Inspection on 29/08/06 for Ridgeway Manor

This inspection was carried out on 29th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 26/06/07

Ridgeway Manor 11/12/06

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 Denise Debieux Key Unannounced Inspection 29th August 2006 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.V309435.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.V309435.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) gratwick@mistral.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.V309435.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Of the 43 residents accommodated, up to 10 may fall within the category of either MD(E) or DE(E) One named person may be accommodated within the category of DE Date of last inspection 12th January 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 £450 - £720 per week. This fee does not include newspapers, chiropody, hairdressing, optician, dentist or day centre. This information was provided on 18/08/06. Ridgeway Manor DS0000013764.V309435.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place over 11.5 hours and was carried out by Denise Débieux, Regulation Inspector. Mrs Vera Bulbeck, Regulation Inspector, was present for three hours during the morning and spent that time talking with service users, their relatives and members of staff. Ms Janet Browne (Registered Manager) was present as the representative for the establishment. A tour of the premises took place. Six of the forty-two service users, three visiting relatives and five on-duty staff were spoken with during the visit. In addition, eight service user survey forms and three relatives’ survey forms were completed and handed in to the inspector on the day of this visit. Some of the comments made to the inspector and made on the survey forms are quoted in this report. The home had completed a pre-inspection questionnaire and service user care plans, staff recruitment and training records, health and safety check lists, menus, policies, procedures, medication records and storage were all sampled. The lunchtime meal and medication round was observed and the home was toured. The inspector would like to thank the service users and staff for their time, assistance and hospitality during this visit. What the service does well: What has improved since the last inspection? The home continues with it’s ongoing maintenance and decoration programme. The carpet identified at the last inspection had been replaced and the controlled drug records were up to date. Ridgeway Manor DS0000013764.V309435.R01.S.doc Version 5.2 Page 6 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. Ridgeway Manor DS0000013764.V309435.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.V309435.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home needs to ensure that comprehensive pre-admission assessments are carried out prior to offering a service user a place. The home does not offer intermediate care. EVIDENCE: Three care plans were sampled in depth for the most recent admissions to the home. In two cases, pre-admission assessments had been partially carried out, prior to admission during a visit from the manager to the service users. In another case the manager had used a nurse’s faxed report to the home. Pre admission assessments are carried out by either the manager or one of the two deputy managers. The home is using a new booklet style assessment form that would provide in depth information if fully completed. The forms seen had only been partially completed. Important risk assessments had not been completed (e.g. falls and nutritional risk assessments) and the forms had not been signed or dated by either the person completing the form or the service users or their representatives to signify their involvement or Ridgeway Manor DS0000013764.V309435.R01.S.doc Version 5.2 Page 9 agreement. Some information that the home had used was also noted to be 2 years old and may not have been current information. The need for comprehensive pre-admission assessments was discussed with the manager and a requirement has been made. All eight service users surveyed confirmed that they had been given a contract and that they had received enough information before making a decision to move to the home. Ridgeway Manor DS0000013764.V309435.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home needs to ensure that all service users have an up to date, individual care plan that details the care required to fully meet all aspects of their health, personal and social care needs. Policies, procedures and practices are in place to ensure the safe administration of medication. However, the home needs to ensure that staff follow the policies and procedures and any professional guidelines for the safe handling of medications and associated record keeping. Service users feel they are treated with respect and that their right to privacy is upheld. EVIDENCE: The care plans sampled during this visit were all drawn up shortly after the service users’ admission to the home. The manager explained to the inspector that they are trialling a new care planning system, hence some of the care plans were in the new format and some in the old. At present there is no clear system and both the inspector