Inspection on 12/06/08 for Ridgeway Manor

This inspection was carried out on 12th June 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ridgeway Manor 26/06/07

Ridgeway Manor 11/12/06

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Ridgeway Manor Ridgeway Manor Barrow Green Road Oxted Surrey RH8 9HE Lead Inspector Marion Weller Key Unannounced Inspection 12th June 2008 10:45 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.V365473.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.V365473.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) janet.browne@cnv-care.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.V365473.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 accommodated within the category of DE Date of last inspection 26th June 2007 Brief Description of the Service: Ridgeway Manor is a spacious listed building situated in a quiet rural area on the outskirts of Oxted. The home has an extensive garden which is accessible to service users and is surrounded by woodlands. Space for visitor car parking is available to the front of the property. The original house has been redesigned and developed to provide accommodation for up to 43 older people. Rooms are mainly for single occupancy, although 3 rooms can be used as double bedrooms. A number of bedrooms have en-suite facilities. There is ample communal space. The Homes staffing team comprises the manager, deputy and assistant managers, senior care staff and care staff that works a roster that gives 24hour cover. The Home also employs other staff for catering, domestic duties, administration and maintenance tasks. Fees range from £318 - £750 per week according to individual assessed need. The fee does not include the market cost of newspapers, chiropody, hairdressing, optician, dentist or costs for attendance at local day care centres. The manager should be contacted for further information. Ridgeway Manor DS0000013764.V365473.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. This key unannounced inspection was conducted by Marion Weller, Regulatory Inspector, who was in Ridgeway Manor from 10:45 a.m. until 6.30 pm. During that time the Inspector spoke with some residents, two visitors, a district nurse, a visiting care manager and some members of staff. Parts of the home and some records were inspected and care practices observed. A number of survey forms were received prior to the inspection. Residents, and their relatives largely responded that they liked the home and thought that it offered them good standards of care. Survey forms included the comments: • • • “Kind and loving care in a peaceful clean environment”. “They really seem to care and to take an interest”. ‘I am very spoilt here and happy’ Other statements made are quoted in the text of the report. The Manager and staff gave their full co-operation and help throughout the inspection. Feedback was provided to the Manager and the Responsible Individual at the end of the site visit. The Care Homes Regulations 2001 and the National Minimum Standards for Care Homes for Older People refer to people who use the service as “service users”. People living at Ridgeway Manor prefer to be referred to as “residents”. Accordingly this shall be done in the text of this report. What the service does well: Assessment documentation is in place to ensure the individual needs of residents are clearly identified before they move in. This ensures peoples needs can be met by the home. Residents say they are well looked after by staff that are competent, well trained, kind and caring. They know that any requests for care or support will be responded to promptly. Ridgeway Manor DS0000013764.V365473.R01.S.doc Version 5.2 Page 6 Residents’ physical and mental health needs are well met with access to health professionals. Residents like living in a house that has plenty of communal space, a nice garden and where they have rooms they can personalise and which they know will be kept clean. People who use the service are offered a balanced diet. There is an open and friendly atmosphere with good interaction between residents, staff and visitors. Visitors are always made welcome in the home. Residents know there are people who they can talk to about any concerns, who will listen and who will take action to improve the situation. What has improved since the last inspection? Environmental issues identified as needing repair or attention during the last inspection have been addressed to ensure residents continue to live in a safe and comfortable environment. The practice of keeping fire doors open with wedges has ceased. New fire risk assessments have recently been completed by an external contractor to ensure the home is compliant with the requirements of the local fire service and have appropriate procedures and practices in place, designed to protect people who are living, visiting and working in the home. All of the home’s radiators are now covered to further protect residents from any potential for harm. Hand written medication records are now signed and dated by the author and witnessed for accuracy of transcription by a second person. This is to ensure that residents are not given the wrong medication. The home has made arrangements to ensure that the staff receives training appropriate to the work they are to perform. Since the last inspection staff have received training in maintaining effective infection control measures and health and safety issues to ensure that the health, safety and wellbeing of residents are promoted at all times. Staff files evidence that two written references are obtained by the home before a new member of staff commences employment, which ensures the protection and welfare of people living in the home. Ridgeway Manor DS0000013764.V365473.