Inspection on 14/03/07 for Ridgeway Nursing Home

This inspection was carried out on 14th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ridgeway Nursing Home 11/02/09

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Ridgeway Nursing Home Crich Lane Ridgeway Belper Derbyshire DE56 2JH Lead Inspector Susan Richards Key Unannounced Inspection 14 March 2007 09:30 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 Nursing Home DS0000067194.V321376.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 Nursing Home DS0000067194.V321376.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ridgeway Nursing Home Address Crich Lane Ridgeway Belper Derbyshire DE56 2JH 01773 853500 01773 853957 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) Sudera Care Associates Limited Ms Paula Browne Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places Ridgeway Nursing Home DS0000067194.V321376.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3 places for younger PD aged over 50 included in the total number of registered beds The maximum number of service users that may be admitted to Ridgeway Nursing Home is 37. New registration (company). Date of last inspection Brief Description of the Service: Ridgeway Care Home operated as a registered care home for many years, however, during the inspection year of 2006-07 there has been a change of registration from individual named providers to a company registration. This is therefore the first key inspection of that service following this change of registration. The home provides nursing and personal care for up to 37 older persons, with the total numbers including up to three places for young physically disabled adults aged 50 years and over. The original large detached brick house has been extended to provide purpose built accommodation standing within it own ground in a pleasant rural setting. It is not on a public transport route, although the home accesses community transport on behalf of service users. It is located within 2 miles of the market town of Belper, having a good range of shops and amenities. There are thirty-three single and two double/shared bedrooms (with one of the shared doubles being used as a single at the time of the inspection). All bedrooms rooms have wash hand basins, although no en suites are provided and there is a choice of bathroom and toilet facilities. There is a range of equipment and adaptations to assist those persons with physical disabilities, including a passenger lift to the first floor and an emergency call system throughout. The registered manager has been in post for approximately one year, although has worked at the home since 1997 as Registered General Nurse. Care and support for service users is provided from a team of nursing, care and hotel services staff and including a part time activities co-ordinator. The range of weekly fees charged by the home per service user are in accordance with social services fees structure (2006-07), which are as follows: Residential (personal care only) – Low band - £300.00 to High band £331.60 Nursing care - Low band - £378.65 to High band £471.65 (It is understood that these may be subject to review from 01 April 2007 in accordance with Social Services revised fees structure – to be determined). Ridgeway Nursing Home DS0000067194.V321376.R01.S.doc Version 5.2 Page 5 Ridgeway Nursing Home DS0000067194.V321376.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. There has been a change of registration since the last inspection of this service. Therefore this is considered to be the first inspection of this service since that change. Case tracking was used as part of the methodology for the inspection. This involved the random sampling of three service users (out of a total of 25) whose care and service provision was examined more closely. This involved discussions with them and their representatives about their care and the services they receive, examination of their care plans and associated care records and inspection of their private and communal accommodation. What the service does well: What has improved since the last inspection? Ridgeway Nursing Home DS0000067194.V321376.R01.S.doc Version 5.2 Page 7 Not applicable – this is a new registration. 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 Nursing Home DS0000067194.V321376.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ridgeway Nursing Home DS0000067194.V321376.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 1, 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are reasonably well informed and supported during their admission process and their needs are effectively met, although the lack of information about the home and its services and facilities in alternative formats may be a disadvantage to some service users. EVIDENCE: Discussions were held with a number of service users about the arrangements for their admission, their needs and how these were met and the recorded Ridgeway Nursing Home DS0000067194.V321376.R01.S.doc Version 5.2 Page 10 needs assessment information of those service users case tracked were examined. All service users who were able to express a view said that they felt their needs to be well met in accordance with their individual choices, lifestyle preferences and given capacities. They also said that their needs had been discussed with them prior to their admission or with their nearest relatives where they had chosen this. The majority had been provided with key written information about the home by way of a combined statement of purpose/service users guide, which they kept in their own rooms, including individual written terms and conditions/contracts. Copies of the latter were also provided within individual’s own care records. However, service users comments about the service were not included within the statement of purpose/service user guide and one service user case tracked was unable to read the information and was not aware of its existence in the room due to their severe sight impairment. Recorded needs assessment information for service users case tracked were suitably recorded, including care review details. Comments received from service users and relatives, included: “Staff are usually available when I need them.” “Staff are patient, help me and always encourage me to do the things I am able and wish to do for myself.” “Staff work hard and are caring and supportive.” The home does not provide for intermediate care. Ridgeway Nursing Home DS0000067194.V321376.