CARE HOMES FOR OLDER PEOPLE
Ridgwell House 95 Dulwich Road Holland on Sea Essex CO15 5LZ Lead Inspector
Sara Naylor-Wild Unannounced Inspection 17th February 2006 11:00 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 Ridgwell House DS0000060997.V284182.R01.S.doc Version 5.1 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. Ridgwell House DS0000060997.V284182.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Ridgwell House Address 95 Dulwich Road Holland on Sea Essex CO15 5LZ 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) 01255 815633 01255 815633 Prestige International (EC) Ltd Mrs Geraldine Denise Chalk Care Home 16 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (16) of places Ridgwell House DS0000060997.V284182.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. Persons of either sex, aged 65 years and over, falling only within the category of Old Age (not exceeding 16 persons) Four persons, over the age of 65 years, falling only within the category of Dementia, whose names were made known to the Commission in February 2003 The total number of service users accommodated in the home must not exceed 16 persons 30th October 2005 Date of last inspection Brief Description of the Service: Ridgwell House is an established care home for older people in the village of Holland on Sea, near the town of Clacton on Sea. The home has been open since 1985, and was registered to the present owners Prestige International (EC) Ltd in July 2004. The accommodation offers care for 16 service users on the ground and first floors. At the time of the inspection a double bedroom was used to accommodate a single person and therefore all accommodation is in single rooms for 15 service users. There is a stair lift to the first floor. The majority of the accommodation is on the ground floor, with 4 service users on the first floor. There are 3 bathrooms and 1 shower room, all with toilets. In addition, there are 3 separate toilets around the home. Catering and laundering facilities are found in the centre of the home. Communal areas consist of a front and rear lounge and a large dining room. The rear lounge overlooks the rear garden, which is laid to lawn with flowers, shrubs, fruit trees and vegetable beds. In the garden there is a summerhouse, a green house and shed. Seating is provided during the summer in the garden. The front garden has a semi-circular driveway offering some off-road parking. Flowerbeds, plant pots, flowering shrubs and trees bring colour and interest to this area. Ridgwell House DS0000060997.V284182.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection visit took place on 17th February 2006, however the full inspection process was not concluded until 1st March 2006 whilst information in respect of health and safety records was awaited from the manager. The majority of the key standards had been assessed at previous visits to the home, and therefore this inspection centred on those areas not previously covered. These included staff recruitment, supervision and training. During the course of the visit the inspector viewed staff files, policy files, and documents relating to health and safety. The manager Geraldine Chalk had been registered with the CSCI since the previous inspection, and was present throughout the inspection process. What the service does well: What has improved since the last inspection?
There was continued development in compliance with the National Minimum Standards (NMS), which resulted in some requirements being addressed. This included the documentation required in relation to staff recruitment. This demonstrates a robust recruitment system that reduces the risk posed to service users from abuse.
Ridgwell House DS0000060997.V284182.R01.S.doc Version 5.1 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. Ridgwell House DS0000060997.V284182.R01.S.doc Version 5.1 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 Ridgwell House DS0000060997.V284182.R01.S.doc Version 5.1 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): These standards were not assessed at this visit. EVIDENCE: Ridgwell House DS0000060997.V284182.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this visit. EVIDENCE: Ridgwell House DS0000060997.V284182.R01.S.doc Version 5.1 Page 10 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): These standards were not assessed at this visit. EVIDENCE: Ridgwell House DS0000060997.V284182.R01.S.doc Version 5.1 Page 11 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 & 18. There is a suitable complaints policy and procedure The policy in respect of protection of vulnerable adults was in place. EVIDENCE: The complaints policy contained relevant information in respect of the process and timescale in which complaints will be addressed. The documents had not been updated for some time and required some minor updates in relation to the manager and proprietor’s names. The home maintains a complaints log, which did not contain any entries for the previous 12 month period. The protection of vulnerable adults policy was in place and also required some minor alterations. Staff training had not been updated in respect of POVA issues and this was highlighted with the manager as an essential issue within the services training programme. Ridgwell House DS0000060997.V284182.R01.S.doc Version 5.1 Page 12 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): These standards were not assessed at this visit. EVIDENCE: Ridgwell House DS0000060997.V284182.R01.S.doc Version 5.1 Page 13 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): 29. The staff recruitment processes were robust. EVIDENCE: The files of two staff were viewed and found to contain the elements of Care Homes Regulation 19, Schedule 2. This documentation ensured that the home reduced the risk of recruiting candidates who were unsuitable to work in the care industry and protected service users form the risk of abuse. Ridgwell House DS0000060997.V284182.R01.S.doc Version 5.1 Page 14 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): 33 & 36. There is not a quality assurance programme operating in the home. Staff supervision has not been consistently operated. EVIDENCE: The staff files did not contain reference to a consistent staff supervision programme. The manager confirmed that the supervision format was ready and she planned to introduce this to the staff at the next staff meeting. Staff supervision is a central part of the way in which individuals performance is monitored and provides an opportunity to ensure there is an understanding of the home’s philosophy and cultures. Ridgwell House DS0000060997.V284182.R01.S.doc Version 5.1 Page 15 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X 2 X X Ridgwell House DS0000060997.V284182.R01.S.doc Version 5.1 Page 16 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 Regulation 14 Requirement The registered person must ensure that a comprehensive assessment is carried out for each service user using an appropriate holistic assessment tool. This standard was not assessed at this visit and is therefore carried over to the next inspection. 2 OP7 15 31/05/06 Timescale for action 31/05/06 The registered person must ensure that a service user plan of care generated from a comprehensive assessment is drawn up with each service user to provide the basis for the care to be delivered. This standard was not assessed at this visit and is therefore carried over to the next inspection. Ridgwell House DS0000060997.V284182.R01.S.doc Version 5.1 Page 17 3 OP8 13(4) The registered person must ensure that risks to the welfare of each service user are assessed and steps taken to minimise these. This standard was not assessed at this visit and is therefore carried over to the next inspection 31/05/06 5 OP27 18 The registered person must ensure that the staffing numbers and mix of skills are sufficient to meet the assessed needs of service users and demonstrate this through the recommended calculation tool. This standard was not assessed at this visit and is therefore carried over to the next inspection 31/05/06 6 OP30 18 The registered person must ensure that the training provided for staff meets the expectations of the TOPPS standards. This is a repeat requirement. 30/06/06 7 OP33 24 The registered person must ensure there is a quality assurance system operating in the home, the findings of which are audited and an action plan produced. 30/06/06 8 OP36 18 The registered person must ensure that staff supervision is consistently carried out. This is a repeat requirement. 31/05/06 Ridgwell House DS0000060997.V284182.R01.S.doc Version 5.1 Page 18 9 OP37 17 Schedule 3&4 The registered person must ensure that records required by regulation for the protection of service users and the effective and efficient running of the business are maintained, up to date and accurate. This standard was not assessed at this visit and is therefore carried over to the next inspection 31/05/06 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 Refer to Standard OP11 Good Practice Recommendations The registered person should ensure that individuals’ wishes concerning their spiritual needs, rights and function in relation to death and dying are recorded and observed through care planning. The registered person should ensure that service users’ choices and preferences in relation to daily living, activity, social emotional and spiritual needs are recorded and opportunities to exercise these are further developed. The registered person should progress their plans to ensure that a minimum of 50 of staff are trained to NVQ 2 or equivalent. 2 OP12OP13 3 OP28 Ridgwell House DS0000060997.V284182.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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