CARE HOMES FOR OLDER PEOPLE
Ridgeway Manor Barrow Green Road Oxtead Surrey RH8 9HE Lead Inspector
Graham Cheney Unannounced Tuesday 23rd August 2005, 11:00am 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 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 HO9 H58 s13764 Ridgeway Manor v239928 230805 stage4.doc Version 1.40 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 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 Application pending OP 43 Category(ies) of DE(E) number:10 registration, with number MD(E) number:10 of places OP number:32 PD(E) number: 1 Ridgeway Manor HO9 H58 s13764 Ridgeway Manor v239928 230805 stage4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 1 The age/age range of the persons to be accommodated will be: 65 Years and over. 1 April 2002 2 Of the 43 residents accommodated, up to 10 may fall within the category of either MD(E) or DE(E) 17 May 2002 Date of last inspection 14 September 2004 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 ensuite facilities. Ridgeway Manor HO9 H58 s13764 Ridgeway Manor v239928 230805 stage4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the first inspection of Ridgeway Manor Hall in the CSCI year 2005/2006. It was an unannounced inspection, which meant that residents and staff did not know in advance that it was to take place. The inspection started at 10.15 a.m. and finished at 2.30 p.m. The inspector spent time with the home manager and assistant manager to start with, to get an update on developments with the home and its operation and then met with a group of staff. The inspector then had a tour of the home and spent time talking with residents before lunch. The rest of the time was taken 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 a programme of redecoration and refurbishment underway. Some areas needed attention; please see below in the section headed ‘what they could do better’. 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 did not always have much time to spend with residents other than for personal care. There were comments made that it sometimes took a while for staff to respond to the call system when residents needed help. The home’s management recognised that maintaining staffing levels had been problematic and area in which the home could do better. Improvements to the call system were also planned. Please see section below. Residents said that they enjoyed the food and some explained that they were offered an alternative if they did not like the main meal. In the main 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. Ridgeway Manor HO9 H58 s13764 Ridgeway Manor v239928 230805 stage4.doc Version 1.40 Page 6 All of the residents said they liked their rooms and especially having their own toilet. Some however did not feel it was as good as being in their own home, although most enjoyed having the company of others. Comments from relatives, staff and visiting professionals were generally very positive about the way the home was run and the accommodation. What has improved since the last inspection? What they could do better: Ridgeway Manor HO9 H58 s13764 Ridgeway Manor v239928 230805 stage4.doc Version 1.40 Page 7 The general practice of administration recording and storage of medication was evidenced to be in line with good practice. However there were certain aspects, which were a cause for concern. These were as follows: • • • There was evidence that medication was not being checked on receipt. Gaps were found in the medication administered record sheet. Staff had taken to writing room numbers in large print over the pharmacist label, which provides the legal authority and instruction on how to administer. This included controlled drugs. Evidence of findings and requirements have been reported in the main body of this report. Given that requirements relating to the maintenance of accurate medication records was made at the last inspection, the manager was cautioned that any such failings at future inspections might lead to enforcement action being taken. A review of staff files and discussion with the manager indicated that two of the permanent care staff had not provided all of the information to obtain a CRB (criminal record bureau) and POVA (Protection of Vulnerable Adults) check. Such checks are legally required for staff to continue to work with older people and a requirement has been made. The manager was cautioned that failing to comply with the requirement might lead to enforcement action being taken. Sampling of care plans and discussion with the manager indicated that whilst care plans provided a satisfactory level of information about the individual further improvements could be made. The manager said that a new system may be introduced to provide a more effective way of recording information and evidence that needs were being consistently met. The inspector fully supported this initiative. As stated above whilst the home provided a good standard of accommodation there some areas that needed attention, these were: • • • • The assisted frame and toilet seat in the first floor communal toilet needed to be replaced. The flush mechanism also needed attention. Taps were observed protruding from the floor adjacent to the toilet in the en suite of room 35, these could present a hazard. The carpet in room 14 was noted to be rucking up presenting a tripping hazard. A radiator adjacent to the toilet off the main reception was not covered and could present a risk to residents. Ridgeway Manor HO9 H58 s13764 Ridgeway Manor v239928 230805 stage4.doc Version 1.40 Page 8 • The laundry door was found to be wedged open, as this was onto the main corridor it was a requirement that this be risk assessed as a matter of some urgency under the home’s fire safety policy. 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 HO9 H58 s13764 Ridgeway Manor v239928 230805 stage4.doc Version 1.40 Page 9 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 Standards Statutory Requirements Identified During the Inspection Ridgeway Manor HO9 H58 s13764 Ridgeway Manor v239928 230805 stage4.doc Version 1.40 Page 10 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 standard(s) None Not assessed on this occasion. EVIDENCE: Ridgeway Manor HO9 H58 s13764 Ridgeway Manor v239928 230805 stage4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 9 Evidence gathered from a review of care plans indicated that NMS 7 was met to a satisfactory level, although plans to improve the care planning system were supported as these would provide effective evidence that assessed needs were being consistently met. A review of the administration of medication identified significant shortcomings which if not rectified could present a significant risk to residents’ safety. Failure to address these concerns could lead to enforcement action being taken. EVIDENCE: Contact books for communication between residents, relatives and staff were observed to be available in each room, this was seen as good practice and their use should be encouraged. Sampling of care plans and discussion with the manager indicated that whilst care plans provided a satisfactory level of information about the individual further improvements could be made. The manager said that a new system may be introduced to provide a more effective way of recording information
