Inspection on 30/08/06 for The Ridings

This inspection was carried out on 30th August 2006.

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

The inspector 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

The Ridings 08/10/09

The Ridings 06/11/08

The Ridings 20/11/07

The Ridings 29/05/07

The Ridings 16/01/07

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

CARE HOMES FOR OLDER PEOPLE The Ridings Farnborough Road Castle Vale Birmingham B35 7JG Lead Inspector Sean Devine Unannounced Inspection 09:20 30 August 2006 th 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 The Ridings DS0000067308.V305008.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. The Ridings DS0000067308.V305008.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Ridings Address Farnborough Road Castle Vale Birmingham B35 7JG 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) 0121 748 8770 0121 747 0163 Dukeries Healthcare Vacant Care Home 82 Category(ies) of Dementia (31), Dementia - over 65 years of age registration, with number (51) of places The Ridings DS0000067308.V305008.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can accommodate up to 82 people in total within the following categories: A maximum of 31 people under the age of 65 years of age can be accommodated to include 11 people also receiving nursing care. In addition 5 of the 31 beds can be used for either care (maximum 25 care only) or care with nursing (maximum 16 nursing care). A maximum number of 51 people can be accommodated over the age of 65 years for reasons of dementia to include 34 persons also receiving nursing care. In adddition 5 of the 52 beds can be used for either care (maximum of 23 care only) or care with nursing (maximum 39 nursing care) No previous inspections. Date of last inspection Brief Description of the Service: The Ridings is a large care home in Castle Vale that has been built by the Dukeries organisation It is registered to provide a service for upto 31 younger adults with a dementia of whom 11 can receive nursing care and upto 51 older adults with a dementia of whom 34 can receive nursing care. The residents rooms all have en-suite facilities and are spread across six independent units, at the time of writing the report the home has 52 residents and four of the six units are open. All units have their own dining room and lounge areas. Each independent unit has a fully adapted bathroom and a shower room to meet a wide range of movement and mobility needs; nine toilets some being spacious for use by wheelchair users are available across the home close by residents rooms. All areas of the home including the first and second floors are accessible by a large passenger lift. The service plans to provide a specialist service for residents who are of working age and have a dementia with a focus upon assessment, rehabilitation and where needed longer term care and support. There are enclosed gardens for residents on all units to experience, however at present much of the plant life needs to mature. There is a large car park at the front of the building. The home is close by many bus and rail routes in and out of the city. The pre inspection questionnaire completed by the manager of the home The Ridings DS0000067308.V305008.R01.S.doc Version 5.2 Page 5 indicated the current scale of charges for this service ranges from £548.00 to £1034.00 each week. The Ridings DS0000067308.V305008.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection visit was the first to the home by the Commission since it was registered in February 2006. It was conducted by three regulation inspectors over a period of one day. The inspectors were able to meet many residents and some relatives, staff were interviewed and the manager was available throughout the inspection. The care of residents was observed, records of how care is planned and delivered were seen including any risks to the residents. During the inspection the inspector was able to meet with many residents, however due to the nature of their dementias it hindered the ability of most residents to clearly communicate their views and opinions about the service they receive. A tour of communal areas on three of the four units was undertaken and an inspector was able to view ancillary areas such as the laundry and the kitchen and records of maintenance and tests of equipment were seen. Prior to this key inspection the pharmacy inspector visited this service on the 14th August 2006, a report has been written and forwarded to the provider under separate cover. The manager completed and returned a pre inspection questionnaire prior to the inspection. Following the inspection the Commission has met with the responsible individual, manager and the head of clinical governance for The Ridings. What the service does well: One relative was pleased that the staff spend some time with the residents besides providing nursing and personal care, this included chatting and exercises. The staff have commenced gathering life history information and have for some residents involved relatives within this process. Two relatives confirmed they were happy with the standard of food provided and stated “its well cooked and nicely presented” and another said, “Mom seems to enjoy it”. The home has developed and commenced a process of quality initiatives, including auditing standards at the home and issuing questionnaires to The Ridings DS0000067308.V305008.R01.S.doc Version 5.2 Page 7 relatives, this has enabled relatives to make comments and make a judgement about the homes performance. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Ridings DS0000067308.V305008.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 The Ridings DS0000067308.V305008.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 6. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The home is not always fully demonstrating it has the ability to assess all the needs of residents prior to admission; this may lead to some residents receiving inappropriate care. The needs of some other residents is well assessed, enabling care to be effectively planned. EVIDENCE: The files of six residents were case tracked across the three units. The standard and availability of assessments for residents to determine their health and social care needs prior to admission was found to vary. For one resident the assessments were not available, some contained very little information whilst others were comprehensively completed. The manager provided evidence of the homes assessments of residents who had not yet been admitted but had been referred to the home; these were seen to be extensive identifying needs, abilities and any risks. The Ridings DS0000067308.V305008.R01.S.doc Version 5.2 Page 10 The home does not provide an intermediate care service. The Ridings DS0000067308.V305008.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The home is failing to fully meet the health and personal care needs of some residents, this may mean some residents do not receive the care they require and may well have their health and well being put at risk. EVIDENCE: The care plans for six residents were seen, two were sampled on three of the four units. The standard of care planning was found to vary. There was evidence of clear and concise care planning written in consultation with relatives. On this occasion the care plans included many likes, dislikes and routines, a relative had given this information. A life history had been taken from the relative and an assessment whilst at the home of activities of daily living. The information was used to devise many care plans. This relative was able to provide information for the review of care plans. The reviews of care plans did include the frequency of review, this was often in excess of monthly. The Ridings DS0000067308.V305008.R01.S.doc Version 5.2 Page 12 However other care plans were not of this standard, for example concerns raised in daily reports such as aggression and risks identified in tissue viability and nutritional assessments did not have a care plan or risk management plan. For some residents cognitive assessments had been completed and given a score it was not clear what the score indicated. All residents had a weight chart, however from the recordings it appears this is not completed monthly. It was a concern that all sampled files did not contain any moving and handling assessments. Yet some of the residents needed to use mobility aids and required some level of support from the care staff. One inspector was concerned that whilst care staff were assisting several residents with a hoist in the lounge on Cheltenham unit there were some residents that often walked very close to the hoist and required the care staff to intervene; the concern was that two nurses were seated at the nursing station completing records and assistance was not offered even though it was evident the residents were at risk and possibly putting the residents who were being hoisted at risk. Risk assessments were seen for a resident who resides upon the unit known as Champion Crescent; the risk assessment about aggression did not record a description of behaviour or what the possible triggers to this behaviour were likely to be and did not provide staff with enough guidance to respond appropriately. The daily records for a resident on this unit stated the GP had visited and an infection was apparent, yet no short term care plan for the infection had been devised and no records on the GP visit sheet were made. In all residents files a form to record professional healthcare visits was available, many were found to be incomplete and it was not evident that residents have access to a dentist, optician and chiropodist. For one resident who was case tracked records of frequent consultation with a GP and physiotherapist had been made. On Champion Crescent unit the treatment room stores the medicines trolley, on entering the room this trolley was not secured to the wall and during further discussions with nursing staff it was evident they did not know the safe storage temperatures for the medicines in the fridge. An inspection of the medication practices had been completed by a pharmacy inspector on the 14th August 2006, the report is yet to be received by the home. Throughout the day many staff were observed supporting residents with their care needs, and on many occasions this was conducted with sensitivity and kindness, however on one occasion an inspector witnessed a nurse assisting a resident with personal care with the door to the bedroom left open. Since the inspection the Commission has been advised that this member of staff was responding to an urgent risk of falling and was not able to close the door. The Ridings DS0000067308.V305008.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All standards. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The home does not adequately demonstrate it has the ability to fully meet the daily life and social activity needs of all current residents. This may lead to residents feeling unfulfilled, frustrated and without a feeling of purpose in their lives. EVIDENCE: An activity organiser is employed part time, this does provide some support to residents and also is a useful resource to help and guide nursing and care staff. It was evident that the part time organiser was unable to meet many of the daily life and social activity needs of residents on a regular basis due to lack of hours allocated to such a role. The activity organiser works 18 hours a week over a period of 5 days and staff help when an activity has been set up. The organiser concentrates mainly on the residential and nursing unit and provides such activities as ball games, exercises, chats, family albums and mobility. There are rooms available to residents to help them develop their life skills, including social skills however at the time of inspection these were locked, it is unclear why. When in use the organiser will provide activity for no more than two residents at any one time in this room. The home does not have any transport of its own. The Ridings DS0000067308.V305008.R01.S.doc Version 5.2 Page 14 Most residents’ files contained life history information including hobbies, interests, significant life events, pastimes and likes and dislikes. A care plan for one resident