Care Home: Ridgeway Lodge

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What the care home does well People who use the service and relatives said that staff spoken to them in a friendly fashion, with respect, and they welcomed visitors to the units without restrictions. Premises and accommodation visited were well maintained and decorated. Garden areas provide pleasant areas for people to sit outside. Rooms visited were personalised. BUPA has a Regional Health and Safety Committee, which provides relevant information from around the world, which is a useful reminder to staff. A robust pre and post assessment package is in place to ensure that the changing needs of people who use the service are being met. The staff at the service have introduced appropriate methods to support the needs of those with Dementia. What has improved since the last inspection? A new care plan format has been devised and is now in place at the service. This focuses on the increased involvement from relatives, friends and or advocates where the person using the service requires or requests this. The format enables staff to quickly refer to the relevant section and act appropriately on residents needs. A named nurse and key worker system is now in place and being continuously developed in each unit. The introduction of the menu manager and the 24 hour snack menu is now in place. This offers the person using the service more choice, variety and easier accessibility to food items and drinks as required. Meetings for the person using the service are now being completed and the minutes are available. Medication systems are suitably in place to ensure all health care and medical needs of the people who use the service are being met. Additional activity room has been provided to increase personal preferences and choices for all. A large cinema style television has been purchased for the cinema club. Commencement has been made on the introduction of "personal best" for all staff. Supervisions have commenced for all staff. Staffing levels have increased following a recent recruitment drive to ensure that the needs of the people who use the service are consistency met with. What the care home could do better: Training in Dementia Care must be provided to ensure that the needs of the people using the service are fully met at all times. Ongoing training should be provided to ensure that all staff complete the required mandatory training. Also ongoing staff training, specific to the service needs to be provided to enable them to fulfil their roles and responsibilities and meet individual needs. Staff should receive one to one, recorded supervision at least six times per year. A detailed fire risk assessment must be developed to enable the service to meet all relevant legislation. Steps need to be taken to ensure that the premises are odour free. People using the service should be consulted with on a regular basis to ensure that the activities being provided are suitable and interesting. Resident meetings should be held regularly to assist with monitoring and improving the quality of life for people using the service. Any issues raised at these meetings should be acted upon and feedback given to the group about the outcome. The Terms and Conditions of contract for those people who are funded through social services should be reflective of those who are privately funded, ensuring equal rights for all. CARE HOMES FOR OLDER PEOPLE Ridgeway Lodge Brandreth Avenue Dunstable Bedfordshire LU5 4RE Lead Inspector Louise Bushell Unannounced Inspection 3rd June 2008 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ridgeway Lodge DS0000014952.V365981.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ridgeway Lodge DS0000014952.V365981.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ridgeway Lodge Address Brandreth Avenue Dunstable Bedfordshire LU5 4RE 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) 01582 667832 01582 478485 briggsde@bupa.com BUPA Care Homes (Bedfordshire) Ltd Ms Deborah Christine Briggs Care Home 61 Category(ies) of Dementia - over 65 years of age (61), Old age, registration, with number not falling within any other category (61), of places Physical disability over 65 years of age (61) Ridgeway Lodge DS0000014952.V365981.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th May 2007 Brief Description of the Service: Ridgeway Lodge is a purpose built care home registered to provide for sixtyone frail adults over the age of sixty-five who may also have dementia and/or physical disabilities. The home was operated by BUPA Care Homes (Bedfordshire) Ltd. The manager had been in post since July 2006, and was registered in 2007. The building had been finished to a high specification that met the National Minimum Standards and provided single room accommodation on the two levels of the home. The layout of the building had been designed to promote the ethos of small group living, each of the units having a lounge and dining area with toilets and bathrooms in close proximity. The building had an inner quadrangle type garden that was well stocked with flowers and shrubbery and provided a pleasant out look and congenial place for relaxation. The home was located in a residential suburb within walking distance of local shops. The towns of Dunstable, Houghton Regis and Luton were short car journeys away. Fees for accommodation were between £414 and £655 weekly. Excluded from the fee are items and services such as hairdressing, personal news papers, toiletries and chiropody. The service make information available to the people who use it, including Commission for Social Care Inspection reports by making them available in the front foyer of the building, through distribution on request and discussion in resident / relative meetings. Ridgeway Lodge DS0000014952.V365981.