Inspection on 26/04/07 for Ridgwell House

This inspection was carried out on 26th April 2007.

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

Ridgwell House 14/04/09

Ridgwell House 07/05/08

Ridgwell House 27/09/06

Ridgwell House 17/02/06

Ridgwell House 30/10/05

Ridgwell House 04/02/05

Ridgwell House 08/09/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Ridgwell House 95 Dulwich Road Holland on Sea Essex CO15 5LZ Lead Inspector Sara Naylor-Wild Key Unannounced Inspection 26th April 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ridgwell House DS0000060997.V337944.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. Ridgwell House DS0000060997.V337944.R01.S.doc Version 5.2 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 F/P 01255 815633 Prestige International (EC) Ltd Manager post vacant 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.V337944.R01.S.doc Version 5.2 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 have been made known to the Commission in February 2003 and September 2006 respectively The total number of service users accommodated in the home must not exceed 16 persons 27th September 2006 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 Residents 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 Residents. There is a stair lift to the first floor. The majority of the accommodation is on the ground floor, with 4 Residents 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. The range of fees charged by the service are between £367 and £400 per week. There are additional charges for hairdressing, chiropody and staff escort fees. This information was provided to the Commission by the provider in August 2006. Ridgwell House DS0000060997.V337944.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out over two days on the 26th April 2007 and 3rd May 2007. During the second visit to the service the inspector conducted an observation of Residents using the Short Observational Framework for Inspection tool or SOFI. This tool was specifically designed to be used to consider how Residents with dementia experience the delivery of the service. As well as the SOFI observation the inspector undertook a tour of the premises spoke to staff and documents relating to care, staff, and medication were selected and various elements of these assessed. Duna Abrahim, a Director of the company and currently acting as a general manager assisted the inspector at the site visit. Feedback on findings was given during the visit with the opportunity for discussion or clarification. The inspector would like to thank the Mrs Abrahim the staff team, residents, relatives and visiting professionals for their help throughout the inspection process. What the service does well: What has improved since the last inspection? The documentation used to support staff in delivering consistent quality of care has improved. This includes the residents’ assessment of need and the care planning documents, which now reflect a greater detail of how the individual should be supported by staff. Staffs’ skills continue to be built on, with a training consultant being used to provide sessions in dementia care, and activities with older people. The staff Ridgwell House DS0000060997.V337944.R01.S.doc Version 5.2 Page 6 spoke positively about the sessions and how they would utilise the information they had been given to enhance the care they provided to residents. Although without a manager for some months, the staff group, and as a consequence the residents, appear settled and more confident than at previous inspections. Those staff spoken with were very happy with their work and felt there was a strong team spirit. The observations of staff interaction with residents was very positive, and although further development could be given to skills used in communication with residents with cognitive impairments, they obviously benefited from the attention of staff whenever it was offered. 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. Ridgwell House DS0000060997.V337944.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 Ridgwell House DS0000060997.V337944.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents can be confident that the service will understand their needs and whether they can meet these. The service does not provide intermediate care. EVIDENCE: As part of the case tracking methodology used at this inspection the assessments of three residents were considered. The assessment format and information included in this had been updated from the previous inspection. The assessment is carried out by representatives of the homes management team and contained good detail of the individuals strengths and needs across a range of areas such as personal care, mobility etc. They were in sufficient detail to determine whether the home could meet these and if additional resources would be required. Ridgwell House DS0000060997.V337944.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can be confident that staff will understand how to best support them in their daily lives. Records that identify how residents should be supported are person centred, but would benefit from further development. EVIDENCE: The same three residents care plans were considered during the visit to assess if the requirements made at the last inspection had been addressed. In all three cases the documentation had been updated and although obviously at the early stages of implementation they provided a much improved level of detail in how individuals should be supported. Ridgwell House DS0000060997.V337944.R01.S.doc Version 5.2 Page 10 The Care plans start with a daily routine explanation of the residents preferences. This is written in a person centered way with the strengths at the beginning of the statement.so for example “J needs help to wash and dress and they will need the water run in the sink and prompted to use the flannel, J is able to put their arms in their dress, J can brush their own hair and clean their teeth. J is then taken to the dining room or lounge it is Js choice where they will have breakfast.” The acutal care plan largely repeats some of the statements made in the daily routine sheet, but some information is not yet included and they need development to ensure all knowledge held by staff is incorporated into plan. Overall they provide suffient details for staff to carry out support