and the manager found it difficult to find information easily in the care plans. Ridgeway Manor DS0000013764.V309435.R01.S.doc Version 5.2 Page 11 The care plans sampled did not include all areas of need identified in the preadmission assessments, the service users’ preferences and individual needs were recorded in different areas and it was difficult to obtain an accurate picture of the up to date care required or the way the service user would like that care to be carried out. E.g. One service user was identified in their preadmission documentation as having a pressure sore and needing a pressure relieving mattress. The risk assessment on admission showed that the service user was at high risk of developing pressure sores. The home had made a referral to the local district nurse team to carry out an assessment but there was no documentation to show what action had been taken by the home to prevent skin breakdown or whether a pressure relieving mattress had been supplied at the time of the service user’s admission to the home. Daily notes made by the care staff did not evidence that the staff were monitoring the situation. For another service user, a dental problem had been treated by a Dentist but there was no care plan to advise staff of the treatment and no plan had been developed to prevent the problem recurring. The inspector was advised that each service user is weighed once a month. However, on looking at the records of monthly weight, these had not been carried out since May. Risk assessments for the risk of falls, skin breakdown, manual handling and nutritional status were all included in the new care plan booklets but these had not been completed for all service users and had not been reviewed since admission. No care plans included social care needs and none sampled had been signed by service users or their representatives to signify their agreement with the contents. In addition, the person carrying out the assessments had not signed or dated their entries. Daily notes are made but do not provide evidence that specific needs are being met. Requirements have been made regarding the care planning system at the home. All service users surveyed and spoken with felt that they receive the care they need and all relatives confirmed that they were satisfied with the overall care provided at the home, with one relative commenting ‘‘Very much so. Mother always looks nice and clean.’ The medication administration records, medication blister packs and medication storage were all sampled. Generally the blister packs and medication administration record (MAR) sheets tallied. However, there were a few gaps on one MAR sheet. A check on the blister pack showed that those medications had in fact been given. In another case there were some medications left in the blister pack that had not been given but had been signed for as given. The lunchtime medication round was observed and seen to be in line with the home’s policies and procedures. A requirement has been made regarding medication. Ridgeway Manor DS0000013764.V309435.R01.S.doc Version 5.2 Page 12 During the tour of the home staff were observed to always knock before entering the service users’ bedrooms and service users surveyed and spoken with stated that they felt their privacy was respected. One service user commented that ‘the staff are charming.’ Ridgeway Manor DS0000013764.V309435.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Contacts with family and friends are encouraged. The recent appointment of an activities co-ordinator is a positive step towards ensuring that activities provided will be developed to meet the preferences, expectations and needs of all service users. However, the current limited activities and lack of choice of menu is limiting service users’ opportunities to exercise choice and control over their lives. EVIDENCE: During this visit the manager discussed how the home had recognised that they needed to improve their activity provision and had recently employed an experienced activity co-ordinator who is expected to start work in September. Of the eight service users surveyed two felt there were always activities they could take part in, four answered ‘usually’ and two answered ‘sometimes’. One service user commented that ‘there is not much to do here’ but went on to say how he enjoyed going to the day centre. Other service users commented on how they were sometimes bored. Ridgeway Manor DS0000013764.V309435.R01.S.doc Version 5.2 Page 14 Some service users are able to attend a local day centre and also a local work centre. On the day of this visit there was a pianist playing in the ground floor reception area and service users were sitting and enjoying the music. The menus for four weeks were sampled during this visit. The main hot meal of the day is at midday with soup and a lighter meal in the evening. However, the service users are not offered a choice of hot meal, with just one main dish on the menu each day. Service users told the inspector that they can have sandwiches if they do not like the main meal. However, it was seen from the menus that on three evenings a week the supper consists of sandwiches. This potentially means that, on occasions where service users have opted for a sandwich at lunchtime, and the evening meal is soup and sandwiches, the service user would not have had a hot meal all day. This is unacceptable and must be rectified without delay. A requirement has been made. The lunch time meal took place during this visit and the service users spoken with were enjoying their meal. Of the eight service users that were surveyed, three stated that they always liked the meals at the home and five answered ‘usually’ with one service user adding that the meals are very good. Another service user told the inspector that ‘Every meal is a surprise’. Ridgeway Manor DS0000013764.V309435.