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for the people who use the service and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting four people and tracking the care they received through looking at their care records, discussion where possible with the people who use the service, the care staff and observation of care practices. The visit was unannounced and planning for the visit included assessment of the notifications of significant events, which had been received from the service to the Commission for Social Care Inspection. We looked at the last Inspection Report and information on safeguarding and complaints since the last inspection and we looked at the feedback received from questionnaires circulated to relatives, staff and people who use the service. During the visit information was gathered from the relatives satisfaction survey and resident customer satisfaction survey which was conducted by Ridgeway Lodge in December 2007. One safeguarding concern had come to the attention of the Commission for Social Care Inspection (CSCI) since the last inspection visit. The local authority investigated the safeguarding concern there was found to be no evidence to take the issue further. The visit took place between 10.40am and 16.45pm. This enabled the two inspectors to directly and indirectly observe the care practices and the day to operations of the service. A selected tour of the building was conducted during which the inspectors spoke with people who use the service, staff and visitors and the registered manager. Ridgeway Lodge DS0000014952.V365981.R02.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? A new care plan format has been devised and is now in place at the service. This focuses on the increased involvement from relatives, friends and or advocates where the person using the service requires or requests this. The format enables staff to quickly refer to the relevant section and act appropriately on residents needs. A named nurse and key worker system is now in place and being continuously developed in each unit. The introduction of the menu manager and the 24 hour snack menu is now in place. This offers the person using the service more choice, variety and easier accessibility to food items and drinks as required. Meetings for the person using the service are now being completed and the minutes are available. Medication systems are suitably in place to ensure all health care and medical needs of the people who use the service are being met. Additional activity room has been provided to increase personal preferences and choices for all. A large cinema style television has been purchased for the cinema club. Commencement has been made on the introduction of “personal best” for all staff. Supervisions have commenced for all staff. Ridgeway Lodge DS0000014952.V365981.R02.S.doc Version 5.2 Page 7 Staffing levels have increased following a recent recruitment drive to ensure that the needs of the people who use the service are consistency met with. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ridgeway Lodge DS0000014952.V365981.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ridgeway Lodge DS0000014952.V365981.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 1,2 & 3 (Standard 6 is not applicable in this service) Quality in this outcome area is good. Pre and post admission assessments are completed with sufficient information to ensure that the needs of the people who use the service are being met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service has developed a statement of purpose, which sets out the aims and objectives of the service, and includes a guide, which provides basic information about the service and the specialist care that is available. The guide details what the prospective people using the service can expect and gives a clear account of the specialist services provided, quality of the Ridgeway Lodge DS0000014952.V365981.R02.S.doc Version 5.2 Page 10 accommodation, qualifications and experience of staff and how to make a complaint. All people who use the service are given a copy of the guide. When requested the service can provide a copy of the statement of purpose and guide in a format which will meet the capacity of the resident. The statement of purpose did not contain the recent findings from the last inspection report or the comments and findings of the experiences of people who use the service. The statement of purpose should be reviewed to ensure that the people who use the service have up to date information available so they can make informed decisions about the service prior to admission. One person using the service stated, “I like it here and I had lots of information about it”. Admissions are not made to the service until a full needs assessment has been undertaken. A skilled and trained person always completes the assessment prior to admission to the service. During the inspection a member of staff returned following the completion of an assessment. The assessment was detailed and appropriate to the policy and procedure in place. The assessment explored areas of diversity including preferences, religious and cultural needs, involvement from family, partners and advocates, race and disability. It was evident that the service strives to seek the information and assessment through care management arrangements, prior to admission. The service has the capacity to support people who use the service and respond to diverse needs that may have been identified during the assessment process. A total of four comment cards were received from people who use the service, all determined that they had enough information to make informed choices about the service. Privately funded people who use the service are provided with a statement of terms and conditions or a contract. This sets out in detail what is included in the fee, the role and responsibility of the provider, and the rights and obligations of the individual. People who are funded receive a social service contract. Discussions with the area manager and the manager of the service occurred regarding the need to develop an internal terms and conditions between BUPA and the person who uses the service to ensure that the same information is provided equally to both funded and privately funded people. Contracts are reviewed when there is a change in the needs of the person using the service. Ridgeway Lodge DS0000014952.V365981.R02.