Inspection on 26/06/07 for Ridgeway Manor

This inspection was carried out on 26th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ridgeway Manor 12/06/08

Ridgeway Manor 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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Ridgeway Manor Ridgeway Manor Barrow Green Road Oxted Surrey RH8 9HE Lead Inspector Joseph Croft Unannounced Inspection 26th June 2007 10:00 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.V337336.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.V337336.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) ridgeway@cnvltd1.wanadoo.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.V337336.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Of the 43 residents accommodated, up to 10 may fall within the category of either MD(E) or DE(E) One named person may be accomodated within the category of DE Date of last inspection 11th December 2006 Brief Description of the Service: Ridgeway Manor is a spacious listed building situated in a quiet rural area on the outskirts of Oxted. It has an extensive garden accessible to service users and is surrounded by woodlands. The original house has been re-designed and developed to provide accommodation for up to 42 older people. Rooms are mainly for single occupancy, although 3 rooms can be used as doubles. Many rooms have ensuite facilities. Fees range from £490 - £720 per week. This fee does not include newspapers, chiropody, hairdressing, optician, dentist or day centre. Ridgeway Manor DS0000013764.V337336.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) undertook an unannounced site visit on the 26th June 2007 using the new ‘Inspecting for Better Lives’ (IBL) process. Regulation Inspectors Mr Joe Croft and Mrs Lisa Johnson undertook this visit, and the registered manager assisted them throughout the site visit. The Responsible Individual arrived at the home during the afternoon, and was included in the feedback at the end of this site visit. This site visit took place over a period of seven and a half hours, commencing at 10:00 and concluding at 17:45. The inspection process included a tour of the premises and sampling of residents’ care plans and risk assessments. Other documents sampled included the staff duty rota, menu, policies and procedures and records of medication. During this site visit the Inspector had discussions with members of staff on duty, visiting relatives, the activity coordinator, hairdresser, the cook and the majority of residents who live at the care home. Residents were able to convey to the Inspector that they are very happy living at the home, that the staff are very nice, and that they thought the food is usually good. Residents were observed to be appropriately cared for, with staff attending to and supporting individuals as and when required. Staff spoken to were complimentary about the manager of the home. Due to their needs, some residents who were part of the case tracking process were not able to communicate with the Inspectors. The Annual Quality Assurance Assessment (AQAA) completed by the home and comment cards received from two residents, four relatives and one other associated professional have been used as a source of evidence in this report. The inspectors would like to thank the manager, members of staff and residents for their cooperation during this visit. Feedback was provided to the manager and Responsible Individual at the end of this site visit. Ridgeway Manor DS0000013764.V337336.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? 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.V337336.R01.S.doc Version 5.2 Page 7 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.V337336.R01.S.doc Version 5.2 Page 8 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): Standards 3 and 6 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Assessment documentation is in place to ensure the individual needs of residents can be met. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) provided by the manager indicates that the home completes pre- admission assessments carried out by both the manager and deputy. The home has an admissions policy in place. The pre- admission assessments were sampled for two people. One person had been admitted in January 2007 and the pre- admission assessment was sampled which had been carried out in December 2006. A copy of the community care assessment is obtained for residents who are funded. The assessment covers health, personal care, and emotional and social and cultural needs. The AAQA states that residents are admitted on a month’s trial basis. The home does not support residents with intermediate care. Ridgeway Manor DS0000013764.V337336.R01.S.doc Version 5.2 Page 9 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): Standards 7, 8, 9 and 10 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are protected by the home’s medication procedures. Physical and health care is offered in such a way as to promote service users’ privacy and dignity. EVIDENCE: All residents have a completed care plan in place and during this visit four care plans were sampled. The home has introduced a new care plan format, which was provided in booklet form. Care plans included the religious and cultural needs of residents. All plans contained a photo of each individual and a personal profile. Plans were based on full needs assessment. It was evident that plans were reviewed monthly and residents and/or their relatives had signed them. During discussions, staff informed the Inspector that they do not work a key worker system in the home, however, they were aware of the contents of care plans and the need to review on a monthly basis. 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. One person was identified as Ridgeway Manor DS0000013764.V337336.R01.S.doc Version 5.2 Page 10 requiring a specialised mattress. Nutritional screening was conducted and moving and handling assessments completed, identifying any equipment that is required. A risk assessment was completed identifying residents at risk of falls, with instructions for staff recorded. Plans sampled indicated that a range of health care professionals including a General Practitioner, chiropodist and a district nurse who was seen visiting the home during this visit, support residents. Records were maintained of all health care consultations received by residents. The home’s medication policies and practices were examined. There was a medication procedure in place. Each medication administration record sampled (MARs) had a photograph present and a list was maintained of all staff authorised to administer medication. 