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users health is effectively promoted and their health care needs met by a staff group who treat them with dignity and respect. EVIDENCE: The written care plans of service users case tracked were examined and discussed with staff and service users as able. Staff was not able to consult with two of those service users about their care plans due to their individual given capacities. However, the other service user had signed their agreement to their care plans, with signatures of nearest relatives in place for the two who were unable. Care plans examined were formulated in accordance with service users risk assessed needs and overall were reflective of evidence based practise and guidance concerned with the care of older persons. However, for two of the service users case tracked who had bed rails in situ, although risks of falls were identified via their moving and handling risk assessments and the Ridgeway Nursing Home DS0000067194.V321376.R01.S.doc Version 5.2 Page 12 actual provision of bedrails, there were no dedicated recorded risk assessments in place in respect of the actual use of bed rails. This was discussed with the manager during the inspection. The arrangements for the organisation and delivery of care and support were also discussed with service users and staff and some observations were also made during the inspection with regard to some aspects care delivery. Staff was conversant with service users needs and were observed to treat them with dignity and respect. Discussions with service users confirmed this. Comments received included: “Staff always treat me properly.” “All staff are friendly, good humoured, caring and helpful.” A staff workshop had recently been held with regard to promoting empathy with and the dignity, respect and privacy of service users. Individual care plans examined recorded each service users preferred name of address and staff said that they regularly discussed care plans during the verbal hand-over from shift to shift, with particular regard to new admissions or changes/reviews to any care plan. Arrangements for service users access to outside health care professionals, including that relating to routine health screening were also well accounted for. The arrangements for the management and administration of service users medicines were examined and discussed with staff and service users. There was no service user who managed their own medicines, although a small number had chosen to retain and administer their own prescribed creams and were provided with suitable storage in their own rooms for these. The medicines administration record (MAR) sheets for those service users case tracked were examined. Overall these were well recorded and maintained, with the exception of - one persons’ medicines, which due to their recent admission were handwritten onto the MAR sheet, but were not signed or dated by the person writing these or countersigned by another staff member witnessing this. The MAR sheet of another service user case tracked had a small number of gaps where there was no staff signature to indicate as to whether prescribed medicines were given or a coded record to indicate the reason why they had not. Ridgeway Nursing Home DS0000067194.V321376.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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The importance placed by the home on promoting and developing service users access to leisure/social activities and community contacts, together with good nutrition is in service users best interests. EVIDENCE: Discussions were held with service users and staff about individual’s daily living routines, arrangements for leisure, social, cultural and religious activities and observance, contacts with friends and families and meals. Service users spoken with said that a range activity is offered, which they chose whether to join or participate. Ridgeway Nursing Home DS0000067194.V321376.R01.S.doc Version 5.2 Page 14 The home employs a part-time activities co-ordinator who is very enthusiastic` and works hard to promote a range of social and leisure activities in accordance with service users known preferences and abilities. Details of these are regularly posted on the service users information board. Service users confirmed that there is regular organisation of entertainment and music, card games, board games, skittles, origami, crafts, jigsaws and puzzles, soft play darts, together with gentle exercise sessions, which were recently introduced. Poetry readings are regularly undertaken via a fundraising committee member for the home, support for reading letters, magazines/newspapers is provided on a one to one for those who have difficulty and there is opportunity to join a reading circle. Seasonal celebrations are always organised, including service users birthdays and reminiscence albums are available for service users to browse. There is also an activities ‘room’, providing a variety of equipment relating to the above. A St Patrick’s day party was organised for the weekend following the inspection and also St George’s day and Easter plans were in hand. Other key activities, which took place in February, included a Valentine lunch and a slide show of ‘Old Belper.’ The manager advised that they were planning to trial a ‘virtual walk’ film via the Alzheimer’s Society given that there are a number of service users accommodated in the home with short term memory loss. The home is not on a bus route. However, access to community transport is provided and the home had recently joined Amber Valley Volunteer Service including a befriending service. One service user spoken with said that she went out every week via this service and regularly enjoyed trips into Belper. The manager advised that she was seeking to increase volunteer inputs into the home and also to increase key worker/carer one to one time with service users aside from personal care tasks. Minutes of the most recent meetings of the fund raising committee were provided, together with a monthly newsletter for service users. Current fundraising is focusing on the provision of new garden furniture, together with a sensory garden and an audio loop for one of the lounges. Visiting to the home is open, with a number of relatives being actively involved in the home, for example via the fund raising committee. The home has also recently become a member of NAPA (National Association for the provider of Activities for Older Persons). This aims to enable the home to put a greater emphasis on activities in the home and for the activities coordinator to network with other activity co-ordinators concerned with older persons. She was also due to attend a training day organised by the association. There were no service users accommodated from diverse cultural or religious backgrounds. The manager advised that she was continuing to experience Ridgeway Nursing Home DS0000067194.V321376.R01.S.doc Version 5.2 Page 15 difficulties in accessing a visiting Church of England minister to provide a regular/monthly service, although had recently secured a monthly service via the Catholic Church for a small number of practising service users and was continuing to pursue this. One service user case tracked received a personal visit from their local minister during the inspection. Menus were examined and discussions held with service users regarding meals. Menus are displayed on a daily basis and include details of snacks available between meals. The organisation and serving of lunches was also observed. This was done in a calm and unhurried manner. Tables were attractively set in the main dining room, where a small number of service users chose to attend. Many service users chose to eat in their own rooms, which were served on individual trays by staff. Service users who required were provided with suitable assistance with eating and drinking, with food prepared and presented in accordance with their risk assessed needs. All those spoken with said the standard of food provided was good and enjoyable, with plenty of ‘home’ cooking and there was always sufficient. All said the chef was very good. A choice/range of breakfast and teatime menu is offered on a daily basis, with a set lunch providing an alternative for those who wish. Drinks and snacks are always available. There is a clear nutritional strategy in place, which has recently been reviewed, with a clear aim of promoting and improving service users nutritional status in accordance with their assessed needs. The arrangements for consultation and personal choice in respect of personal finances management and personal possessions brought into the home, was examined and discussed and are satisfactory, although there was no open provision of information for service users and their families regarding local advocacy services. Ridgeway Nursing Home DS0000067194.V321376.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are confident to raise any concerns or complaints they may have and are protected from abuse. EVIDENCE: The home has a written complaints procedure in a standardised format, which is openly displayed. Information regarding how to complain, raise concerns and suggestions is detailed within the service user guide, which is provided in each bedroom for service users, again in standard format. Contact details of the Commission are also included in this information. The Inspector advised the manager of up to date contact information for the Commission, which the manager agreed to revise accordingly. Service users spoken with said that the complaints procedure had not been formally discussed with them, but said they would raise any complaints they may have with the manager or staff, although did not have any complaints. All said they were confident that the manager would listen to any concerns or complaints and deal with them effectively. One of the service users case tracked had severe sight impairment and was therefore unable to read the information provided in her room, although knew how to complain and felt confident to do so if necessary. Ridgeway Nursing Home DS0000067194.V321376.R01.S.doc Version 5.2 Page 17 There had been one complaint made since the previous inspection made by the relative of a service user. This related to conflicts of opinion arising in respect of the service users capacity to make choices about their personal care and staffs duty of care. This was discussed with the manager and the complaints record examined in respect of this. Full details of the complaint were recorded, together with action taken and outcomes. The complaint is fully resolved and the serviced user continues to reside in the home and the relative continues to be actively involved with the home and in the service users care. Discussions were held with staff regarding dealing with complaints and also their responsibilities with regard to recognising abuse and safeguarding adults. All staff spoken with had either undertaken training for the protection of vulnerable adults or received some instruction via their induction process. The majority were wholly conversant with their responsibilities and duty of care and aware that there were written procedures in the home to follow in the event of any suspicion or allegation of abuse. However, one senior carer, who had worked in the home for approximately 6 months, was not familiar with recognised procedures, although demonstrated that she would take a reasonably appropriate course of action in accordance with her duty of care should she ever witness the abuse of any service user. There have been no complaints made to the Commission about the home over the last twelve months and no allegations made, which would require reporting, and/or investigation under safeguarding adults’ procedures. Ridgeway Nursing Home DS0000067194.V321376.