included; involve in daily menu and note the views and preferences of this resident. However a programme of activity or care plan about engaging in purposeful recreation and occupation was not fully available to inform staff and direct them in how to meet the abilities and needs of residents. Another care plan had been written informing staff to involve family and involve with daily tasks, this lacked specific information for all staff in how this was to be achieved including how family are involved and how the resident is supported to take part in these daily tasks including what the tasks are. On the unit known as Champion Crescent some residents’ files did include an assessments of strengths and weaknesses, however for some residents life histories were found to be very brief. There was some evidence that the residents on this unit have their independence encouraged, as they are involved in washing up, meal preparation and cleaning and tidying their rooms. All residents on this unit also have regular opportunity to go out of the home either alone or with staff. No formal activity programme or plan for residents to go out of the home was seen; the inspectors were informed that this was being developed. On each of the units a member of staff collects meals from the main kitchen upon a heated trolley. When on the unit meals are served from the trolley. It was unclear how the residents do make a choice of meal; the menus seen appeared to be well-balanced and nutritional with two choices of main meal. Most units have residents from a traditional white UK background, however there are some residents from a different background and culture and it was not evident that the meals provided fully promote their requirements, this was discussed with the manager who confirmed she was not aware of this. The Ridings DS0000067308.V305008.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The home does demonstrate it has the capacity to enable residents and their representatives to raise and have complaints managed effectively. They also have policies and a training programme to guide staff to protect residents, however all staff do not have the ability at present to implement adult protection policies and this may leave residents at risk of abuse. EVIDENCE: The home has a record of complaints that is maintained in the central office. The records indicate that the home has a good system to record complaints, it records the details, response and whether the complaint has been resolved. Recent information shared with the Commission prior to inspection suggested that the policy was not always fully implemented. Letters were seen in response to concerns raised and the record had been completed. Relatives and residents who met with the inspector had no complaints and many were aware of how to raise their concerns, should they have any. The home has an adult protection policy that meets with local guidelines from Social Services. Staff training records indicate that since March 2006 a total of nineteen staff both nurses and care assistants have received training in protecting adults from abuse. The manager advised that this training would continue. There are The Ridings DS0000067308.V305008.R01.S.doc Version 5.2 Page 16 concerns about staff knowledge and understanding of adult protection, this has been recorded within the staffing standards of this report. The Ridings DS0000067308.V305008.R01.S.doc Version 5.2 Page 17 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): Standards 19 and 26. The quality in this outcome area is good. This judgement has been made using available evidence and a visit to the home. The home has demonstrated it has the capacity to maintain the premises to a good and safe standard thus promoting the health and well being of residents. EVIDENCE: The communal areas on three units were seen, including lounges, dining areas and rooms, activity rooms and large corridors. It was evident that the standard of fabric and decoration including furnishings was good and that routine maintenance was being conducted. All areas were tidy and the residents could access most areas on their units. All units have a door with a coded lock. There is a large foyer area on entering the home used for residents and their representatives to meet and have refreshments. Infection control practices in all high -risk areas such as the laundry, kitchen, bathrooms and toilets were found to be good, including the management of The Ridings DS0000067308.V305008.R01.S.doc Version 5.2 Page 18 waste products. Throughout the home there are good hand washing facilities and safe systems for moving laundry about the home. The Ridings DS0000067308.V305008.R01.S.doc Version 5.2 Page 19 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): All standards. The quality in this outcome area is poor. This judgement has been made using available evidence and a visit to the home. The home has not fully demonstrated it has the ability to provide the residents with staff who are well trained, competent and skilled for the roles they undertake. This will put the health, safety and well being of residents at risk. EVIDENCE: The manager advised that she does not do the staffing rosters; this is completed by each of the unit managers. The staffing levels for each unit are as follows: Since the inspection the commission has been advised by the home that the actual staffing levels applied at the time were are as follows; Residential Unit 8am to 8pm two care assistants, and 8pm to 8am two care assistants. (as of 30/8/06 10 residents accommodated). 