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ridgeway Manor DS0000013764.V365473.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.V365473.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): 36 Service users experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents can be confident that they are appropriately placed due to good preadmission assessments and benefit from being able to visit the home prior to admission. EVIDENCE: The home has an admissions policy in place. The Manager described how a pre-admission assessment is made of each prospective resident to ensure the home can meet his or her needs. The assessment covers all aspects of the individual’s health, personal care, emotional support and social and cultural needs. Both the manager and her deputy carry out assessments. They would, if practical, visit the prospective resident to ensure the initial information they had been provided with remained current and accurate. Ridgeway Manor DS0000013764.V365473.R01.S.doc Version 5.2 Page 10 Records show that prospective residents, their families, advocates, and relevant health care professionals are involved in the assessment process. Specialist advice is sought from external sources where required. A copy of the community care assessment is obtained for residents who are funded. The manager stated that residents are admitted on a month’s trial basis. Residents said they or their families had been able to visit Ridgeway Manor before moving in. A resident’s relative who was visiting confirmed this and said staff are very helpful in assisting new residents to settle in. Respite care can be provided if a room is available and the service can meet the resident’s needs. There is no specific accommodation for short-term care; the resident is free to join in with daily life in the home. Ridgeway Manor does not provide Intermediate Care. Ridgeway Manor DS0000013764.V365473.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 10 11 Service users experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s health and social care needs are clearly set out in individual plan of care ensuring their needs will be met. They are largely protected by the home’s policies and procedures regarding medication administration. They can be confident that where minor shortfalls exist the home will review its arrangements and facilities to secure their safety and protection. The privacy and dignity of service users is considered important and their independence is promoted. EVIDENCE: All residents have a care plan. Three care plans were looked at in detail. The home’s care plan format is produced in a bound booklet style, which enables easy review and audit of content. All plans contained a photo of each individual and a personal profile. Plans were based on a full needs assessment and set out in detail the action required to ensure all aspects of the health, personal and social care needs of the individual are met. It was evident that plans were being reviewed monthly. Each residents or their representative had signed the Ridgeway Manor DS0000013764.V365473.R01.S.doc Version 5.2 Page 12 care plan to illustrate their involvement in its compilation and agreement to it. Where individuals lacked capacity to understand the content of their care plan, it was discussed that the home should record the reasons why the individual is not signing the care plan. Staff were observed during the site visit referring to peoples care plans and updating content. Staff spoken with were aware of the content of residents care plans and the need to review them regularly. Resident’s daily records were being maintained. Entries were however dependent on the skill and knowledge of the staff member making it, and were therefore variable. Entries of ‘all care given’ were being made on occasions, which is neither helpful or adequate as it does not evidence that care is being provided, as detailed in the care plan. It was discussed that improvements to daily records will help the manager audit the care being provided and ensure staff are following guidelines in care plans. It is in the home’s interests to be able to show what they have done, along with providing the evidence on which to base the monthly review and that staff are closely following the assessment of need. The health needs of individuals were identified and their preferences for support were documented. Each person had an assessment completed identifying any risk of developing pressure sores. Preventative equipment had been provided where it was necessary. Nutritional screening was conducted and moving and handling assessments completed, identifying any equipment that was required. A risk assessment was completed identifying residents at risk of falls, with clear guidance for staff to help protect the individual. Care plans indicated that a range of health care professionals, including a General Practitioner, chiropodist and a district nurse visits the home regularly to support residents. Records were being maintained of all health care consultations and interventions received by residents. The home’s medication policies and practices were audited on this site visit. There was a medication procedure in place. Each medication administration record sampled (MAR’s) had a