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has a simple, clear and accessible complaints procedure which includes timescales for the process. The policies and procedures in place to protect service users from harm or abuse need to be reviewed in line with the Surrey Multi-agency Procedure and the Department of Health ‘No Secrets’ guidelines. Current recruitment practices, lack of comprehensive care planning and limited staff training is placing the service users at possible risk of harm and abuse. EVIDENCE: The home has a complaint’s procedure in place that is available to all service users and their relatives. Of the eight service users surveyed, seven answered that they always knew who to speak to if they were not happy and one answered ‘sometimes’. Service users surveyed and spoken with all said that they felt safe at the home. The home has a policy on the prevention of abuse but this is not in line with the Department of Health ‘No Secrets’ guidelines. The staff were unaware of the Surrey Multi-agency Procedure for the Protection of Vulnerable Adults and the home does not provide training in this subject. Requirements have been made. Care planning is addressed in the ‘Health and Personal Care’ section of this report and staff recruitment and training is addressed in the ‘Staffing’ section of this report. Ridgeway Manor DS0000013764.V309435.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home and extensive gardens are well-maintained and provide the service users with a homely environment in which to live. Some environmental changes could add to the quality of life for service users with confusion, dementia or mobility/sensory problems. EVIDENCE: During this visit the home was toured. All areas were seen to be clean and warm with furniture and adaptations made to provide for the needs of the service users. Personal bedrooms were bright and many had been personalised with the service users’ own belongings. The grounds are extensive and provide a pleasant outlook from the bedrooms, with seating areas provided for the warmer weather. There were numerous communal rooms and all were seen to be cheerfully decorated. The home has an ongoing maintenance and decoration programme and the carpet mentioned in the previous report has now been replaced. Ridgeway Manor DS0000013764.V309435.R01.S.doc Version 5.2 Page 17 Service users spoken with were happy with their personal rooms and felt that the home was kept fresh and clean. One service user commented that ‘the cleaners are very good’. One of the communal lounges is on the ground floor and the inspector was advised that this lounge is mostly for the service users that need a higher degree of supervision or assistance. It was stated that there were always three care assistants allocated to this area during the daytime. This room opens directly onto the grounds via two double patio doors. However, the inspector was advised that these doors are generally kept shut as it would not be safe for the ambulant service users with confusion or dementia to have open access to the grounds. It was mentioned to the inspector that, during the heat wave in July, this room had been very hot as there was only one window that could be safely left open. It was added that the home had provided fans but that they had only helped a little. Many of the carpets in this area are highly patterned, and there are many doors coming off of the corridors and out of the communal lounge. This can be confusing for those with dementia or mobility/sensory problems. A recommendation has been made that the home commission an environmental assessment from someone with specialist knowledge of adaptations that can be made to the environmental that are known to help people with dementia and/or mobility and sensory problems. The home offers accommodation for up to ten service users with dementia. At present, due to the open and extensive nature of the grounds and gardens, there are no parts of the grounds that service users can enter without a substantial risk to their safety unless they are closely supervised. A recommendation has been made that the home explore ways that a safe area could be provided. The home employs two laundry assistants, who ensure that a laundry service is provided seven days a week. The laundry is located in the basement and was seen to be well equipped. Hand washing facilities are located throughout the home. In order for standard 26 to be fully met, the home need to ensure that all staff have received training and updates in the control of infection. Ridgeway Manor DS0000013764.V309435.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is poor. 