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 blister packs. The pharmacy last visited the home in March 2007 to carry out an audit of the medication. All medication administered had been signed for with no gaps in records. However, one person’s medication record card had been hand transcribed by staff and the inspectors were told that this had been due to the other card being spoiled due to a spillage. On examination this card had not been signed and dated by the author and it was immediately required that this matter was actioned, with a further recommendation that this should be checked and signed by two members of staff ensuring the health, safety and welfare of residents. During this visit this matter was completed with evidence provided to the inspector that this matter had been completed. Residents who wished to self medicate had a risk assessment in place. Staff training regarding to administering of medication involves working through a training book and being assessed in the home. The home does not currently have any controlled drugs. The district nurse visits the home to administer medication for one person who suffers from diabetes. The home maintained medication disposal records, which were reviewed. Residents informed the Inspector that they are treated with dignity and respect. Staff informed the Inspector that they respect residents’ privacy through attending to personal care needs in private, knocking on bedroom doors and addressing residents by the names they preferred. Only two comment cards were received from visiting health care professionals, both of which informed that individuals’ privacy and dignity is always respected. During this visit staff were observed to talk to residents with courtesy and respect. Evidence found during the site visit supported the information that was provided in the AQAA. Ridgeway Manor DS0000013764.V337336.R01.S.doc Version 5.2 Page 11 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): Standards 12, 13, 14 and 15 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ lifestyles matched their needs and preferences, and where possible they are able to maintain contact with family and friends. People who use the service are offered a balanced diet. EVIDENCE: Individual care plans recorded each individuals hobbies, social and leisure interests. Cultural and religious needs were recorded. Current residents are all white British and their religions are that of Church of England and Roman Catholic. Staff informed the Inspectors that the Roman Catholic Priest visits the home on a weekly basis to administer Holy Communion to those of that denomination and who request it. It was recorded in the care plan of one individual that they like to receive Holy Communion. The manager informed the Inspector that Church services are conducted in the home once a month. During discussions staff informed the Inspector that they respect residents’ religious beliefs. The home has an Equal Opportunities Policy and Procedure dated 2005. Information provided in the AQAA informs that, following admission, residents are encouraged to discuss their beliefs and a plan is put in place to recognise and allow choice. The home employs a diverse work force. Ridgeway Manor DS0000013764.V337336.R01.S.doc Version 5.2 Page 12 The home has employed an activities coordinator since the last inspection who provides sessions each afternoon. The coordinator has developed an activities profile that identifies each individual’s interests and hobbies with an action plan for each person. Records of activities received by residents were recorded. During discussions the activity coordinator informed the Inspectors that she attends the home four days each week to undertake group and individual work. Activities provided include discussions on self-worth, reminiscence, board games, puzzles and art and craft sessions. The home has an activities room where pieces of work are displayed; this included a collage that was made by residents. External activities have taken place and more are to be arranged at the request of residents. The activities coordinator has included relatives in the activities, for example; they were used to judge the Easter bonnet competition. During this site visit an external entertainer was at the home playing the piano for residents. Residents informed the Inspector that they are able to choose the activities they wish to part take in. Two surveys were returned from residents, one informed that they choose not to take part in activities; one informed they sometimes join the activities. Residents maintain links with their families, which was recorded in care plans. During this site visit relatives were seen visiting the home. Discussions took place with a visiting relative who informed the Inspector that their relative was happy living at the home that the staff team are good and they felt the home has improved since the new manager has been in post. There had been an issue in regard to their relative’s medication, but this has now been resolved. Some residents have their own landline telephones in their bedrooms, one resident informed the Inspector that she is to have a telephone put into her bedroom. Residents were wearing their own clothes and are able to have their hair done by a visiting hairdresser that was taking place during this site visit. During a tour of the home it was observed that residents could bring their own furniture and possessions into the home, which was seen on display. During lunch residents were provided with choice of their preferred drinks with their meals and residents were asked if they would like to wear a clothes protector. Where residents chose or are unable to use a key for their room this had been recorded in the care plan The menu was displayed on each table in the dining room. Choices of meals are provided and were documented on the menus. Menus were observed to be varied and nutritious. The lunchtime meal was observed. There was a choice of lamb stew or steak and kidney pie, and was served with mashed potatoes and fresh vegetables. The dessert was either bakewell tart and custard or fruit salad. The meal was well presented. Specialist diets were provided such as Diabetic and pureed meals. The upstairs dining room was laid with tablecloths, Ridgeway Manor DS0000013764.V337336.R01.S.doc Version 5.2 Page 13 glasses and condiments. Other choices can be provided, such as omelettes. The teatime meal observed was a choice of soup, fishcakes or sandwiches. Choices were available for breakfast including the provision of cooked breakfast. Residents spoken with during the mealtime stated that they were satisfied with the meals provided. 