photograph present and a list was maintained of all staff authorised to administer medication in the home. Authorisation had been obtained from the GP in respect of the administration of homely remedy medication. Medication was obtained from Boots the Chemist and dispensed in a monitored dosage system. The supplying pharmacy visits the home annually to carry out an audit and to give good practice advice. All medication administered had been signed for with no obvious gaps in records. It was possible to evidence improvement in the procedures for hand written transcriptions on MAR’s since the last inspection. These are now signed by the author and by a second person, checking for accuracy of transcription. This ensures residents are not given the wrong medication. Some residents were prescribed variable dose and ‘when required’ medication by their GP. Some medication administrators were recording the amount of Ridgeway Manor DS0000013764.V365473.R01.S.doc Version 5.2 Page 13 tablets administered on each occasion and others were not. This omission could result in residents being given more than the recommended amount of medicine in any 24-hour period and therefore places them at risk. Residents who wished to self medicate had a risk assessment in place. The assessment could be further improved by assessing if the individual knew what would happen if they did not take their medicine as prescribed. Topical medicines were observed to be left in bedrooms, clearly on view and not locked away when not in use as good practice demands. Due to the vulnerability of some of the residents accommodated in the home, this needs to be addressed to ensure everyone’s safety and welfare. Staff training regarding the administration of medication currently involves working through a training book and being assessed in the home. It was recommended that staff with lead responsibility for medication administration would benefit further from a more comprehensive training course that would provide them with a clear overview of current good practice. The district nurse visits the home to administer medication for one person who suffers from diabetes and to apply CD preparations to another two. The home has a CD cupboard and maintains a CD Register. An entry in the CD register that was incorrect was addressed whilst the inspector was present. The home was able to evidence medication disposal records, which were robust. The thermometer used to record the holding temperature of the medication fridge had been replaced, but not made immediately available to staff. This had resulted in a six-day period when temperatures had not been recorded. Minor shortfalls detailed above were discussed with the manager and senior staff. The inspector is confident the home will quickly review its arrangements and facilities to secure residents safety and protection. Residents felt that staff was kind and considerate, this was confirmed by observation and discussion with visitors. Staff are also considerate of the age and dignity of residents and were observed to treat them with courtesy and respect. The home aims to care for people until the last stage of life. Christian support is offered where the resident wishes. Last wishes are identified and recorded in a compassionate way. Relatives and friends can be with the resident if the resident so wishes. Ridgeway Manor DS0000013764.V365473.R01.S.doc Version 5.2 Page 14 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 15 Service users experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service Residents’ lifestyles match their needs and preferences, and where possible they are able to maintain contact with family and friends and enjoy activities of their choosing. EVIDENCE: Individual care plans record each residents hobbies, social and leisure interests. Cultural and religious needs are also clearly recorded. The manager provided information that the local Priest visits the home on a weekly basis to administer Holy Communion to those who are Catholic and whom request it. Regular C of E church services are also conducted once a month in the home. Residents are encouraged to discuss their beliefs and an individual plan is created to recognise and support their religious/ spiritual diversity and personal choice. The home normally employs an activities coordinator but the post is currently vacant. The manager is aware how important it is to offer meaningful and stimulating activities to residents. They have regular entertainers visit and are making every effort to recruit. Currently they are advertising in professional magazines and on websites. The manager remains hopeful of a positive Ridgeway Manor DS0000013764.V365473.R01.S.doc Version 5.2 Page 15 outcome and being able to find an individual who has experience of the older person and empathy with people who have dementia. Residents spoken with said they are able to choose the activities they wish to part take in, or not for that matter. Residents maintain links with their families and friends, which is also recorded in care plans. During this site visit relatives were seen visiting the home. Discussions took place with a visiting relative. They said their relative had lived in the home for some years and was very happy and content. They particularly mentioned the staff whom they said was, ‘marvellous’ and the laundry service provided was ‘simply brilliant, they never lost a single thing’ Some residents have their own landline telephones in their bedrooms and there is a communal telephone provided