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 the service users at the home. Action must be taken to improve the staff recruitment and training procedures to ensure that the service users’ safety is protected. EVIDENCE: The staff rota evidenced that staff are provided in sufficient numbers to meet the needs of the service users at the home. Of the eight service users surveyed, two stated that staff are always available when needed and six answered ‘usually’. The home is working towards having 50 of care staff qualified to National Vocational Qualification (NVQ) level 2 in care. The inspector was advised that, of the twenty-three care staff, five have achieved NVQ level 2 or above in care and five are in progress and expected to finish soon. During this visit the files of five recently recruited members of staff were sampled. In one file there were no references and no proof of identity. No Criminal Record Bureau check had been applied for and therefore there had been no check to see if the person was listed on the Protection of Vulnerable Adults (POVA) register. The application form also had significant gaps that had not been explored. Ridgeway Manor DS0000013764.V309435.R01.S.doc Version 5.2 Page 19 In the remaining four files, all had completed application forms (although one was not signed) all contained two references and all had valid enhanced Criminal Record Bureau (CRB) certificates which included a check on the POVA list. However, none of the files had recent photographs, three of the four application forms had gaps in employment that had not been explored or explained and two did not have references that related to their last place of employment which involved working with vulnerable adults. No staff spoken with were aware of the General Social Care Council (GSCC) code of conduct and practice and had not been provided with a copy by the home. The home had a copy of the original Care Homes Regulations 2001 but the staff were unaware that these regulations have been amended numerous times by supplemental regulations, adding substantially to the recruitment requirements for care staff. The training records for the same five staff were checked. Only two of the five members of staff had received manual handling training and none had received training in the control of infection. In addition, the last fire safety training at the home had been in 2003. Induction training records were unavailable for inspection and there was no clear system in place for recording training provided or ensuring that mandatory safe working practice updates are carried out. The current staff recruitment and training practices at the home are placing service users at risk of potential harm or abuse and must be addressed as a matter of urgency. Requirements have been made. Ridgeway Manor DS0000013764.V309435.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The registered manager is qualified and has the experience to run the home and meet it’s stated purpose, aims and objectives. The home does not have an effective quality assurance and monitoring system in place that is based on seeking the views of the service users. Service users’ financial interests are safeguarded by the financial policies and procedures at the home. Service users’ best interests are not safeguarded by the home’s record keeping practices. Action must be taken to protect and promote the health, safety and welfare of service users and staff. Ridgeway Manor DS0000013764.V309435.R01.S.doc Version 5.2 Page 21 EVIDENCE: Ms Browne has been the manager at the home since January 2005, and was registered by CSCI earlier this month. She has worked in care settings since 1983 and has held managerial positions for the past three years. She holds the Registered Manager’s Award and an NVQ 4 in management. The staff spoken with on the day of this visit were complimentary about the manager with comments made that included: ‘Staff morale has improved’ ‘the manager has done a lot’ and ‘the manager is good to work for’. The inspector was advised that the home holds residents, meetings twice a year and service users’ views are sought on an informal basis. However, there is, at present, no effective quality assurance and monitoring system in place and there has been no internal quality assurance audit carried out in at least the past twenty months. This situation must be rectified and a requirement has been made. Service users are provided with lockable storage in their rooms for the safekeeping of any small items of value. Personal money is held on account for service users, with individual records held for each service user and receipts kept of any transactions. These records and receipts were sampled and found to be well maintained. During this visit various areas of concern have been highlighted regarding the systems of administration and documentation. This had already been recognised by the manager and an administrative assistant has recently been employed who is due to start working at the home within the next few weeks. This should provide additional support to the manager in working towards meeting the National Minimum Standards for older people and the requirements made in this report. During this visit, ways for the manager to obtain guidance, information and to keep