Inspection on 13/04/04 for Ridgeway Manor

Care Home For Older PeopleRidgeway ManorBarrow Green Road Oxted Surrey RH8 9HEUnannounced Inspection13th April 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Ridgeway Manor Address Ridgeway Manor, Barrow Green Road, Oxted, Surrey, RH8 9HE Email address Name of registered provider(s)/company (if applicable) CNV Limited Name of registered manager (if applicable) Type of registration Care Home No. of places registered (if applicable) 43 Tel No: 01883 717055 Fax No:Category(ies) of registration, with (number of places) Dementia - over 65 years of age (10), Mental Disorder, excluding learning 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) Registration number H090000422 Date first registered Date of latest registration certificate 26th February 2003 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspection 14th August 2003 YES NO 08/12/03 If Yes refer to Part CRidgeway ManorPage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 313th April 2004 10:00 am Graham CheneyID Code075644Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionElizabeth KnowlesRidgeway ManorPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementRidgeway ManorPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Ridgeway Manor. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Ridgeway ManorPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. 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 ManorPage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.)Ridgeway ManorPage 6 This was the first inspection to be undertaken in the Commission for Social Care Inspection year April 2004 to March 2005 and was planned as an introductory visit to meet the recently appointed manager. For detail of how each standard was met please refer to the main body of the report. It will be necessary to review both inspection reports for 2004-05 to obtain a full understanding of the extent to which the home meets The National Minimum Standards for Older People A requirement of the last inspection that an investigation into an anonymous complaint be undertaken was not directly met, however the investigation of a subsequent complaint of a similar nature was investigated by the homes management consultants and appropriately resolved No further complaints or evidence of poor practice have been forthcoming. Choice of home (Standards 1 to 6) Standards 1 to 5 were not assessed. Standard 6 was not applicable. Health and personal Care (Standards 7 to 11) Standards 8 and 11 were assessed as met. Standards 7,9 and 10 were considered nearly met. A requirement under NMS 9 was made that the medication administered record sheets must be accurately maintained at all times. Recommendation of the last inspection relating to indexing the controlled Drugs book and that care objectives needed to be more specific about how the individuals needs were to be met remain. Daily Life and Social Activity (Standards 12 to 15) Standards 12 and 14 were assessed as nearly met. Standard 15 was not assessed. Standard 13 was assessed as met. Senior staff continue to develop activities and improve the level of opportunities for service users. Complaints and Protection (Standards 16 to 18) Standard 18 was assessed as met. Standard 16 was assessed as nearly met. Standard 17 was not assessed. Service users with whom the inspector spoke felt able to express their concerns to staff or the manager. An anonymous complaint had been received prior to the last inspection which had raised a series of concerns, which the inspector was not able to substantiate, the homes management were required to undertake a full investigation and report to the NCSC. Please refer to NMS 16 for details. Environment (Standards 19 to 26) Standards 21 to 24 were not assessed. Standard 25 was assessed as partly met. Standard 26 was assessed as met. The home was equipped to a good standard and provided a good level of accommodation for all service users. The home was generally clean, hygienically kept and well maintained. Staffing (Standards 27 to 30) Standard 27 was assessed as met. Standards 28 to 30 were not assessed. Staffing levels were being maintained. Management and Administration of the Home (Standards 31 to 38) None of these standards were assessed.Ridgeway ManorPage 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. No. Regulation Standard Required actions Timescale for action It was a requirement that the homes management undertake a full investigation of the concerns raised by the anonymous complainant, as detailed under NMS 16, and provide a full report to the CSCI. It was a requirement that all communal areas within the home are accessible and appropriately heated at all times. 22/01/04 see NMS 16 Ongoing from 8/12/03122(3)OP16223(2) (h)((p)OP20Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard It was recommended that care objectives needed to be more specific about how the individuals needs were to be met. Notes made by staff should correspondingly indicate the progress or otherwise made towards achieving the objectives. It was recommended that the indexing of the controlled drugs register be kept up to date. It was recommended that details of the homes activities programme should be recorded to provide evidence that this standard is being met.1OP72 3OP9 OP12CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Ridgeway ManorMet (Yes / No)Page 8 Ridgeway ManorPage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements and recommendations are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action It was a requirement that the medication administered record sheets must be accurately maintained at all times. Ongoing from date of inspection 13/04/04113(2)OP9RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s) No. Refer to Good Practice Recommendations Standard * It was recommended that care objectives needed to be more specific about how the individuals needs were to be met. Notes made by staff should correspondingly indicate the progress or otherwise made towards achieving the objectives. It was recommended that the indexing of the controlled drugs register be kept up to date.1OP72OP9Ridgeway ManorPage 10 3OP10It was recommended that service users plans should be reviewed, to include a reassessment of personal care needs and redefinition of care objectives. It was recommended that details of the homes activities programme should be recorded to provide evidence that this standard (NMS 12) is being met. It was a recommendation that the quality of personal care provided be closely monitored to minimise the potential for poor practice.4OP125OP16* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Ridgeway ManorPage 11 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct Observation Indirect Observation Sampling · Pre-inspection Questionnaire · Records · Care Plans / Care Pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting Professionals survey / feedback Tour of Premises Formal Interviews Document reading Additional Inspection Information: Number of Service Users spoken to at time of inspection Number of Relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the Responsible Individual seen CRB check for the Manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of Inspection Time of Inspection Duration Of Inspection (hrs) YES YES NO YES YES NO NO NO YES YES YES YES YES YES NO NO NO YES NO YES 8 0 1 YES NO YES NO X X 13/04/04 10 3.5Ridgeway ManorPage 12 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older persons have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Ridgeway ManorPage 13 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide Range of fees charged From (£) X To (£) XAny charges for extras If yes, please state what the extras are: Key findings/Evidence Not assessed.YES PERSONAL ITEMS. 