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 19, 21, 22, 24 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is clean and comfortable and for the most part is reasonably well maintained suiting service users overall needs. However, the poor state of some floor coverings and commodes undermines the quality of the environment and may also compromise the promotion of good infection control. EVIDENCE: The private and communal accommodation of those service users case tracked were inspected, together with a few additional bedrooms. Overall the home was clean, comfortable, well ventilated and lit. Service users rooms were personalised and they expressed overall satisfaction with their environment. Equipment was provided in their rooms in accordance with their assessed Ridgeway Nursing Home DS0000067194.V321376.R01.S.doc Version 5.2 Page 19 needs, including special mattresses. However, some service users and staff were dissatisfied with state of carpets in the main lounge and corridor areas particularly. Despite regular cleaning, these were very heavily stained and worn. Some bedroom carpets were also stained and worn – again the manager advised that this was despite regular cleaning with a small number having stale urine odours. Bedroom doors are not fitted with locks to afford privacy. Service users said they had not been consulted about these. The large bathroom on the ground floor having a specialist Parker bath, sink and toilet, is used by a small number of service users due to their mobility problems. The flooring here was worn, split and not sealed around the edges, with considerable lift away from the edges. This bathroom was extremely cluttered with other items stored, including wheelchairs, hoists and commodes, making access extremely difficult. There is a separate designated storage area for wheelchair which was full. There is also a bathroom on the first floor, although this is unassisted and the toilet is in need of repair there. Staff advised that the majority of service users used the large walk in shower rooms available and that no one used the first floor bathroom. Service users accommodated on the first floor use the ground floor showers/parker bathroom. A number of bathrooms and toilets had domestic type non-occlusive waste bins for discarded hand washing material, presenting a potential infection control hazard. Commodes in many bedrooms were very old and worn, with varnish peeling off presenting a potential infection control hazard. The laundry was suitably equipped, clean and well organised and there are two hand sluices provided. However, the manager advised that a mechanical sluice had been ordered. Ridgeway Nursing Home DS0000067194.V321376.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems and arrangements for the recruitment, induction, training and deployment of staff in the home are satisfactory, thereby promoting the protection and safety of service users. EVIDENCE: At the time of the inspection there were twenty-five service users accommodated (twenty two for nursing care and three for personal care only). Service users overall dependencies and needs were discussed with the manager and staff and reported to be medium to high, although there was no formal tool in place to assess individual’s overall dependencies. The arrangements for the recruitment, induction, training and deployment of staff were discussed with the manager and staff and associated records were examined. All felt that staff training arrangements had improved considerably over the last year and the manager had devised a staff-training matrix. There are suitable arrangements in place to ensure that all staff access appropriate induction and core health and safety training, with further planned (first aid Ridgeway Nursing Home DS0000067194.V321376.R01.S.doc Version 5.2 Page 21 and infection control). Progress will be assessed at the next inspection of this service). There is a number of overseas staff employed from diverse cultural backgrounds. Discussions held with one of those staff indicated the home’s promotion of equal opportunities and support with regard to their employment. Well over 40 of care staff had achieved at least NVQ level two with others due to commence either NVQ level 2 or 3. Arrangements were also made for all staff (and one relative) to undertake dementia awareness training and there had been recent training workshops with regard to promoting service users dignity and privacy. Extended role nurse training had also been provided with regard to syringe drivers. Developments were also taking place with regard to the provision of clinical link nurses. This had been established in respect of continence and was planned with regard to infection control and tissue viability. In addition all registered nurses employed have recently undertaken training in respect of the Liverpool care pathway, which is concerned with the care of dying person. Service users said that staff worked hard, knew how to care for them and were usually available when they needed them. The personal files of four of the most recent staff starters were examined. These were satisfactory, containing all required information in respect of their employment/recruitment and induction. The manager advised of her intention to review and develop the current staff induction programme. Progress with this and staff training will be assessed further at the next inspection of this service. Ridgeway Nursing Home DS0000067194.V321376.