up-to-date with the most current legislation were discussed. Much of this information is now available on the CSCI website as well as other local organisations and government websites and many of the publications are available for download from the internet. However, when the manager attempted to obtain The Surrey Multi-agency Procedure for the Protection of Vulnerable Adults via the internet, the computer was not able carry out the task. The provider must ensure that the manager has the means to keep up to date with any changes in legislation and best practice guidelines related to the running of a care home and the provision of care and support to service users. A recommendation has been made that the provider review the computer provision at the home. In the course of this visit the inspector noted that some incidents that should have been notified to the CSCI under Regulation 37 of The Care Homes Ridgeway Manor DS0000013764.V309435.R01.S.doc Version 5.2 Page 22 Regulations 2001 had not been made. Required notifications must be made without delay and a requirement has been made. During the tour of the home areas of concern were noted in the kitchen area: • opened food was stored in the refrigerator without being dated or labelled; • wall cupboards in the kitchen were domestic in nature and in disrepair; The last Environmental Health inspection had been carried in June 2005 and recommendations had been made. On the day after this visit the inspector contacted the Environmental Health Officer (EHO) to discuss the concerns identified. Later that same day and after visiting the home, the EHO contacted the inspector and provided an update. She said she had found that the staff had obviously worked hard and the kitchen was very clean with all food in the refrigerators being correctly labelled Some recommendations have been by the EHO made and her report will be sent directly to the home. The need for the staff to receive training in safe working practices is addressed earlier in the ‘Staffing’ section of this report. Ridgeway Manor DS0000013764.V309435.R01.S.doc Version 5.2 Page 23 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 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X X 2 X X X 2 STAFFING Standard No Score 27 3 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 X 1 1 Ridgeway Manor DS0000013764.V309435.R01.S.doc Version 5.2 Page 24 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 OP3.1 Regulation 14(1) (a-d) Requirement The registered person must ensure that, so far as it is practicable to do so, no service users are admitted to the home without having had his/her needs fully assessed and been assured that that these will be met. The registered person must review all care plans and ensure that each service user has an individual plan of care that includes the following: • A comprehensive assessment of needs covering all areas of health, personal and social care (activity) needs; • Risk assessments, to include: prevention of falls, use of bed rails, nutrition, risk of pressure sore development, moving and handling; • Details of all individual needs identified, including social care needs; • Goal/objective for each need; • Actions to be taken to ensure the goals are met and to include the service users’ preferences; DS0000013764.V309435.R01.S.doc Timescale for action 29/08/06 2 OP7 OP8 14(2)(a) (b) 15(1) 15(2) (a-d) 16(2)(m) (n) 29/12/06 Ridgeway Manor Version 5.2 Page 25 • 3 OP8 12(1) (a)(b) 4 OP9 17(1)(a) Schedule3 5 OP15.1 OP15.2 OP15.7 16(2)(i) 6 OP18 13(6) Daily report writing to evidence that identified needs and goals are being met; • Newly identified needs or problems must be promptly added to the care plan; • Signature of service user/representative to signify their involvement and agreement with the plan; • Date and signature of staff member(s); • A review of care plans and risk assessments must take place at least once a month. The registered person must make proper provision for the health and welfare of service users. Where it is identified that a service user is to be admitted who requires equipment for the promotion of tissue viability and prevention or treatment of pressure sores, that equipment must be obtained and available at the time of the service user’s admission to the home. The registered person must ensure that complete and accurate records of all medication administered to service users are kept. The registered person must ensure that service users are provided with a varied and nutritious diet; that service users are offered a choice of meals; and that service users are provided with at least one hot meal a day. The registered person must ensure that all staff are aware of the Surrey Multi-agency Procedure for the Protection of Vulnerable Adults. 