0 Standard met?Ridgeway ManorPage 14 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 0 Key findings/Evidence Standard met? Not assessed.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 0 Key findings/Evidence Standard met? Not assessed.Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? Not assessed.Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 0 Key findings/Evidence Standard met? Not assessed.Ridgeway ManorPage 15 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff to deliver short-term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? Not applicableRidgeway ManorPage 16 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 2 Key findings/Evidence Standard met? Service user plans sampled demonstrated that there had been little or no improvement in the level of information provided. However the inspector recognised that the home had been through an unsettling time with the departure of the registered manager just after the last inspection and the newly appointed manager having only been in post for a week. The recommendation (of the last two inspections) that care objectives need to be more specific about how the individuals needs are to be met and daily diary notes should be made by staff to indicate the progress or otherwise made towards achieving the objectives, remains in place. Ways of recording information were discussed with the manager and deputy. Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. Number of incidents where service users have been taken to Accident and Emergency during last 12 months Number of service users with pressure sores at time of inspection (from information taken from care notes)1 03 Key findings/Evidence Standard met? The inspector spoke with a community nurse who explained that there was a good relationship between the home and visiting nurses. Staff were said to be very helpful and willing to ask for help and advice when needed. It was also confirmed that the home has a pro-active approach to preventing pressures. Any service user who may develop a sore would be referred to the community nurse who could provide pressure relieving cushions and mattresses.Ridgeway ManorPage 17 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 2 Key findings/Evidence Standard Met? Medication administration record sheets were generally observed to be accurately maintained. However details of the receipt of one service users anti-biotic had not been recorded on the medication administration record sheet, although it had been recorded in a separate receipt book. Also details of why a service users medication was not given had not been recorded. It was a requirement that the medication administered record sheets must be accurately maintained at all times. The indexing of the controlled drugs register had not been kept up to date, this remains a recommendation. Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with and examination by health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 2 Key findings/Evidence Standard met? Observations during the course of the inspection and discussions with service users and staff provided evidence of a good level of compliance with this standard. Service users with whom the inspector spoke were generally happy with the care and support provided. In the main they found staff kind and helpful, although comments were made that staff were very busy and suggested that support with personal care varied. The manager took prompt and appropriate action to investigate and address the issues raised. It was recommended that service users plans should be reviewed, to include a reassessment of personal care needs and redefinition of care objectives. Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 3 Key findings/Evidence Standard met? The manager stated that the homes pre-admission assessment format included a section requesting details of the individuals needs and wishes in this respect and was very aware of the need for a sensitive approach to asking for such information.Ridgeway ManorPage 18 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 2 Key findings/Evidence Standard met? At the time of the last inspection there were concerns about a lack of activities in the home. Evidence was presented to indicate that an activity programme of regular exercise sessions, sing-along and bingo have become established. The homes senior staff recognised that this could be further developed with planned and spontaneous activities proposed. Once developed this standard should be met.Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences 3 Key findings/Evidence Standard met? Indications from observations and discussions with service users was that visitors were welcome at any time and could be provided with a drink or with notice a meal. Those able were provided with the opportunity to access the local community, with staff willing to drive them. Only one service user was able to go out independently. The risks associated with this had been appropriately assessed and acknowledged by the service users family. Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 2 Key findings/Evidence Standard met? Service users with whom the inspector spoke said that they felt in control of their lives. They felt able to choose how they spent their day with only meal times being set. The lack of opportunities to take part in activities, please refer to NMS 12, limited their choices.Ridgeway ManorPage 19 Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet which is suited to individual, assessed and recorded requirements and that meals are taken in a congenial setting and at flexible times. 