1st Floor nursing unit, 8am to 8pm one first level nurse and four care assistants, 8pm to 8am one first level nurse and two care assistants. (as of 30/08/06 13 residents accommodated). The Ridings DS0000067308.V305008.R01.S.doc Version 5.2 Page 20 2nd Floor nursing unit, 8am to 8pm one first level nurse and three care assistants, 8pm to 8am one first level nurse and two care assistants. (as of 30/08/06 16 residents accommodated). Working age dementia unit, 8am to 8pm one first level nurse and two care assistants, 8pm to 8am one first level nurse and one care assistant. (as of 30/08/06 10 residents accommodated). The rosters seen by the inspectors indicate that to maintain these staffing levels agency staff are needed, the manager advised that she has made attempts to book regular agency staff so they do become familiar with the residents and staff, she also informed the commission that the organisation continues in its attempts recruit new staff. The staffing levels at the time of inspection are appropriate to meet the needs of residents. The inspectors informally interviewed four staff and formally interviewed two staff; it was evident that all staff had an understanding of the needs of residents and many processes such how residents are admitted and the importance of team work, however there was some concern about the responsibilities some staff undertake, such as on-call where it was evident the person had little experience of the role and important decisions that will at times needs to be made; it was a concern that a trained nurse was unable to reflect upon best practice in respect of adult protection and would not always make situations safe in line with the home policies. Since the inspection the home has advised that the nurse has completed adult protection training. This nurse advised that she had only worked with people with dementias whilst on placement during nurse training and is at times in charge of the working age dementia unit. The home provided a pre inspection questionnaire on which it indicated that five of the twenty-eight care staff had attained the NVQ in Care at level 2. Since the inspection the home has advised the commission that all but five staff are now doing the NVQ award. The recruitment practices of the home were sampled for four of the staff, two nurses and two care assistants. Records indicated that in most areas this had been done safely ensuring the protection of the residents. Most required checks had been completed, application forms had been completed and interviews had taken place. However for one nurse a recent CRB Disclosure from the most recent employer was accepted and there was no evidence of the Statement of Entry on the Nursing and Midwifery Council (NMC) register. Since the inspection the commission has been advised that a PIN verification from the NMC had been completed for all nurses and that these are available at the home. The home also advised that they had completed all of their own The Ridings DS0000067308.V305008.R01.S.doc Version 5.2 Page 21 enhanced CRB disclosure checks and that these are maintained confidentially at the home. Records of staff training were available on a matrix, it was evident that many staff are receiving training yet there are many gaps for example: of the twenty six care assistants fifteen had completed moving and handling, fourteen had completed first aid and three had attended a course about dementia. There was little evidence on the training matrix that newly appointed care staff undertake a TOPSS based induction. Of the twelve nursing staff three had received training in food hygiene, five had recent training in moving and handling and all had received fire safety training. Since the inspection the Commission has been advised by the home that twenty five members of staff attended Dementia training during March 2006 and that four staff members attended training specific to Working Age Dementia in May 2006. The home advised that a rolling programme based upon Skills for Care induction training is due to commence on the 10th October 2006. The Commission was also advised that the training matrix had not been kept upto date. The Ridings DS0000067308.V305008.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The home does not fully demonstrate it has the capacity to ensure it is managed and administered in an effective, transparent and consultative manner, which may lead to the poor management of services and have a negative impact on care standards. EVIDENCE: The manager advised that she had been in post for the past five weeks. The commission has had communication from the responsible individual when managers have left the service. This is the homes third manager since February 2006. The manager advised that she was in the process of auditing, for example staff training and supervision and care planning and the risk assessments of residents. She has identified a unit manager for each of the The Ridings DS0000067308.V305008.R01.S.doc Version 5.2 Page 23 four units and has commenced their supervisions. As yet a full application has not been received on behalf of the organisation to register this manager with the commission, however since the inspection a full application has been received. Staff who were interviewed described the manager as being supportive and approachable in her style of management. The manager advised that although there had been little consultation with residents at present she had commenced a process of audits including medication management, dependency levels and pressure sores. The manager advised that meetings with residents and relatives had commenced, which had been confirmed by relatives prior to inspection, minutes of this initial meeting were available at the home. The manager also advised that a questionnaire has been devised to ask residents and relatives about the quality of the service they receive, however as yet they have not been given out. No annual report is available in respect of quality assurance. The service has been in operation for less than eight months, however audits of standards are not available. Since the inspection the home have provided additional information which was not made available at the inspection; this evidence indicated that audits against standards are routinely undertaken, that questionnaires are completed by many relatives and that an action plan has been developed to guide improvements. The results of the questionnaire issued to relatives are being developed in to a report identifying the strengths and weaknesses of the home and will be available shortly. The home does manage some money on behalf of residents and provides a safekeeping service. The practice on one unit was observed, Champion Crescent; to enable the residents