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. Meal times were relaxed and unrushed. Residents who required support with feeding were appropriately supported. Evidence found during the site visit supported the information that was provided in the AQAA. The home has recognised that they could, and will, provide better information on forthcoming events. Ridgeway Manor DS0000013764.V337336.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have access to a satisfactory complaints system that enables residents and their families to raise concerns. Staff having knowledge, training and an understanding of adult protection issues protects residents. EVIDENCE: The Commission For Social Care Inspection has not received any concerns, complaints or allegations in regard to the home. The home has a complaints procedure in place and this was seen on display in the home. The manager stated that no complaints have been received since the previous visit, although it was recommended that the manager maintain a complaints register should anybody wish to raise a complaint or concern. All surveys returned from residents, and three of the four returned by relatives, indicated they knew how to make a complaint. The home had in its possession the February 2005 copy of the local authority Surrey multi- agency safeguarding adults from abuse policy and procedures. This is available to all staff, and Protection of Vulnerable Adults notices are displayed in the care home. The home also had the No Secrets document. The company also had their own protection of vulnerable adults policy in place that was viewed by one Inspector. Information provided in the AQAA states that the manager has attended the Surrey Multi-Agency training in regard to the Protection of Vulnerable Adults, Ridgeway Manor DS0000013764.V337336.R01.S.doc Version 5.2 Page 15 and has cascaded this training to all care staff. This was verified during the site visit. During discussions, staff gave an account of who they would report suspicions of abuse to, and stated they would not hesitate to report bad practice. Staff informed the Inspector they had received training in regard to the Protection of Vulnerable Adults and read the Policies and Procedures in regard to this area. Ridgeway Manor DS0000013764.V337336.R01.S.doc Version 5.2 Page 16 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): Standards 19 and 26 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People using the service are provided with clean and tidy communal and individual living space, however, identified areas require attention to ensure it continues to be a safe and comfortable place to live. EVIDENCE: A tour of the premises was undertaken. The accommodation is situated on four floors. Bedrooms and communal spaces were brightly decorated, and residents had their own personal possessions that included photographs, televisions and radios. Bedrooms viewed had call bells within easy reach of residents. The manager informed the Inspector that bedrooms are redecorated as and when required, and also when they become vacant. Residents spoken to stated that the bedrooms are pleasantly decorated and the home is always very clean and tidy. All communal areas are accessible to residents. The home has grab rails that help residents to maintain their independence. Ridgeway Manor DS0000013764.V337336.R01.S.doc Version 5.2 Page 17 Requirements were made in the previous inspection in regard to the cleanliness of the kitchen. The home has a cleaning plan in place that details the work undertaken to ensure it is kept clean and tidy. The home had an inspection from the Environmental Health Office; however, the report was not available during this site visit. The manager stated that she would forward a copy of this to the Commission For Social Care Inspection. Food in the fridge was appropriately stored and labelled. A requirement has been made under the Management and Conduct part of this report in regard to the fire doors. A physiotherapist undertook an assessment in January 2007 in regard to the ground floor that accommodates residents who have Dementia. The report recommends that carpets would benefit residents if they were of a calmer design, chairs and furniture should be rearranged into smaller groups, and chairs need to be replaced with chairs of varying heights to accommodate the different heights of residents. The report also states that the garden area needs to be completely re-organised to create a safe but pleasant environment for residents to sit in warm weather. The manager has obtained quotes in regard to the carpets and furniture and is waiting to have the work commissioned. During the site visit the Inspector had discussions with external contractors who were laying a sloping footpath from the garden to the patio. They also stated that they are to lay two paths across the very large garden that will meet in a seating area where residents can sit and relax. The patio area was covered in moss that must be cleared to ensure it is safe for use. The manager informed the Inspector that there are plans to have the surfaces replaced, and all areas are to be made assessable to wheelchair users. During the tour of the premises, identified issues were discussed with the manager. The sluice room requires attention to the floor cover, and a missing light cover must be replaced. Bedroom 33 had a cracked lavatory pan and the bath panel requires attention. Bedroom 31 had a malodour, and bedrooms 8 and 9 did not have radiator covers fitted. The activities room had a crack in the safety glass that must be replaced to ensure the safety of residents and staff when using this room. The home has recently provided walk in wet room showers, and there are plans to replace and/or refurbish all bathrooms. The property is an old building, and maintenance is ingoing throughout the year. Evidence found during the site visit supported the information that was provided in the AQAA. Ridgeway Manor DS0000013764.V337336.R01.S.doc Version 5.2 Page 18 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): Standards 27, 28, 29 and 30 were assessed. Quality in this outcome area is adequate. 