29/08/06 29/08/06 29/08/06 29/09/06 Ridgeway Manor DS0000013764.V309435.R01.S.doc Version 5.2 Page 26 7 OP18 13(6) 8 OP18 13(6) 9 OP29 19(1)(b) Schedule2 10 OP29 19(1)(b) Schedule2 11 OP29 18(3) (a-b) 19(1)(b) Schedule2 The registered person must ensure that all staff receive training in the protection of vulnerable adults. The registered person must obtain a copy of The Surrey Multi-agency Procedure for the Protection of Vulnerable Adults. The registered person must not employ a person to work at the care home unless he/she is fit to work at the care home and the registered person has obtained the information and documents specified in paragraphs 1-9 of Schedule 2 of The Care Homes Regulations 2001 (as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004). The registered person must check all staff files and obtain the information and documents specified in paragraphs 1-9 of Schedule 2 of The Care Homes Regulations 2001 (as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004) retrospectively for all staff employed since 26th July 2004. The registered person must ensure that any staff that do not have all the required checks and documentation in place, are closely supervised until all requirements of Regulation 19 and the amended Schedule 2 of the Care Homes Regulations 2001 are fully met. 29/11/06 29/09/06 29/08/06 05/09/06 29/08/06 Ridgeway Manor DS0000013764.V309435.R01.S.doc Version 5.2 Page 27 12 OP29 18(1) (c)(i) 19(1)(a-c) Schedule2 13 OP29 14 OP30 15 OP30 16 OP33 The registered person must ensure that all staff responsible for staff recruitment are aware of, and understand, the requirements of The Care Homes Regulations 2001 and Schedule 2 (as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004). This must take place before any further recruitment of staff. 18(4) The registered person must provide all staff with a copy of the GSCC code of conduct and practice and ensure they are aware of the contents. 18(1)(a-c) The registered person must ensure that all staff receive training appropriate to the work they are to perform. Where employees have not received appropriate training the registered person must limit their involvement in the work activities until such time as they have received the relevant training. 18(1)(a-c) The registered person must draw up a training plan to address the gaps in staff training and ensure staff are competent to provide care to service users. A written plan must be submitted to the CSCI, Eashing office in respect of this requirement. 24(1) The registered person must 24(5) establish and maintain a system for evaluating the quality of the services provided at the home. This system must include consultation with the service users and their representatives. 29/08/06 29/11/06 29/08/06 29/09/06 28/02/07 Ridgeway Manor DS0000013764.V309435.R01.S.doc Version 5.2 Page 28 17 OP38 37(1)(2) 18 OP38 23(5) 19 OP33.10 24A(1-3) The registered person must ensure that all notifications required of Regulation 37 of the Care Homes Regulations 2001 are made to the CSCI, Eashing office without delay. The registered provider must ensure that recommendations made during the inspection by the Environmental Health Officer on the 30th August 2006 are met within the timescale set. The registered person must submit, to the CSCI, Eashing office, an improvement plan, setting out exactly how requirements 1-18 will be met in full. The plan must set out the methods by which, and the timetable to which, the registered person intends to improve the services provided in the care home. A copy of this plan must be made available to the service users and their representatives. 29/08/06 29/08/06 18/10/06 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 2 3 Refer to Standard OP16.4 OP18 OP18 Good Practice Recommendations It is recommended that the complaint’s procedure is amended to say that a complainant can approach the CSCI ‘at any stage’ of the process. It is recommended that the home revise their policy on the prevention of abuse to reflect the Surrey Multi-agency Procedure for the Protection of Vulnerable Adults. It is recommended that the manager and two deputy managers enrol on the next available course for the Surrey Multi-agency Procedure for the Protection of Vulnerable Adults. DS0000013764.V309435.R01.S.doc Version 5.2 Page 29 Ridgeway Manor 4 OP22 5 6 OP22 OP30 7 OP37 It is recommended that that the home commission an environmental assessment from someone with specialist knowledge of adaptations that can be made to the environmental that are known to help people with dementia and/or mobility and sensory problems. It is recommended that the home explore the possibility of providing a safe area of the grounds/gardens that can be utilised by service users with dementia. It is recommended that the registered person develop and maintain a training log for all staff showing dates that training has been undertaken; topic of training and dates when next updates are due (where appropriate). This log should include all mandatory safe working practices and protection of vulnerable adults training plus additional training required to meet the specific needs of the service users accommodated at the home. It is recommended that the registered provider review the computer provision at the home to enable the manager to easily access the latest guidance and information and provide a means for the manager to keep abreast of changes in legislation and guidelines related to the management of a care home and the care of service users. Ridgeway Manor DS0000013764.V309435.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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.V309435.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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