and are a significant improvement in recording a consistent quality of care delivery. The indiviudals daily records are completed by staff at the end of each shift. These should detail how well the care plans instructions work in meeting the individual needs. However the records examined tended to instead refect staffs views of how well the day has gone, with comments such as “Good day” and , “eaten well” etc. These statements do not provide sufficient informaiton to understand wether the care plan was successful and require staff to develop their skills in recording. The plans contained separate sheets that detail the monitoring of health care visits from Doctors, district nurses and Physio therapy. The information from these docments was used to update care plans in some cases although there needs to be a more consistent procedure for ensuring the impact on the exisiting care plan of any health care changes. Risk assessments for Moving and handling, skin integrity, falls assessments were in place and corresponding entries were found in the care plan to help staff understand how to appropriately reduce the risks whilst allowing residents to carry out the activiity. Review sheets held on the file contained information about the progress of the residents wellbeing,and demonstrate a monthly audit of care plan. Although there was evidence of changes to the individuals daily routine in daily records and other monitoring sheets the corresponding change to the plan had not always been changed at the review. Medication administration has been assessed as operating to a good standard in the service over the previous inspection visits. There was not any information gathered at this visit to contradict that assessment. Ridgwell House DS0000060997.V337944.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Residents have some opportunities to engage in People who use the service are able to make choices about their life style, and supported to develop their life skills. Social, educational, cultural and recreational activities meet the individual’s expectations. EVIDENCE: The inspector was able to use the (SOFI) Short Observational Framework for Inspection methodology to assess the way in which residents with dementia received the service. The observations were cantered on the care of the three people whose records had been tracked earlier in the inspection and included comparisons made between the records and how staff delivered care to them. The record from this session identified some issues for staff in how they engage with residents as well as the opportunities on offer to residents for diversion and occupation in their day. There were two care staff and the proprietor on duty, with other staff present in the home for a training session taking place away from residents. During Ridgwell House DS0000060997.V337944.R01.S.doc Version 5.2 Page 12 the observed timeframe, the staff frequently moved through the communal rooms, either in the course of other duties in other areas of the home or specifically to attend to residents seated in the room, and on each occasion they engaged with residents. Residents responded very positively to staff’s approaches, and peoples faces literally “lit up” when staff spoken with them, and in the case of one resident this was the only time they opened their eyes at all. Staff approach was respectful and responsive to the individuals. They did not speak too loudly, but made sure they were facing residents and either knelt, sat or bent down towards the seated resident when speaking with them. They made enquiries of how the resident felt, whether they wanted anything and helped them access refreshments. Apart from staff speaking with residents for short periods and the TV being switched on, there were not other activities offered during the period observed. The staffs skills in communication with residents could be developed, as many of the questions staff asked were closed and did not encourage residents to respond beyond a yes or no answer. So for example a staff member would ask, “Hello J, are you alright?” the resident would respond yes and the conversation ended. This was discussed with the proprietor as a staff development issue to enable them to gain confidence and skill in their approach to communication to gain greater outcomes. . It was noted that staff on duty worked together for the whole period, which meant that for residents they either had all the staff on duty with them or none. A better use of this valuable resource would be for staff to consider how they worked and unless there was a significant reason to work in pairs, they should alternate the time they spent with residents. During the inspection relatives of residents attended the home, and sat with them. Staff offered tea and coffee and engaged in conversations with them. It was apparent from the exchange that the visitors were at ease with the staff and were comfortable with the visit. The layout of the sitting room was discussed during the visitors time at the home, and from observations the seating plan and use of the room as a link with other areas of the home does present issues to ease of communication. This was raised with the proprietor at the end of the inspection visit and alternative options discussed to provide a better environment for residents to engage with both visitors and each other. Residents were observed eating a midday meal during one of the two visits to the home. They ate well and enjoyed the homemade meals on offer. The menu and delivery of ingredients continues to be appealing with delivery of fresh produce and changes made to accommodate seasonal availability. Ridgwell House DS0000060997.V337944.R01.S.doc Version 5.2 Page 13 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): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ views are listened to and the service is improving its responses to expressions of dissatisfaction. The protection of residents from abuse is supported by the homes policy and practice. EVIDENCE: The service has a complaints policy in place that reflects the requirements of the National Minimum Standard. This means it sets out the way in which complaints can be made, who they should be made to, how they will be responded to and the timescales in which the response will be made. The service needs to consider how it understands the satisfaction