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 residents. The home has a recruitment policy and procedure in place; however, this has not always been followed when recruiting staff, therefore not fully protecting the residents. EVIDENCE: The duty rota viewed during the site visit provided evidence that there are sufficient numbers of staff on duty to meet the needs of residents. Senior care staffs are on duty for all shifts. There are three waking night staff each evening, which the manager stated includes a senior care worker. Information provided in the AQAA informs that there are twenty three care staff employed at the home, nine staff hold the minimum of NVQ level 2 or above, and six are currently working towards the NVQ level two and above, therefore the home is on course to meet the National Minimum Standards in regard to a minimum of 50 of staff to hold the relevant NVQ qualifications. The home has a Recruitment policy and procedure that was viewed during the site visit. This was last reviewed in 2005. The manager informed the Inspector that she is now fully responsible for staff recruitment. Four recruitment files were sampled from the twenty-four care staff employed at the home. One did not contain an application form. The manager informed the Inspector that this person was employed by the previous manager, and is leaving the home in two weeks time. Ridgeway Manor DS0000013764.V337336.R01.S.doc Version 5.2 Page 19 The other recruitment files contained application forms, employment history and Protection Of Vulnerable Adults first checks (POVA). The manager showed the Inspector the recorded reasons for gaps in employment that were identified. Two recently recruited staff had made application for Criminal Record Bureau clearances, but each did not commence work until the manager had received the POVA first check. One of the recruitment files sampled contained a police clearance from the country of their origin and a current work permit. The manager informed the Inspector that these staff will not work unsupervised until Criminal Record Bureau documentation has been received. One recruitment file only included one written reference. The manager had made a written note in the file of a telephone conversation made to the referee concerned requesting this to be forwarded to the home. Requirements in regard to staff recruitment had been made in the previous inspection report; however, these have not been fully met, and therefore the home’s recruitment procedures are not robust. A requirement has been made that all staff must have two written references before commencing employment. In two recruitment files there was a date recorded by the manager of telephone conversations with last employers requesting written references. However, these were not forthcoming and second written references were received from other sources, one of which was from another previous employer. This was discussed with the manager who informed the Inspector of the difficulties with acquiring written references from past employers. The manager was advised that it is her responsibility to ensure that staffs employed are fit to work at the care home. All files sampled included a photograph and proof of identification. The manager informed the Inspector that new staff are undertaking their induction and have their training books with them; therefore these were not viewed during the site visit. However, the manager showed the Inspector the training book that is used by the home, and this was found to be in line with the Skills for Care Common Induction Standards. The manager informed the Inspector that staff are supervised throughout their induction period. Recruitment files included training staff had undertaken, with the exception of the most recently employed member of staff who is undertaking induction training. The manager stated that recent in-house training has included Dementia, Tissue Viability, Basic Personal Care and Diabetes. Training in regard to Visual Impairments has been identified as a need, and dates for this are to be arranged. This was confirmed during discussions with staff. A good practice recommendation was made at the last inspection that a training matrix showing dates of training undertaken by staff should be maintained. The manager has completed this, however, it should also include all in-house training that is provided to staff. A recommendation has been made that the Ridgeway Manor DS0000013764.V337336.R01.S.doc Version 5.2 Page 20 matrix should be reviewed to ensure that the actual dates of training undertaken, and dates of refresher training are made very clear. Judgements in regard to the mandatory training have been made under the Management and Administration section of this report. Ridgeway Manor DS0000013764.V337336.R01.S.doc Version 5.2 Page 21 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): Standards 31, 33, 35, 36, and 38 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was evidence of areas of good management and practice within the home; however, issues in regard to staff recruitment, training and health and safety must be addressed to ensure the safety and welfare of the residents is maintained. EVIDENCE: The manager informed the Inspector that she has been managing the home since January 2005, and holds the Registered