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 31, 32, 33, 35, 36, 37 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being well managed and developed in order to promote service users best interests and their health, safety and welfare are being suitably promoted and protected. EVIDENCE: The registered manager worked at the home for a number of years as a registered nurse before taking up the post as manager earlier last year. She is a registered general nurse and also has a BA honours degree in complementary therapies. She is also due to commence nationally recognised training for the Registered Manager’s Award in April 2007. Ridgeway Nursing Home DS0000067194.V321376.R01.S.doc Version 5.2 Page 23 Staff and service users spoke highly of the manager and felt that there was a good sense of leadership and direction in the home with a clear framework for communication. Mechanisms for ensuring effective quality assurance and quality monitoring were discussed with the manager and some staff. A variety of service and clinical audits had been introduced and were being undertaken on a regular basis. Results of those audits were available for inspection. A service user satisfaction survey was in place being on its second round of surveying and an annual development plan was in place based primarily on the outcomes of the above. However, formal mechanisms for the publishing and feedback of the results of the surveys to existing and prospective service users and their representatives were not established. A number of records, which are required to be kept by the home, were examined during the course of the inspection. These included service user’s care plans, medicines records and associated care records, staff records, accident records, food records, records relating to safekeeping of service users monies and valuables. Overall these were properly maintained and stored. Discussions were also held with staff about mechanisms for their supervision. There is no formal system of individual supervision although staff felt reasonably well supported as part of the normal management process and said that they could approach the manager at any time. The manager advised of her intentions to attend formal training with regard to establishing a formal system of individual staff supervision. Discussions were also held with the manager and staff regarding the arrangements for ensuring safe working practises and environmental health and safety. General observations were also made in relation to these during the tour of the premises and a number of records were also sampled. These included staff induction and training records, maintenance records and accident and incident records. Overall these were satisfactory Ridgeway Nursing Home DS0000067194.V321376.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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 4 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 2 3 X 3 X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 X 3 2 3 3 Ridgeway Nursing Home DS0000067194.V321376.R01.S.doc Version 5.2 Page 25 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 Requirement Timescale for action 30/04/07 2. OP19 23, 13 3. OP21 23, 13 4. OP26 13 The arrangements for the recording and administration of service users medicines must be effectively maintained. (Gaps of recording must not be left and had written instructions must be signed and dated and countersigned by persons responsible). (OP26 also applies here). 30/09/07 Carpets, which are damaged and worn must be replaced as necessary – lounge and corridor and those bedrooms where necessary. Bathrooms must be kept in a 30/06/07 good state of repair and be accessible to service users. Damaged and worn bathroom floor coverings must be suitably repaired or replaced and the broken toilet repaired. Suitable arrangements must be 30/06/07 made to prevent the spread of infection and toxic conditions. In this instance - commodes must be in a good state of repair or replaced, as necessary and occlusive waste bins used for DS0000067194.V321376.R01.S.doc Version 5.2 Ridgeway Nursing Home Page 26 discarded hand washing materials must be provided in communal areas. 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. Refer to Standard OP1 OP1 Good Practice Recommendations The service user guide should include service users views of the home. (NMS 16 also applies here). Information about the home and its service provision (including how to complain) should be offered in alternative formats suitable for the service user, for example, large print, audio tape. Dedicated risk assessments for the use of bed rails should be introduced and recorded for those service users who have these in situ. Information regarding local advocacy services should be provided and actively promoted within the home. Sufficient and suitable storage areas should be provided for aids and equipment, including wheelchairs. Suitable locks should be fitted to the door of service users own rooms, accessible to staff in the event of an emergency. At least 50 of care staff should have achieved at least NVQ level 2. The results of service user surveys should be published and made available to current and prospective users, their representatives and other interested parties. 3. 4. 5. 6. 7. 8. OP8 OP14 OP22 OP24 OP28 OP33 Ridgeway Nursing Home DS0000067194.V321376.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Nursing Home DS0000067194.V321376.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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