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Quality in this outcome area is good. The service has suitable care plans and arrangements in place for the receipt, storage, administration and disposal of medication, meeting all people’s medical, health and social care needs. EVIDENCE: A total of three care plans were case tracked fully, it was established that people who use the service receive personal and healthcare support using a person centred approach. Personal healthcare needs including specialist health; nursing and dietary requirements are clearly recorded in each persons care plan. The care plan provides clear information and a comprehensive guide for staff to know how to support the person. The care plan is generated from the pre admission assessment and includes clinical guidelines, risk assessments for the management of falls, bed rails, manual handling and self medication. One person using the service had recently had a fall, evidence was found of this is being appropriately recorded, however there was not a Ridgeway Lodge DS0000014952.V365981.R02.S.doc Version 5.2 Page 12 short term care plan implemented to support the care staff in the provision of care that was required following the fall. It was observed that personal support is responsive and tailored to meet the individual choices, needs and preferences. Staff were observed to respect the privacy and dignity of all people. A good practice example of this was seen at the service, where each room has a small visible sign attached to the side of the door stating whether personal care was in progress or not. The service listens and responds to individual choices and decisions about who delivers their personal care. People are supported and helped to be independent and can take responsibility for their personal care needs. Residents have access to healthcare and remedial services. The health care needs of residents unable to leave the service are managed by visits from local health care services. Clear evidence was seen in the care plans of specialist health care support services visiting the service and in addition to the care plan there were detailed notes made by the specialist visiting the service for example the District Nursing team and General Practitioners. A number of comments were received directly from people that use the service, their relatives and friends. One person commented that, ‘I consider that the service does every thing to make the residents happy in every way they can, such as entertainment, good food, outings and caring.’ A number of comments have been received that have determined that the care is provided to meet the needs of the people who use the service. One relative commented that “personal care for residents is excellent – my mother always looks neat and tidy her room is also always clean. The staff are kind and caring towards the residents and also willing to discuss any issues that arise”. The service has an efficient medication policy supported by procedures and practice guidance, which staff understand and follow. Medication records are fully completed, contain required entries, and are signed by appropriate staff. The management of controlled drugs is effective with records being accurate and stock balances being correct. A total of four people’s medication was case tracked in order to ensure compliance. Fridge and room temperatures were being recorded in all the medication rooms. Ordering and returns documentation was up to date and accurate. The service works with individuals regarding any refusal to take medication. The people using the service are given the support they need to manage their medication. If individuals prefer or where they lack capacity, care staff can manage medication on their behalf. Thought has been given to providing safe but sensitive facilities for keeping medication. Risk assessments are in place for the self administration of medicines. The service has a good record of compliance with the receipt, administration, safekeeping, and disposal of controlled drugs. Staff have completed and passed an appropriate medication course. An assessment has been carried out Ridgeway Lodge DS0000014952.V365981.R02.S.doc Version 5.2 Page 13 to ensure each member of staff is competent to handle, record and administer medication properly. On the day of the inspection it was directly observed that people who use the service were being supported and provided with specialist treatment in their own rooms and in private. Ridgeway Lodge DS0000014952.V365981.R02.S.doc Version 5.2 Page 14 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): Standards 12, 13, 14 and 15. Quality in this outcome area is good. People who use services are able to make choices about their life style, and are supported to develop their life skills, ensuring that social, educational, cultural and recreational activities meet individual’s expectations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who use the service have the opportunity to develop and maintain important personal and family relationships. Feedback from relatives determined that they are able and welcomed to visit the service. A number of people that use the service have stated that they the