Managers Award (RMA) and NVQ level 4. The manager has undertaken training in regard to staff supervision, recruitment, disciplinary and grievance, and the Surrey Multi-Agency Protection of Vulnerable Adults. The manager stated that she is looking at other training to ensure that she remains up to date with changes in regard to legislation affecting residential care homes. Ridgeway Manor DS0000013764.V337336.R01.S.doc Version 5.2 Page 22 Residents’ and relatives meetings are held on an annual basis, and the home produces a newsletter that is sent to all people connected to the home. A quality assurance survey of residents, their relatives and other associated professionals has been undertaken by the home, a summary of the findings was viewed during this site visit. The manager informed the Inspectors that the outcome of this survey had been fed back to residents and their relatives. The requirement made in regard to this has now been complied with. Regulation 26 visits are being conducted and reports were available for inspection at the home. The home maintains some monies of behalf of residents, which is used for items such as hairdressing. Records were sampled for four residents. The reasons for expenditure were recorded, receipts were maintained and balances for each individual were documented. Monies were maintained in a lockable tin and safe. Monies held on each individual’s behalf were stored together in one tin and it was recommended that a written record of total running balance regularly checked and documented. During discussion, staff informed the Inspector that they are receiving formal one to one supervision on a regular basis. A sample of staff supervision records were viewed which supported this. Fire doors had been fitted with magnetic holders and door guards. However, during this site visit two doors were being kept open with the use of door wedges. The manager immediately removed these. A requirement was made at the last inspection in regard to the use of door wedges. Whilst it was observed that all other fire doors had the appropriate appliances in place, this requirement has not been fully complied with. Therefore a requirement in regard to the use of door wedges has been carried over. Radiators identified during this site visit had not been covered. A requirement in regard to this has been made. The manager provided evidence that staff had received training in regard to Fire Safety, Moving and Handling and Food Hygiene. These were recorded on a training matrix that was recommended at the previous inspection. Some, but not all staff had received training in regard to First Aid. Training in regard to Infection Control and Health and Safety had not been delivered to staff. The manager informed the Inspector that this training was to have taken place in the week prior to this site visit, but had to be postponed. This was a requirement made at the previous inspection that should have been completed by the 11th December 2006. The manager has since forwarded dates for this training to be undertaken, however, this requirement will be carried forward, and the manager must ensure it is complied with. Ridgeway Manor DS0000013764.V337336.R01.S.doc Version 5.2 Page 23 Information provided in the AQAA informed that the relevant Health and Safety annual checks had been undertaken. Some of these were sampled during this site visit, and included electrical installation certificate, fire detection and fire fighting equipment, fire risk assessments and fire drills. The manager informed the Inspector that weekly checks are undertaken on the water temperatures. Ridgeway Manor DS0000013764.V337336.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 Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 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 2 X 3 X 3 3 X 2 Ridgeway Manor DS0000013764.V337336.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP19OP19 Regulation 23 (2) (b) (d) Requirement Timescale for action 26/07/07 2. OP29 19(1)(b) Schedule2 Identified issues in regard to the environment of the home must be addressed to ensure residents continue to live in a safe and comfortable environment. A second written reference must 26/07/07 be obtained for the member of staff identified during the inspection. This person must not work unsupervised until this has been received. This requirement has been carried forward from the previous inspection as it has not been fully met. Fire doors must not be kept open 26/06/07 through the use of wedges. (Reference The Regulatory Reform (Fire Safety) Order 2005.) 3. OP38 23(4A)(b) 4. OP38 This requirement has been carried forward from the previous inspection. 18(1)(a-c) All staff must receive training in regard to Infection Control and Health and Safety to ensure the health, safety and wellbeing of DS0000013764.V337336.R01.S.doc 20/08/07 Ridgeway Manor Version 5.2 Page 26 residents is promoted at all times. This was a requirement made at the previous inspection that has partially been met. Radiators identified must be covered or replaced with low temperature surfaces. 5. OP38 23 (2) (p) 27/08/07 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 OP9OP9 Good Practice Recommendations It is recommended that medication, which is hand transcribed by staff on to the medication administration record, should be checked and signed by two members of staff. The menus should be reviewed with a dietician to ensure residents are provided with quantities of suitable, wholesome nutritional food, which is varied and properly prepared. It is recommended that the manager maintains a complaints register should anybody wish to raise a complaint or concern. It is recommended that the training matrix includes all inhouse training that has been provided for staff. The manager should review the matrix to ensure dates of training undertaken, and dates refresher training are due, are made very clear. 2. OP15OP15 3. 4. 5. OP16OP16 OP30OP30 OP30OP30 Ridgeway Manor DS0000013764.V337336.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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.V337336.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. 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