Ridgeway Manor HO9 H58 s13764 Ridgeway Manor v239928 230805 stage4.doc Version 1.40 Page 12 and evidence that needs were being consistently met. The inspector fully supported this initiative. The general practice of administration recording and storage of medication was evidenced to be in line with good practice. However there were certain aspects, which were a cause for concern. These were as follows: • There was evidence that medication was not being checked on receipt. Controlled medication was found to have been supplied on 16/07/05 but not recorded as received in the controlled drug book until 08/08/05 and the MAR sheet until 23/07/05. Gaps were found in the medication administered record sheet. There was no evidence that medication had been given as prescribed recorded on the MAR sheet for the evening of 20/08/05. Staff had taken to writing room numbers in large print over the pharmacist label, which provides the legal authority and instruction on how to administer. This included controlled drugs. • • Given that requirements relating to the maintenance of accurate medication records was made at the last inspection, the manager was cautioned that any such failings at future inspections might lead to enforcement action being taken. Ridgeway Manor HO9 H58 s13764 Ridgeway Manor v239928 230805 stage4.doc Version 1.40 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 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. Catering standards were being met, based on the positive comments from residents. EVIDENCE: In the main 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. Comments from relatives, staff and visiting professionals were generally very positive about the way the home was run and the accommodation. Ridgeway Manor HO9 H58 s13764 Ridgeway Manor v239928 230805 stage4.doc Version 1.40 Page 14 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 standard(s) None Not assessed on this occasion. EVIDENCE: Ridgeway Manor HO9 H58 s13764 Ridgeway Manor v239928 230805 stage4.doc Version 1.40 Page 15 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 standard(s) 19, 20, 21, 23, 24, 25 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 a programme of redecoration and refurbishment underway. All of the residents said they liked their rooms and especially those having their own toilet. Some however did not feel it was as good as being in their own home, although most enjoyed having the company of others. Comments from relatives, staff and visiting professionals were generally very positive about the way the home was run and the accommodation. As stated above a programme of re-decoration (rooms 35, 18, 15, 32 and 29 all having been done) and re-carpeting was underway and in addition the
Ridgeway Manor HO9 H58 s13764 Ridgeway Manor v239928 230805 stage4.doc Version 1.40 Page 16 outside of the property was being refurbished. Improvements to the number of maintenance staff had enabled this to take place. The manager also stated that agreement had been reached for improvements to the bathing/showering arrangements in the home and the creation of a treatment room. The Environmental Health Officer had visited in June and evidence was presented to confirm that the home had fully complied with the requirements. Improvements were also planned to enhance the call system by adding panels on the basement and first floor levels to alert staff when the system has been activated. Also independent alarms were to be fitted to external doors to warn staff that a resident may have wandered off inappropriately. Whilst the home provided a good standard of accommodation there some areas that needed attention, these were: • • • • • The assisted frame and toilet seat in the first floor communal toilet needed to be replaced. The flush mechanism also needed attention. Taps were observed protruding from the floor adjacent to the toilet in the en suite of room 35, these could present a hazard. The carpet in room 14 was noted to be rucking up presenting a tripping hazard. A radiator adjacent to the toilet off the main reception was not covered and could present a risk to residents. The laundry door was found to be wedged open, as this was onto the main corridor it was a requirement that this be risk assessed as a matter of some urgency under the home’s fire safety policy. Ridgeway Manor HO9 H58 s13764 Ridgeway Manor v239928 230805 stage4.doc Version 1.40 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30 Evidence gathered indicated that standard 27 was almost met, although the staffing for the morning shift needed to be reviewed. Standards 28 and 30 were considered to be met, with residents appearing to be in safe hands and with a firm commitment to staff training and development. It was however a cause for concern that certain of the existing staff had not been CRB or POVA checked yet continue to work unsupervised in the home. Regulation 19 “Fitness of Workers” of The Care Homes Regulations 2001 as amended states – The registered person shall not employ a person to work at the care home unless these and other checks are in place. 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 did not always have much time to spend with residents other than for personal care. There were comments made that it sometimes took a while for staff to respond to the call system when residents needed help. The home’s management recognised that maintaining staffing levels had been problematic and an aspect in which the home could do better. Improvements to the call system were also planned, which may help. Evidence presented indicated a marked improvement in the number of staff undertaking NVQ. The manager stated that 10 staff were undertaking an NVQ in care and 3 in housekeeping. In addition in house training was also being provided with minimal handling, hoist training and medication all said to have been undertaken by staff recently.