in the home’s entrance hall. During a tour of the home it was observed that residents could bring their own furniture and possessions into the home. Bedrooms seen clearly reflected the personality and interests of the occupants and were very comfortable. Residents may choose to have a key for their room. Individual choices and capabilities in regard to keys and locking doors are recorded in care plans. At the last inspection it was recommended that the menus be reviewed with a dietician to ensure residents are provided with quantities of suitable, wholesome nutritional food, which is varied and properly prepared. The manager arranged this. A dietician from East Surrey Hospital assessed and approved menus used in the home. The daily menu was displayed on each table in the dining room. A choice of meals is available and specialist diets can be provided. People can have a cooked breakfast daily if they wish. Residents spoken with said they were very satisfied with the meals provided. One resident said, ‘I enjoy the meals here very much’ and another said, ‘I can have food brought on a tray to my room if I want it, which is a blessing.’ Meal times during the site visit were observed to be relaxed and unrushed. Residents who required support to enjoy their food were appropriately supported. Residents were able to choose to have wine, beer or an aperitif with their main meals. Alcoholic beverages are supplied to residents free of charge by the home. Ridgeway Manor DS0000013764.V365473.R01.S.doc Version 5.2 Page 16 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 18 Service users experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service People who use the service can be confident that their concerns and complaints are taken seriously and acted upon. They are also systems and procedures in place to protect them from the risks of abuse. EVIDENCE: The home’s complaints procedure is readily available to residents and their relatives. They said they feel confident that they would be listened to and any necessary action would be taken if they had a concern. A visitor spoken with during the visit said, “If there are any problems, they are always quick to sort things out”. A resident said, “I understand how to make a complaint – but I never need to get to that stage”. There have not been any formal complaints received by the home in the last 12 months. The Commission has not received any concerns, complaints or allegations in regard to the home in that time. In line with a recommendation made at the last inspection, the manager has developed a complaints register. The manager stated that information would be recorded in future to enable the home to evidence their good practice in responding promptly and thoroughly to any issues of concern raised with them. If necessary, residents would be encouraged to use the services of an advocate. There are procedures for responding to suspicion or evidence of abuse or neglect to ensure the safety and protection of residents. The staff induction Ridgeway Manor DS0000013764.V365473.R01.S.doc Version 5.2 Page 17 and NVQ training have elements of adult safeguarding training and there has been POVA training for staff. Those spoken with have a sound understanding of adult abuse and protection procedures and stated they would not hesitate to report bad practice. The Manager stated any allegation of abuse would be referred to the concerned agencies without delay. There have not been any alerts in the last twelve months. Ridgeway Manor DS0000013764.V365473.R01.S.doc Version 5.2 Page 18 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 26 Service users experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service Residents live in a clean, comfortable and homely environment that meets their needs. They have benefited from some areas of the property being repaired, refurbished and redecorated since the last inspection. The service has a rolling programme of improvements that will ensure it continues to offer people a safe and comfortable place to live. EVIDENCE: Ridgeway Manor is a spacious listed building situated in a quiet rural area on the outskirts of Oxted. The home has an extensive garden which is accessible to service users and is surrounded by woodlands. A tour of parts of the premises and grounds was undertaken. Resident’s accommodation is laid out across four floors of the home. Bedrooms and communal spaces were seen to be well decorated and residents had been encouraged to personalise private accommodation to reflect their own interests and personality, many bringing favourite pieces of furniture into the home with them. Ridgeway Manor DS0000013764.V365473.R01.S.doc Version 5.2 Page 19 Bedroom accommodation had call bells within easy reach of residents. The manager said that bedrooms are thoroughly cleaned, redecorated and have new carpet laid when a room becomes vacant. All communal areas are accessible to residents. The home has grab rails that help people to maintain their independence and there is a passenger lift to enable them to access all four floors. The home is commendably clean and free from any offensive odours. A recent report written by a specialist health protection nurse following a full infection control audit of the home stated, “ An extremely high standard of cleanliness was observed throughout the home.” Environmental issues identified as needing repair or replacement during the last inspection have been addressed to ensure residents continue to live in a safe and comfortable