levels of those residents who are unable to express themselves verbally. At the first visit to the home the general manager and deputy manager stated that there had not been any complaints since the previous inspection, and therefore a log had not been maintained. However from further enquires it was clear that there had been concerns raised that were considered not serious enough to be recorded, particularly if they could be resolved. It is important that all levels of concerns are recorded, this allows recognition that residents are listened to acknowledges that each individual rates their concerns Ridgwell House DS0000060997.V337944.R01.S.doc Version 5.2 Page 14 differently and that a small one off complaint may become a more difficult issue if not resolved or the complaint has to be repeated. Following discussions with the inspector about the recording, auditing and analysing of satisfaction comments the proprietor had initiated a log by the second day of the inspection visit. This demonstrated a clear record of how staff responded to issues raised with them and the steps taken to address these and would ensure that residents concerns are always listened to. The staff spoken with during the inspection understood the Protection of Vulnerable adults procedures and their explanations matched the homes policy in dealing with allegations of abuse and whistle blowing. Training in POVA is part of the services development programme. Ridgwell House DS0000060997.V337944.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to live in premises that are clean and maintained, but which could be developed to better support service users rights to independence and privacy. EVIDENCE: The inspection report for the visit made in September 2006 raised issues with the layout of the building and how this enabled residents living in the home. During this visit the inspector conducted an observation of the interaction between residents, staff and the environment focusing on the front lounge. The evidence provided from this observation continued to raise questions about how the communal space and the layout of the home supported residents. Primarily this is due to the fact that the building was originally a residential house with additional extensions added at later dates. The layout of the Ridgwell House DS0000060997.V337944.R01.S.doc Version 5.2 Page 16 building is therefore not always obviously flowing with the two lounges and dining room providing access to other parts of the home. The ongoing challenges to the proprietors in developing the way they can best support service users independent movement around the building, and opportunities to socialise, particularly those service users with dementia was discussed with the Mrs. Abrahim at the visit. She reported as a response to these issues, she was attending an Alzheimer society course in creating environments that enable residents Additonally the services of an Occupational Therapist had been engaged to provide a report of their assessment of the premises and this was being used to understand the best way in which the building could be adapted. Examples included changes to shower room to create more useful and accessible space as well as access to outside spaces. In addition Mrs Abrahim reported that the service had successfully applied for a Government Grant distributed by the local authority in order to improve environments in care homes for residents benefit. This was being used to purchase new dining room chairs with sliding feet, new armchairs for two lounges, to replace flooring in some areas of the home and finally to provide some new garden furniture for front and back gardens. There was also work undertaken to provide a new ramp for garden access and a wall that obscured garden views from some residents’ rooms had been demolished. The premises were free from odour, clean and bright. There had been ongoing update of décor and replacement of curtains to communal rooms had taken place since the last inspection. Updates to the fire protection equipment had also been made following discussions with the fire officer and included adaptations such as the alarming of external fire doors and the addition of door opening systems to communal rooms to allow ease of movement of residents. Residents’ rooms were appropriately furnished and were personalised with the individuals’ belongings. Residents were free to use their room whenever they wished and a number had comfortable seating for daytime use. The provision of lockable cupboards facilities for residents to use for secure storage or the number of bedrooms provided with locks was not reviewed at this visit, but remains an issue for the providers to consider in their development plans for the service. There was not reference to risk assessments in care plans to demonstrate why it would not be appropriate for this provision. Although there is not a passenger lift to the first floor, there is a stair lift to provide access to this area. From discussions with the staff and Residents it was clear that they considered the individual Residents ability to mobilise independently when determining where their bedroom accommodation should Ridgwell House DS0000060997.V337944.R01.S.doc Version 5.2 Page 17 be situated in the home, and some Residents had been offered ground floor accommodation when to support their continued independence. During a tour of the premises the rooms were clean with no noticeable odour. The service has a contract with a hygiene collection company for the removal of clinical waste. Ridgwell House DS0000060997.V337944.