staff practices promote individual rights and choice, but also consider the protection of individuals in supporting them to make informed choices. A number of relatives made the following comments. Ridgeway Lodge DS0000014952.V365981.R02.S.doc Version 5.2 Page 15 “I have never seen such dedication given by all the staff to all the residents in the service; in fact you would think that they were looking after their own parents”. “I consider that the service does every thing to make the residents happy in every way they can, such as entertainment, good food, outings and caring”. “Personal care for residents is excellent – my mother always looks neat and tidy her room is also always clean. The staff are kind and caring towards the residents and also willing to discuss any issues that arise”. One person and relative commented that they would like more opportunity for religious worship at the service. The service respects the human rights of people using the service with fairness, equality, dignity, respect and autonomy underpinning the care and support being provided. The staff team help with communication skills, both within the service and in the community, to enable residents to fully participate in daily living activities. Residents are involved in meaningful daytime activities of their own choice and according to their individual interests, diverse needs and capabilities. They have been fully involved in the planning of their lifestyle and quality of life. Other support may be offered in the service by a skilled and trained team. Residents can access and enjoy the opportunities available in their local community, such as using public transport, library services, the local pub, and local leisure facilities. Trips were arranged and planning taking place. It was observed that a local trip to the Zoo and a meal at the local pub had recently occurred. One person who uses the service stated that “I like to go out with the staff, its good fun”. The service also provides a library link for those that do not access the community library. This appeared to be well used. The service has also now provided a large cinema style television which enables small groups of people to engage and socialise together whilst watching films of their choice. A new activities room is also available on the first floor where people can choose to participate in activities, relax or socialise as they please. The manager has also identified on the completed Annual Quality Assurance Assessment that the people who use the service are being further consulted about their choice of activities to increase their involvement in the running of the service. Resident meetings are commencing and the manager and the staff feel that this will further empower people who use the service. The service’s action plan following the internal annual quality assurance system, determined that 33 of excellent / good feedback was received from the people who use the service regarding activity provision. Ridgeway Lodge DS0000014952.V365981.R02.S.doc Version 5.2 Page 16 The menu is varied with a number of choices including a healthy option. It includes a variety of dishes that encourage individuals to try new and sometimes unfamiliar food. The meals are balanced and nutritious and cater for the varying cultural and dietary needs of individuals. The service is introducing Menu Master, this will help to promote and ensure that the nutritional choices made by the people that use the service are balanced. Following the last inspection the service has introduced a 24 hour snack menu system, this is now available in the kitchenette areas. The manager also highlighted within the Annual Quality Assurance document that a new chef manager is in post and new menus have been developed in consultation with the people who use the service. One person who uses the service commented that “the food is good and I do get a choice, I can always have something else later”. The Introduction of a Hostess, to help with breakfast service and dining room preparation prior to lunch has freed up the care staff so that they are available to provide personal care to others. The hostess serves breakfast at any time after 8.30am. The care staff are sensitive to the needs of those residents who find it difficult to eat and give assistance with feeding. They are aware of the importance of feeding at the pace of the resident, making them feel comfortable and unhurried. Ridgeway Lodge DS0000014952.V365981.R02.S.doc Version 5.2 Page 17 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): Standards 16 and 18. Quality in this outcome area is good. The service has a robust complaints procedure in place, good staff awareness and attitude towards safeguarding issues so people who use the service are safe and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service has an open culture that allows people who use the service to express their views and concerns in a safe and understanding environment. People who use the service have commented that they are happy with the service provided; feel safe and well cared for. A number of comments received determined that people who use the service and relatives and friends are aware of what to do if they have any concerns. One person who uses the service stated that they did not know how to complain. The manager of the service has identified in the Annual Quality Assurance Assessment that improvements are being made including the commencement of monthly residents meetings for the people that use the service. The service has a complaints procedure that is clearly written and easy to understand. It is available in a number of formats such as different languages Ridgeway Lodge DS0000014952.V365981.R02.S.doc Version 5.2 Page 18 on request. The complaints procedure is supplied to everyone living at the service and