environment. The practice of keeping fire doors open with wedges has ceased. New fire risk assessments have recently been completed by an external contractor to ensure the home is compliant with the requirements of the local fire service and have appropriate procedures and practices in place to protect people who are living, visiting and working in the home. All of the home’s radiators are now appropriately covered to further protect residents from any potential for harm. A physiotherapist undertook an assessment in January 2007 in regard to the ground floor that accommodates residents who have Dementia. The report made some environmental recommendations for improvement that would benefit the client group. The area has since undergone an extensive refurbishment programme with the provision of new furniture, carpets, lighting and decoration. The report also stated that the home’s immediate garden area needs to be completely re-organised to create a safe but pleasant environment for residents to sit in warm weather. On this visit, the exterior grounds were seen to have had two new pathways laid which both led to seating areas where residents could sit and relax. The main patio area at the back of the home was covered in moss. The manager is aware that this is a slip hazard. Since the last inspection she had organised the application of chemical weed killer to the area, however this had not been totally successful. It is recommended in this report that other solutions are investigated to enable its safe removal and ensure the area is safe for people to use. The home has recently provided some walk in wet room showers, and there are plans to replace and/or refurbish all residents’ bathrooms and public bathrooms. The property is an old building, and maintenance is ingoing throughout the year. The manager stated that they have a continuous improvement programme in place. Ridgeway Manor DS0000013764.V365473.R01.S.doc Version 5.2 Page 20 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 30 Service users experience good quality outcomes in this area. 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 service users and they are in safe hands. There have been improvements to the home’s recruitment policy but it does not yet fully protect service users. EVIDENCE: Survey forms included the comments: • “Staff members are extremely helpful”. • “They are kind, caring and always act just as they should do’ • “Marvellous staff” A manager, deputy and assistant managers, and head of care, senior carers and care assistants, staff the home. There are ancillary staff that carry out catering; laundry, maintenance, administration and cleaning duties so care staff can focus on direct care and support. There is three waking night staff on duty each night. Staff generally feel there are enough staff on duty to meet the needs of residents. Although there are times when they are busy, they also have opportunities to chat with residents and to offer one to one care and support. Residents like the staff and find them approachable, polite and kind. Throughout the site visit there was evidence of good relationships between staff and residents. Staff mentioned how much they liked working with the Ridgeway Manor DS0000013764.V365473.R01.S.doc Version 5.2 Page 21 residents in the home and this was reflected in the way care and support was given. Staff obviously know the residents well and how best to put them at ease. The manager said that people applying to work at the home have to complete an application form, provide two references and have a POVA and Criminal Records Bureau (CRB) check and attend an interview. All staff files inspected on this visit evidenced that two written references had been obtained by the home for all staff employed. This has addressed the requirement in relation to the home’s staff recruitment practices issued at the last inspection. The files of the most recently recruited staff showed that appropriate checks are made prior to them commencing duties. The home’s recruitment process would be even more robust however if a full employment history was in evidence on all staff files, together with a satisfactory written explanation from the applicant of any gaps in their previous employment. To meet the demands of amended legislation, the application form for staff needs to be updated to include a statement as to the applicant suitability in relation to their physical and mental health. The manager stated her intention to address the shortfalls discussed. The home has made arrangements to ensure that staff receives training appropriate to the work they are to perform. Since the last inspection staff have received training in maintaining effective infection control measures and health and safety issues to ensure that the health, safety and wellbeing of residents are promoted at all times. Training offered to staff includes core training, mandatory training, client specific and personal development with some training carried out in house and others accessed from external sources. A training matrix is used to give a management overview of staff training needs. All staff follows a recorded induction process, which reflects the required Skill for Care elements. Ridgeway Manor is proactive in ensuring staff obtain NVQ qualifications. A number of staff already hold NVQ qualifications with others undertaking NVQ’s in care. Ridgeway Manor DS0000013764.V365473.