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by a staff group in sufficient numbers and with sufficient skills to meet their basic needs. Although further benefits would be provided to residents from development of the teams skills in providing occupation and stimulation. EVIDENCE: Staffing numbers are maintained at two care staff and a person in charge during the waking day, with additional staff to cook and clean the home. These numbers reflect the reduced occupancy of residents currently living at the service and discussions with the proprietor indicated an awareness of how staffing levels should be calculated according to the increase in occupancy and the assessed needs of residents. The service had developed a staff training profile provided to audit staff training. There was evidence that staff had undertaken courses in mandatory subjects such a as moving and handling, fire safety medication and dementia care, food hygiene, record keeping and NVQ. Additionally individual training profiles were in place and were being updated to from a picture of what Ridgwell House DS0000060997.V337944.R01.S.doc Version 5.2 Page 19 training staff had undertaken and to identify possible training requirements from supervision. During the inspection visit training in dementia care and the provision of occupation and stimulation to all residents was taking place. This formed part of a specifically tailored programme of training sessions being provided by a training consultant in the home. Observation of staff participating in the sessions indicated their active participation and discussions with staff following the session evidenced that they had been stimulated by the training and were enthusiastic about how they could use the information in their daily routine with residents. Recruitment records held on staff files demonstrated a robust system to underpin the appointment of staff to work in the service. This includes the completion of a full application from, gaining of two written references and CRB checks prior to commencement. The service currently uses an training organisation to provide Skills for care training induction package but the Proprietor and deputy manager had both undertaken training to become Skill for Care induction trainers, and planned to provide this in house in the future. New staffs files contained evidence of an induction programme being completed. Ridgwell House DS0000060997.V337944.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are benefiting from an improvement in the leadership of the service that has enhanced the outcomes for them. EVIDENCE: The service has been without a registered manager for a number of months and this has been the subject of ongoing discussions with the proprietor. At this visit the inspector was advised that the current arrangements for the co management by the proprietor and deputy manager were being consolidated with both undertaking the NVQ Level 4 Registered Managers Award course. The development in the services compliance with some significant outstanding Ridgwell House DS0000060997.V337944.R01.S.doc Version 5.2 Page 21 issues of compliance with the NMS appears to demonstrate that this arrangement has benefited the operation of the service and consequently also the residents and staff. The management of residents’ finances was considered at this visit. The service does not hold responsibility for any residents’ financial arrangements but does support some residents by holding small allowances in the premises safe. The service maintains individual records with details of all income and expenditure undertaken on behalf of that resident. Examination of the records indicated that receipts for transactions were not attached to the record, some were not present and others did not always correspond with period stated on sheet. The proprietor advised that receipts sometimes given back to the person legally responsible for managing residents affairs such as solicitors and families. As this does not provide a full audit trail of the monies spent the proprietor was advised to review this practice and ensure that the records were accurate and complete. The service had commenced a quality assurance survey with questionnaires distributed to stakeholders. Although responses had been received there had not yet been an audit of the results or a report of the services response published. This was discussed with the proprietor. One to one staff supervision had started to be provided to staff and these discussions were being recorded. Staff spoken with were clear that they had opportunity to discuss their performance and how they contributed to the services objectives. The proprietor stated that the staff training programme would include issues identified through staff supervision. Records required to ensure that the service complies with health and safety risks were present. These included fire safety systems checks, fire risk assessments, annual safety certificates for gas and electrical equipment and moving and handling equipment. Ridgwell House DS0000060997.V337944.R01.S.doc Version 5.2 Page 22 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 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 2 X 3 Ridgwell House DS0000060997.V337944.R01.S.doc Version 5.2 Page 23 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 OP7 OP8 Regulation 15 Requirement Residents’ plans of care must contain all the information gathered about them and is updated when additional information is provided. This will assist staff to support residents consistently in a way that provides the best benefits to the individual. A quality assurance system must be operating in the home, whose findings are audited and an action plan produced. This will assist the proprietors in understanding what is important to people involved with the service and how they can improve their experience. Staff supervision must be consistently carried out. This will support staffs’ development and practice in meeting residents’ needs. Timescale for action 31/08/07 2. OP33 24 30/09/07 3. OP36 18 31/08/07 Ridgwell House DS0000060997.V337944.R01.S.doc Version 5.2 Page 24 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 OP7 OP8 Good Practice Recommendations Staff should be encouraged to share information about how they support individuals. This will help them to provide a consistent approach to the individuals care and improve the residents’ experiences of care. Residents’ choices and preferences in relation to daily living, activity, social emotional and spiritual needs should be recorded and staff should have sufficient skills to be able to provide opportunities to exercise these choices. A manager with appropriate skills and experience to lead the service should be recruited. Residents’ finances should be sufficiently recorded to provide a clear indication of how their money is spent. 2. OP12 OP14 OP7 3. 3 OP31 OP35 Ridgwell House DS0000060997.V337944.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Ridgwell House DS0000060997.V337944.R01.S.doc Version 5.2 Page 26 - 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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