Ridgeway Manor HO9 H58 s13764 Ridgeway Manor v239928 230805 stage4.doc Version 1.40 Page 18 A review of staff files and discussion with the manager indicated that two of the permanent care staff had not provided all of the information to obtain a CRB (criminal record bureau) and POVA (Protection of Vulnerable Adults) check. Such checks are legally required for staff to continue to work with older people and a requirement has been made. The manager was cautioned that failing to comply with the requirement might lead to enforcement action being taken. Ridgeway Manor HO9 H58 s13764 Ridgeway Manor v239928 230805 stage4.doc Version 1.40 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 38 Evidence gathered during this inspection confirmed that the home meets each of the assessed standards and was generally seen to be well run with sound and accountable management support. Compliance with standard 38 was compromised by the failure to comply with the previous requirement regarding radiator covers, which were a safety risk. EVIDENCE: A new manager has been appointed since the last inspection, who having been in post for a few months and become established now needs to submit an application for registration to CSCI. A new assistant manager had also been appointed, although the deputy manager was absent but expected to return. The manager felt that they were developing a sound management team with
Ridgeway Manor HO9 H58 s13764 Ridgeway Manor v239928 230805 stage4.doc Version 1.40 Page 20 the support of four senior carers and one acting senior. The home has been supported by management consultants who visit on a weekly basis. Ridgeway Manor HO9 H58 s13764 Ridgeway Manor v239928 230805 stage4.doc Version 1.40 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 2 3 2 x 3 3 2 x STAFFING Standard No Score 27 2 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 3 3 3 x x x x 2 Ridgeway Manor HO9 H58 s13764 Ridgeway Manor v239928 230805 stage4.doc Version 1.40 Page 22 yes 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) Timescale for action It was a requirement that the Ongoing medication administered record from date sheets must be accurately of maintained at all times. inspection 23/08/05 The practice of staff writing room Ongoing numbers in large print over the from date pharmacist label, which provides of the legal authority and inspection instruction on how to administer, 23/08/05 must be discontinued The assisted frame and toilet One month seat in the first floor communal 23/09/05 toilet needed to be replaced and the flush mechanism needed attention The laundry door was found to One month be wedged open, as this was 23/09/05 onto the main corridor it was a requirement that this be risk assessed as a matter of some urgency under the home’s fire safety policy. Taps were observed protruding One month from the floor adjacent to the 23/09/05 toilet in the en suite of room 35, these could present a hazard. A risk assessment must be undertaken and appropriate action taken. The carpet in room 14 was noted One month
Version 1.40 Page 23 Requirement 2. OP9 13(2) 3. OP21 23(2)(n) 4. OP19 23(4) 5. OP21 23(2) 6. OP24 13(4) Ridgeway Manor HO9 H58 s13764 Ridgeway Manor v239928 230805 stage4.doc 7. OP25 13(4) 8. OP29 19(1)(4) 9. OP27 18(1)(a) to be rucking up presenting a tripping hazard. This must be replaced or refitted. A radiator adjacent to the toilet off the main reception was not covered and could present a risk to residents, this must be covered. The registered persons must ensure that evidence is readily available to confirm that all staff providing personal care to residents have been subject to an enhanced CRB and POVA check. It was a requirement that minimum agreed staffing levels must be maintained at all times and that staffing levels must be reviewed to ensure that the home has the capacity to meet assessed needs at all times. 23/09/05 23/09/05 23/09/05 23/09/05 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 Good Practice Recommendations Ridgeway Manor HO9 H58 s13764 Ridgeway Manor v239928 230805 stage4.doc Version 1.40 Page 24 Commission for Social Care Inspection 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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