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 36 38 Service users experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a service that is run in their best interests by a manager and staff who are committed to providing a good quality of life for older people. EVIDENCE: The Registered Manager has been in post since January 2005. She is personable, easily approachable and adopts a highly visible stance to her management of Ridgeway Manor. The Manager holds an NVQ 4 in Management and has successfully completed the Registered Managers Award. She has undertaken training in regard to staff supervision, recruitment, disciplinary and grievance procedures, and the Surrey Multi-Agency Protection of Vulnerable Adults course. The Manager stated that she is keen to look at other training to ensure that she remains up to date with changes in legislation and good practice affecting residential care homes. Ridgeway Manor DS0000013764.V365473.R01.S.doc Version 5.2 Page 23 There is a deputy manager who is suitably qualified to support the manager’s role and is currently undertaking the RMA course. Suitable systems are put in place to cover any holiday commitments of the manager. Staff receives regular delegated supervision from their identified line managers. Staff considers supervision is useful with supervisors feeling confident in providing good supervision. Residents’ and relatives meetings are held regularly and the home produces a newsletter that is sent to people connected to the home. A quality assurance survey of residents, their relatives and other associated professionals is sent out twice a year. The manager said that the outcomes of surveys are fed back to residents and their relatives. Visits to the home by a representative of the organisation under regulation 26 are carried out and recorded regularly. Reports were available for inspection at the home. All records seen are kept in a manner that preserve confidentiality. General record keeping is good and well ordered. There is a part time administrator employed to support the manager in the home’s administration requirements. The home assists some residents with day-to-day management of their monies. Records are held of transactions with receipts detailing any expenditure on the residents’ behalf. A running balance is kept and monthly accounts are produced. Residents spoken with raised no concerns about the home’s management of their monies. Some residents manage their own affairs and have lockable facilities in their rooms There are records of fire systems checks and fire drills/training and staff spoken with have a sound understanding of emergency procedures. The practice of keeping fire doors open with wedges has now ceased. The requirement issued at the last inspection has been resolved. New fire risk assessments have recently been completed by an external contractor to ensure the home is compliant with the requirements of the local fire service and have appropriate revised procedures and practices in place, which are designed to protect people who are living, visiting and working in the home. The Manager said all records of maintenance and safety checks are up to date. These were not inspected on this occasion. Due to the home’s heavy workload this year the manager stated that it has not been possible to review all of the homes polices and procedures to date. However, she spoke of her firm plans to review them over the next 12 months. Ridgeway Manor DS0000013764.V365473.R01.S.doc Version 5.2 Page 24 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 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 Score X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 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 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Ridgeway Manor DS0000013764.V365473.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations It is recommended that daily records be maintained in such a way as to consistently reflect that staff are following the guidelines in a residents care plan. This is to provide evidence of the care provided and give sufficient detail on which to base the monthly review and to record and evidence that care staff are following the residents assessment of need. It is strongly recommended that the registered person fulfil the stated intention of reviewing the medication administration practices and storage facilities in the home in line with good practice advice to secure residents safety and protection. It is recommended that a permanent solution be found to enable the safe removal of moss on the rear garden patio area. This will ensure the slip hazard is eliminated for people accessing the area, and ensures it is safe to use. It is strongly recommended that the registered person DS0000013764.V365473.R01.S.doc Version 5.2 Page 26 2. OP9 3 OP19 4 OP29 Ridgeway Manor fulfil the stated intention of ensuring the home’s recruitment procedures are amended to ensure they are sufficiently robust to protect residents from any potential for harm. • A full employment history should be in evidence on all staff files, together with a satisfactory written explanation of any gaps in previous employment. • To meet the demands of amended legislation, the application form for staff needs to be updated to include a statement as to the applicant suitability in relation to their physical and mental health. Ridgeway Manor DS0000013764.V365473.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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.V365473.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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