is displayed in a number of areas within the service. There is a detailed record of all complaints and compliments made and received. The service has recently introduced a verbal concerns log with clear actions being taken to seek early resolution for the complainant. It was evident that verbal concerns are also well managed, resolved quickly in the best interest of the person using the service. There have been two written complaints made which have both been investigated and responded to within the time scales as required. There have been a total of 23 compliments logged regarding the service, comments include, “thank you to all the staff at Ridgeway Lodge, you are all special and do a wonderful job caring for everyone, keep it up”. “I can not thank you all enough for the time, commitment and care you have provided to my mother”. The policies and procedures for safeguarding adults are available and give clear specific guidance to those using them. Staff commented that they have received training in safeguarding and felt confident in reporting any issues as they occurred. Staff had a clear understanding of the Whistle-blowing policy and when the use of this may be put into practice. The service understands the procedures for safeguarding adults and attends meetings or provides information to external agencies when requested. There has been one referral made in the previous twelve months. This is now resolved in full with no action being taken. Staff training in the safeguarding of adults is regularly arranged by the Service. The service needs make sure that the Commission for Social Care Inspection are consistently notified of any events in the care service that adversely affect the well being of a person using the service. Ridgeway Lodge DS0000014952.V365981.R02.S.doc Version 5.2 Page 19 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): Standards 19 and 26. Quality in this outcome area is good. The physical design and layout of the service enables the people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service provides a physical environment that is appropriate to the specific needs of the people who live there. The well-maintained environment provides specialist aids and equipment to meet their needs. The service is a pleasant, safe place to live, the bedrooms and communal room provide a personal and homely feel. The layout of the building enables people to move freely with several different seating areas throughout to encourage socialising or enabling the person to have privacy. Ridgeway Lodge DS0000014952.V365981.R02.S.doc Version 5.2 Page 20 The Annual Quality Assurance Assessment completed by the service demonstrates that the layout of the dining room areas on the first floor has recently been changed to encourage socialising with others and homelier feel. The people who use the service appear to like the change and were settled and eating communally or as they wished. However one of the wood effect dining room floors was found to be very slippery. This was discussed with the management who have ensured that remedial action is taken. The people who use the service are encouraged to personalise their bedrooms. All the home’s fixtures and fittings meet the needs of individuals and can be changed if their needs change. The building is designed to support the needs of people with Dementia on the first floor and residential needs on the ground floor. Thoughtful and appropriate additions to the environment have been made in particular on the first floor with memory boxes on display, period style photos and pictures, these enable people with memory loss to identify their own rooms and support people with reminiscence. The dining rooms are laid out to encourage communal dining with a calm relaxed atmosphere. A cinema style television is available to create a film night for the people to attend with a collection of films available. An activities room is also located on the first floor and people can access this freely as they choose. The environment promotes the privacy, dignity and autonomy of residents. The shared areas provide a choice of communal space with opportunities to meet relatives and friends in private. There is a nice garden to relax in. The garden has been adapted with time and consideration spent making separate seating areas and areas of interest for all the people who use the service. The home has a robust infection control policy. The manager of the service has identified works throughout the forthcoming twelve months that will be completed; this includes the repainting of the first floor dining area, replacement of a number of carpets and flooring, curtains for the corridors and blinds for the conservatory. The service is clean, well lit and in general smells fresh. One area was noted to have a malodour present. This was fed back to the manager of the service. Comments were also received from one person using the service about a malodour on one of the units. This was also found during the visit. The information was passed onto the manager and remedial action was being taken. There was restricted access to high risk areas such as the main kitchen and the laundry areas to reduce the risk of cross infection. Ridgeway Lodge DS0000014952.V365981.R02.S.doc Version 5.2 Page 21 Information gathered from the services internal annual quality assurance reports determined that a total of 88 of excellent / good feedback was received about the over all environment and cleanliness of the service. Ridgeway Lodge DS0000014952.V365981.R02.S.doc Version 5.2 Page 22 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): Standards 27, 28, 29 and 30. Quality in this outcome area is good. Most staff are suitably trained and skilled and are in sufficient numbers to support the people who use the service, in line with their care plan, although Dementia care training is needed to ensure needs and changing needs are being met by a consistently competent team. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Feedback from the people who use the service shows that they have confidence in the staff who care for them. Staff Rotas were seen and displayed adequate numbers of staff on duty to meet the needs of the people using the service. Specific attention was given to the busier periods of the day. A deputy manager was usually on shift and supernumerary to the care staff. This enables staffing levels to be maintained for the safety of all and that record keeping was completed and monitored as required. Ridgeway Lodge DS0000014952.V365981.R02.S.doc Version 5.2 Page 23 Staff members undertake external qualifications beyond the basic requirements. Managers encourage and enable this and recognise the benefits of a skilled, trained workforce. Accurate job descriptions and specifications clearly define the roles and responsibilities of staff. People who use the service report that staff working with them are very skilled in their role and are consistently able to meet their needs. There is a good recruitment procedure that clearly defines the process to be followed. This procedure is followed in practice with the service recognising the importance of effective recruitment procedures in the delivery of good quality services and for the protection of individuals. A total of five staff files were audited and were seen to contain all the required documentation. One file contained two references; however one of the references was over the telephone and did not contain sufficient information. The manager was informed and agreed to take remedial action. Four individual staff commented on the strong team culture of the service and felt that following recent recruitment, there are enough staff on duty to meet the needs of the people who use the service. Staff confirmed that the service was clear about what was involved at all stages and was robust in following its procedure. There are clear contingency plans to cover for vacancies and sickness and the use of agency staff was limited. Once recruited staff receive induction and training. The induction process, known as “personal best” is a process where the staff member is trained and mentored through a complete programme. The programme is then signed at the end of each stage. Following discussions with a number of staff and the manager it was determined that this process was being reintroduced to the service to ensure that all staff had fully received this and that evidence was held on their file. Staff confirmed that the senior team provide supervision, however records showed that formal supervision was not occurring at regular intervals. The manager of the service had also identified on the Annual Quality Assurance Assessment, that the supervision schedule for 2008 needed to be followed and that members of the senior team conduct these. The last inspection identified that the service must introduce and implement a staff development plan that has been based on an analysis of individual need. This requirement has been met. The service has scheduled specific mandatory training for each month and is conducted by qualified trainers within the group. Following discussion with the staff and manager, it was determined that the analysis of individuals needs were being added to a central matrix and personal training plans. Staff meetings take place regularly. Notes and action points are taken of meetings and sessions, and progress is regularly reviewed. Ridgeway Lodge DS0000014952.V365981.R02.S.doc Version 5.2 Page 24 The mix of staff is suitable to meet the cultural needs and mix of people that use the service. Staff reported that they felt supported in their roles and that they were able to discuss issues with a member of the senior team if required. A comment received from a relative states that; ‘I have never seen such dedication given by all the staff to all the residents in the service; in fact you would think that they were looking after their own parents’. Ridgeway Lodge DS0000014952.V365981.R02.S.doc Version 5.2 Page 25 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): Standards 31, 32, 33, 34, 35, 36 and 38. Quality in this outcome area is good. The manager of the service is suitably qualified and through clear policies and procedures ensures the care, health, safety and welfare of the people who use the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager has the required qualifications and experience and is competent to run the home. The Registered Manager and the deputy managers Ridgeway Lodge DS0000014952.V365981.R02.S.doc Version 5.2 Page 26 have a clear understanding of the key principles and focus of the service, based on organisational values and priorities. They work to continuously improve the service. Feedback received on the day of the inspection from staff and as part of the feedback questionnaires received determines that the management are effective and approachable. With the introduction of the new care planning format and training around its implementation, there is a focus on person centred thinking, with the people who use the service becoming increasingly more involved. The Registered Manager and deputy managers lead and support a stable staff team who have been recruited and trained to satisfactory levels. The manager is aware of the continued need to ensure that enough staff hold a National Vocational Qualification In Care Level 2. The manager promotes equal opportunities, has good people skills and understands the importance of person centred care and effective outcomes for people who use the service. The service has sound policies and procedures, which are corporately and internally reviewed and updated, in line with