0 Key findings/Evidence Standard met? Not assessed.Ridgeway ManorPage 20 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple clear and accessible complaints procedure which includes the stages and time-scales for the process and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days X X X X X 1 0 2 Key findings/Evidence Standard met? Prior to the last inspection the NCSC had received an anonymous complaint, which raised a number of concerns. These related to a lack of activities, please refer to NMS 12, lack of care/support with personal hygiene, beds not being changed, poor continence management, i.e. service users left in wet clothes, doctors not being called when requested, call bells not being answered, call leads being pulled out to prevent use, incorrect medication practice, accidents and injuries not being reported. These concerns were investigated during the inspection and, apart from the lack of activities, there was insufficient evidence to substantiate the claims. A requirement was made that the homes management undertake a full investigation of the concerns and provide a full report to the NCSC. The management consultants responsible for the home received further complaints which have been appropriately addressed. There have not been further complaints or additional evidence to substantiate the concerns of the complainant. Whilst not directly met the requirement has been withdrawn and replaced by a strong recommendation that the quality of personal be closely monitored to minimise the potential for such poor practice.Ridgeway ManorPage 21 Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 0 Key findings/Evidence Standard met? Not assessed.Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial, or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES 03 Key findings/Evidence Standard met? Evidence was available to confirm that the majority of care staff have attended the Multiagency vulnerable adults protection training.Ridgeway ManorPage 22 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? Ridgeway Manor is a spacious listed building situated in a quiet rural area on the outskirts of Oxted, accessed by a narrow road which could present a high risk to service users walking into the town. 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. Many rooms have en-suite facilities. Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 2 Key findings/Evidence Standard met? Despite previous recommendations the conservatory was locked at the time of the inspection, making it inaccessible to service users and their guests. The manager was not clear why this was the case, but felt that steps leading into the room may present a risk to service users accessing the room independently. The manager stated that a risk assessment would be undertaken.Ridgeway ManorPage 23 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 0 Key findings/Evidence Standard met? Not assessed.Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons including a qualified occupational therapist, with specialist knowledge of the client groups catered for and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 0 Key findings/Evidence Standard met? Not assessedRidgeway ManorPage 24 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite Key findings/Evidence No change. NO YES NO X X X X Standard met? 0 X XX X X XRidgeway ManorPage 25 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user, which is furnished and equipped to assure comfort and privacy and meets the assessed needs of the service user. 0 Key findings/Evidence Standard met? Not assessed.Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 3 Key findings/Evidence Standard met? Risk assessments have been carried out in each room to assess the potential hazards of uncovered radiators and pipes. The fitting of radiator guards has been prioritised to those presenting high risk to service users and was confirmed by senior staff to be ongoing in other areas. This was in compliance with a previous requirement.Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? On the day of the inspection the home was found to be clean and hygienic. Odour control throughout the building was generally found to be good. The home employs a team of domestic staff during the week.Ridgeway ManorPage 26 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X XX X X3 Key findings/Evidence Standard met? The homes staffing rotas indicated that staffing levels were being maintained. The recent appointment of care assistant meant that the home had a full compliment of staff and this was reflected by the use of agency staff being minimised on the rota.Ridgeway ManorPage 27 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 Key findings/Evidence Not assessed. X X Standard met? 0Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? The need for care staff to have Criminal Record Bureaux checks in place before commencing duty was discussed otherwise the standard was not assessed.Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme, which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? Not assessed.Ridgeway ManorPage 28 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 3 Key findings/Evidence Standard met? This inspection was planned as an opportunity to meet the manager had only been in post for a week at the time of the inspection. An application for registration was awaited.Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? Not assessed.Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 0 Key findings/Evidence Standard met? Not assessed.Ridgeway ManorPage 29 Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure that there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? Not assessed.Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders Key findings/Evidence Not assessed. Standard met? 0 X X XStandard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 0 Key findings/Evidence Standard met? Not assessed.Ridgeway ManorPage 30 Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met? Not assessed.Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable, the health, safety and welfare of service users and staff. 0 Key findings/Evidence Standard met? Not assessed.Ridgeway ManorPage 31 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateMr Graham CheneySignature Signature Signature13th April 2004Ridgeway ManorPage 32 PART D(where applicable)LAY ASSESSORS SUMMARYLay Assessor Date Public reportsSignatureIt should be noted that all CSCI inspection reports are public documents.Ridgeway ManorPage 33 PART EE.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 13th April 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleRidgeway ManorPage 34 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONANANote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. E.2 Please provide the Commission with a written Action Plan by , which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on requestYou will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required NOAction plan was received at the point of publicationNAAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planNANANAOther: enter details here NARidgeway ManorPage 35 E.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.E.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or E.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Ridgeway ManorPage 36 Ridgeway ManorPage 37 - 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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