Version 5.1 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed on this occasion. EVIDENCE: Ridgeway Manor DS0000013764.V277856.R01.S.doc Version 5.1 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24 Overall the home provides a good standard of accommodation well suited to the needs of the residents. EVIDENCE: The home provides a high standard of accommodation, with an ongoing programme of redecoration and exterior refurbishment underway. All of the residents who spoke to the inspector said they liked their rooms and especially having their own toilet. Some rooms were also fitted with an ensuite bath, however indications were that these were not commonly used as the majority of residents needed the assistance of a hoist to get in and out of the bath. All of the previous requirements relating to the premises have been met as follows: • The assisted frame and toilet seat in the first floor communal toilet has been replaced. The flush mechanism has also been fixed.
Ridgeway Manor DS0000013764.V277856.R01.S.doc Version 5.1 Page 15 • • • • The taps which were protruding from the floor adjacent to the toilet in the en suite of room 35 have been removed. The carpet in room 14 has been replaced. The radiator adjacent to the toilet off the main reception has been covered. The laundry door now has door hold device which activiates with the noise of the fire alarm. On this occasion the carpet in room 5 was observed to be in a poor condition and rucking up in places, it was recommended that this be replaced. Ridgeway Manor DS0000013764.V277856.R01.S.doc Version 5.1 Page 16 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29, 30 The evidence gathered indicated that standards 27 and 30 were being met. This meant that residents were being well supported and cared for and that there was a good relationship between residents and staff. There were shortcomings in the recruitment process, which meant that standard 29 was not met. The home must adopt more robust procedures. EVIDENCE: All of the residents who spoke to the inspector were happy with the service provided. They said that they found the staff kind and helpful, although some residents said that staff seemed very busy and on occasions a little difficult to understand. The manager recognised that the spoken English of some agency staff was sometimes limited, but the home was generally well staffed; with agency generally used only for sickness cover. The manager stated that there had been some staff turnover, since the last inspection, however they had been successful in recruiting to the vacant posts. Staff roters indicated that staffing levels were six care staff on for the morning shift and five for the afternoon and evening, with three waking night staff. The home’s management team consisting of the manager and two deputies supported these staff and a senior care on duty at all times. At the time of the inspection the home had four vacancies and management staff considered that the current staffing level was appropriate to meeting the level of assessed need in the home.
Ridgeway Manor DS0000013764.V277856.R01.S.doc Version 5.1 Page 17 Evidence presented indicated a marked improvement in the number of staff undertaking NVQ. The inspector had the opportunity to meet an external NVQ assessor who was working with the home’s domestic staff to help them attain NVQ level II awards. A review of staff files and discussion with the manager indicated that there had been progress made in attaining the required recruitment documentation including CRB (criminal record bureau) and POVA (Protection of Vulnerable Adults) checks. However there were still some shortcomings and an ongoing requirement was made, this is detailed in the body of this report. Ridgeway Manor DS0000013764.V277856.R01.S.doc Version 5.1 Page 18 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32 Evidence gathered during this inspection confirmed that the home meets standard 32 with a sound management team in place and was generally seen to be well run. Standard 31 however cannot be considered met until the home has a registered manager in place. EVIDENCE: Since the last inspection the deputy manager has returned following a lengthy absence, currently on a part time basis but recommencing full time in the near future. The manager felt that they were developing a sound management team with the support of the home’s senior carers. Management consultants who visit on a weekly basis on behalf of the registered owner have supported the home. Ridgeway Manor DS0000013764.V277856.R01.S.doc Version 5.1 Page 19 Despite having now been in post for several months the manager has failed to submit an application to become registered with CSCI. This is legally required and must be actioned promptly. Ridgeway Manor DS0000013764.V277856.R01.S.doc Version 5.1 Page 20 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 3 3 3 3 3 X X STAFFING Standard No Score 27 3 28 X 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 3 X X X X X X Ridgeway Manor DS0000013764.V277856.R01.S.doc Version 5.1 Page 21 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. 1. Standard OP9 Regulation 13(2) Requirement Timescale for action 12/01/06 2. OP29 17, 19 3 OP31 8,9 It was a requirement that the home’s controlled drugs register must be accurately maintained at all times. All staff files must be reviewed to 12/02/06 ensure that all the records required by Schedule 2 and 4(6) are in place The manager must submit an 12/02/06 application to register. 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 OP19 Good Practice Recommendations The carpet in room 5 was observed to be in a poor condition and rucking up in places, it was recommended that this be replaced. Ridgeway Manor DS0000013764.V277856.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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