current thinking and practice. The manager ensures that staff follow the policies and procedures of the home. The staff team are positive in translating policy into practice and showed good knowledge of care principles, health and safety and safeguarding issues. This includes the management of finances within the service, where systems were directly observed to be transparent and open, with detailed records being maintained at all times. There was some evidence on staff records that staff have supervision but this is not always carried out on a one to one basis where staff have the opportunity to discuss their personal development. There is a need for all staff to be offered guidance about the role of supervision and for periodical one to one sessions to be documented. Staff confirmed that supervision does occur but not on a regular basis. The manager of the service has identified on the completed Annual Quality Assurance document that they would be improving and following through with regular supervision and staff meetings. The manager also identified a need to ensure that all in house training for staff including team leaders and ancillary staff is completed as scheduled. The service is also in the process of developing further standardised operating procedures to assist the staff to comply with policy and standards. Staff meetings take place regularly and minutes of the meetings are available on each unit. Ridgeway Lodge DS0000014952.V365981.R02.S.doc Version 5.2 Page 27 The home works to a clear health and safety policy. Safeguarding is given high priority and the home provides a range of policies and guidance to underpin good practice. Recent in house training has occurred regarding safeguarding issues. Staff confirmed that this was productive and showed a sound working knowledge of action to take in such an event. A training matrix has been developed, however there is a need for this system to be further developed and revised. Individual training plans are being devised along with the completion and introduction of “personal best”. This process is being facilitated by the deputy managers and team leaders. Through discussions with the management team and it was determined that priority is given to ensure that all staff are in receipt of adequate training, including in house refresher courses and a full complete induction programme. Individual training plans are being developed and will be used, once complete to review the annual performance of staff in their appraisal. A number of staff require training in Dementia Care. A recent inspection was conducted by Bedfordshire and Luton Fire Rescue Service. The findings from their inspection were discussed in full with the management of the service. It determined that there is a need for the service to revise and complete a detailed person specific risk assessment for fire safety and management. Feedback from the fire officer determined that the risk assessments must be generic for the building, highlight individual needs and include detailed building layout and systems that are in place to minimise risk, for example the need for automatic door closures. The service has recently appointed a person suitably qualified to ensure that all health and safety management is implemented with out delay. Ridgeway Lodge DS0000014952.V365981.R02.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 2 X 2 Ridgeway Lodge DS0000014952.V365981.R02.S.doc Version 5.2 Page 29 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. 1 Standard OP30 Regulation 12(1)(a) 18(1)(c) Requirement Training specific to the needs of the people suing the service must be provided, to ensure that the needs of the people are fully met at all times. A detailed fire risk assessment must be implemented to ensure the health and safety the people who use the service. Timescale for action 15/08/08 2 OP38 23 (4) (a) 30/07/08 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 OP28 Good Practice Recommendations The home’s training plan should show how staff will be supported to achieve National Vocational Qualifications in care so that 50 of the home’s care staff hold this qualification. Staff should receive one to one, recorded supervision at least six times per year. 2. OP36 Ridgeway Lodge DS0000014952.V365981.R02.S.doc Version 5.2 Page 30 3. OP1 The Statement of Purpose should be reviewed and contain the findings from the last Commission for Social Care Inspection, and experiences of people that use the service. The results from the quality assurance surveys should be included in the Statement of Purpose. This will assure residents and relatives that their comments are listened to and enable perspective residents to gain an insight into living in this home. Terms and Conditions of contract for those people who are funded through social services should be reflective of those who are privately funded, ensuring equal rights for all. The activities programme should be reviewed to ensure that it reflects the views and references of the people who use the service. Resident meetings should continue to be held to assist with monitoring and improving the quality if life for people using the service. Any issues raised at resident and/or relative meetings should be acted upon and feedback to the group about the outcome. Staff should commence and complete the formal induction programme to ensure a consistent approach to working practices for all. Arrangements should be made to ensure that the environment is free from malodour. 4. OP2 5. 6. OP12 OP33 7. 8. OP27 OP26 Ridgeway Lodge DS0000014952.V365981.R02.S.doc Version 5.2 Page 31 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ridgeway Lodge DS0000014952.V365981.R02.S.doc Version 5.2 Page 32 - 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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