to access their money at all times small amounts of money are transferred from the administrators’ office to the unit. Records are available, however they are not adequately maintained. The record provides for two signatures for all transactions this was rarely completed. The staff advised that wherever possible they will try to get receipts, however this is not always possible as some of the residents are given their own money and are not supervised by staff. On other units records are generally well maintained in the administrators’ office, yet it is a concern that valuables such as items of jewellery are returned to relatives and records are not always available to reflect this. The home as part of the registration process had been subject to site visits prior to commissioning the unit. These visits enabled the commission to determine that all health and safety aspects of the home were being effectively managed including fire safety, utilities and environmental health. The Ridings DS0000067308.V305008.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 1 28 1 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 3 The Ridings DS0000067308.V305008.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No. 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. Standard 1 OP3 Regulation 14(1)(a)(b) Requirement The registered person must ensure that all prospective residents have their needs assessed by a suitable qualified or trained person and that a copy of the assessment is obtained prior to admission. The registered person must ensure that all residents have care plans written that are clear and concise and which enable staff to meet the assessed needs of residents. Timescale for action 31/10/06 2 OP7 15(1) 31/10/06 3 OP7 12(1) 15(1) 4 OP8 12(1) 15(1) The care plans must be reviewed at least on a monthly basis. The registered person must 31/10/06 ensure that short term care plans such as for an infection are written, implemented and shared with the care team and resident. The registered person must 15/11/06 ensure that where risks are identified within nutritional and tissue viability assessments that either a care plan or risk management plan is in place to inform staff of what they must do to improve the health and DS0000067308.V305008.R01.S.doc Version 5.2 Page 26 The Ridings 5 OP8 12(1) 15(1) well being of residents. The registered person must ensure that all residents have moving and handling assessments and a falls assessments. Where needed this must include a plan of how the residents mobility is supported including resources, manoeuvres and staffing. The registered person must ensure that where a resident displays behaviour that may put their health and well being or those of others at risk that a risk assessment and management plan / care plan is written to inform staff of what they must do to reduce the levels of risk. The registered person must ensure that health records are well maintained and provide evidence that residents have access and appointments with a dentist, optician and chiropodist. The registered person must ensure that when the medicines trolley is not in use it is at all times secured. The registered person must ensure that nursing staff have a good knowledge of the safe storage of medicines including safe temperatures of the medicine fridge. The registered person must ensure that all residents have their daily life and social activity abilities and needs assessed and that either a care plan or programme of activity are individually implemented that are clear, concise and informative for staff. Records of all activities must be made. The registered person must 15/11/06 6 OP8 12(1) 17(1)(a) schedule 3 (m). 13(2) 30/11/06 7 OP9 31/10/06 8 OP9 13(2) 31/10/06 9 OP12 16(2)(m)(n ) 31/10/06 The Ridings DS0000067308.V305008.R01.S.doc Version 5.2 Page 27 10 OP15 16(2)(i) 11 OP27 18(1)(a) ensure that there are adequate resources including numbers of skilled staff available to support residents with their daily life and social activity needs. The registered person must ensure that the cultural beliefs and needs of residents are fully assessed including their nutritional and dietary requirements, provisions to meet these needs must be made. The registered person must ensure that staff are fully skilled, experienced and competent to undertake their roles and responsibilities including those of on-call and also when in charge of a unit. 31/10/06 31/12/06 12 OP28 13 OP29 All staff must be able to effectively protect residents from all forms of abuse including making situations safe and implementing home policies on abuse of residents. 18(1)(c)(i) The registered person must ensure that a minimum of 50 of the care staff are qualified to at least NVQ level in Care. 19(1)(a)(b) The registered person must schedule 2 ensure that the organisation (paragraphs completes their own CRB 1 to 7) disclosure checks on all new employees and does not accept old CRB disclosures from previous employers. 18(1)(c)(i) The registered person must ensure that all staff receive appropriate training for the work they are to perform. This must include a full induction based upon TOPSS / Skills for Care units, all safe working practices and training relevant to the specific needs of residents; this must include for some staff a DS0000067308.V305008.R01.S.doc 31/03/07 31/10/06 14 OP30 31/12/06 The Ridings Version 5.2 Page 28 15 OP35 17(2)sch 4(9). 16(2)(i) 13(6) 17(2)sch 4(9). 16(2)(i) 13(6) 16 OP35 basic awareness of dementia care. The registered person must ensure that all transactions relating to the management of residents money have two signatures on the record. The registered person must ensure that records and signatures of when valuables of residents are returned to relatives are completed. The registered person must consult the resident wherever possible before taking this action. 30/11/06 30/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Ridings DS0000067308.V305008.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Ridings DS0000067308.V305008.R01.S.doc Version 5.2 Page 30 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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