CQC report explained · a residential care home
What the CQC found at Ridgeway Manor Residential Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some people did not receive medicines as prescribed, including delayed medicines and no overnight access to pain relief. There were also risks linked to food and drink, fire safety and unsafe areas of the building.
- Effective?
- Requires improvement
- People's health needs were assessed and healthcare referrals were made, but mental capacity records were inconsistent. Modified food was not presented well, and some people were not supported to eat in line with professional guidance.
- Caring?
- Good
- People and relatives described staff as kind, respectful and compassionate. Staff supported choice, privacy and independence.
- Responsive?
- Good
- Care plans had been improved and contained more personalised information. People had activities, communication support and help to maintain relationships with family and friends.
- Well-led?
- Requires improvement
- Managers and staff worked well together, and relatives said communication was good. However, quality checks did not reliably identify or resolve risks and maintenance problems.
What inspectors found, October 2022
Ridgeway Manor Residential Care Home is rated Requires Improvement; inspectors found kind, responsive care, but unsafe medicines, food safety risks, poor maintenance and weak checks.
Inspectors visited without notice on 18 August 2022. They spoke with people, relatives and staff, and checked care records, medicines, recruitment files, training, complaints, accidents, audits and the building. The inspection activity continued until 26 August 2022.
The main safety concerns were medicines not always being given as prescribed, gaps in support for people needing modified food or thickened drinks, fire safety issues and unsafe areas of the building. Some parts of the home were not clean or well maintained, and the environment was not adapted well for people living with dementia.
People described staff as kind and said they were treated with dignity and respect. Care plans had improved and people had access to activities and healthcare. However, checks by managers had not reliably found or fixed problems.
The overall rating was Requires Improvement. Safe, Effective and Well-led were rated Requires Improvement. Caring and Responsive were rated Good. The overall rating was unchanged from the previous inspection, although Responsive improved from Requires Improvement to Good.
Staff available
People said staff were available when needed and did not make them wait for care. Recruitment checks were also carried out.
“People told us staff were available when they needed them. They said they did not have to wait when they needed care” from the report
Personalised care planning
Care plans had been reviewed and improved. They included people's needs, preferences, life histories and interests.
“People's care plans had been reviewed and updated to ensure they were sufficiently detailed and person-centred.” from the report
Access to healthcare
Staff monitored people's health and made referrals to healthcare professionals when concerns were identified. Relatives said staff responded quickly when people became unwell.
“People's care plans contained evidence of referrals to healthcare professionals including GPs, speech and language therapists and specialist consultants.” from the report
Medicines and pain relief
seriousMedicines were not always given at the prescribed time. Some people could not receive pain relief overnight because night staff were not authorised to administer medicines.
“People did not always receive their medicines as prescribed.” from the report
Eating and drinking safety
seriousPeople needing modified food or thickened drinks were not always supported in line with professional guidance. Care plans also contained conflicting instructions.
“People who needed texture-modified food or thickened fluids were not supported to eat and drink safely in a manner consistent with relevant professional guidelines.” from the report
Building safety and condition
seriousA fire risk assessment found fire doors being held open and staff lacked fire extinguisher training. Some areas were unsafe, poorly maintained or not sufficiently clean.
“Some areas of the building presented health and safety risks to people.” from the report
Dementia-friendly environment
needs fixingThe home had not made enough changes to help people living with dementia find their way around. There was no suitable signage or other identifying features on bedroom doors.
“The home was not adapted to meet the needs of people living with dementia.” from the report
Weak quality checks
seriousAudits did not consistently identify problems or ensure that identified improvements were completed. This included food presentation and worn carpets.
“Quality monitoring audits were not always effective in identifying where improvements were needed.” from the report
- 01What has changed to make sure every medicine, including pain relief, is given at the prescribed time, including overnight?
- 02How do you check that people needing modified food or thickened drinks are seated safely and receive the correct consistency?
- 03What work has been completed to make the building safer, cleaner and better maintained?
- 04What changes have been made to help people living with dementia recognise their bedroom and find their way around?
- 05How do your audits now identify problems and make sure agreed improvements are completed?
This was an unannounced inspection covering all five CQC questions, the premises and care provided, including infection prevention and control. This explanation was written from the published report of 11 October 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, November 2019
Rated Requires Improvement; inspectors found kind care, but safety, records and management systems were not consistently reliable.
This was an unannounced inspection over two days. Inspectors spoke with people living in the home, a relative, staff and a visiting professional. They observed care and checked care plans, medicines, staff records, complaints, incidents, training and audits.
People generally said they felt safe and were treated with kindness and respect. Staff knew people well, supported their independence and helped them access healthcare. There were activities, visitors were welcomed and people were involved in their care planning.
However, hot water risks were not fully controlled. Some risk assessments and care plans lacked important details, daily records were incomplete, and some fluid records did not show people receiving appropriate amounts. Mental Capacity Act records and quality checks also needed improvement.
The overall rating was Requires Improvement. Safe, effective, responsive and well-led were all Requires Improvement. Caring was Good. All five ratings had been Good at the previous inspection in December 2016, apart from Caring which remained Good.
Kind and respectful staff
People spoke positively about the staff. Inspectors saw staff protect privacy and dignity, and staff could describe people's histories, interests and preferences.
“Staff knew people well and could tell us about people's past employment, their interests and what was important to them.” from the report
People felt safe
People said they felt safe, and staff understood how to recognise and report abuse. Safeguarding incidents had been reported to the local authority.
“People told us they felt safe living at Ridgeway Manor Residential Care Home.” from the report
Healthcare support
People were supported to see health professionals when needed. Records showed contact with several services, including GPs, dentists, nurses and therapists.
“Records showed people accessed the dentist, GP, speech and language therapy, district nurses, chiropodist, the falls team and the mental health team where required.” from the report
Activities and social life
A range of activities was scheduled during the week, and people generally spoke positively about what was available.
“There was a range of activities scheduled throughout the week which people could attend if they chose.” from the report
Hot water safety
seriousWater checks were not being properly recorded. Twenty-one hot water outlets in bedrooms did not have temperature-regulating valves, and related risk assessments were missing.
“Risks to people being exposed to hot or scalding water temperatures were not being fully managed.” from the report
Incomplete care records
needs fixingSome care plans and risk assessments lacked important current information. Daily records did not always show the support people had received.
“People's care plans were of mixed quality. Whilst there was some person-centred information available in care plans, some areas required additional information.” from the report
Hydration recording
seriousCare plans did not set out clear fluid targets or what staff should do if targets were missed. Records showed that people did not always receive appropriate amounts of fluid.
“Records demonstrated on occasions people were not receiving appropriate amounts of fluid.” from the report
Mental capacity records
needs fixingSome capacity assessments covered several areas rather than one specific decision. The service was advised to seek guidance to bring its practice in line with the law.
“This is not in line with the Act which states assessing people's capacity to make decisions should be decision specific.” from the report
Quality checks missed problems
needs fixingThe home had audits, but they had not identified several of the problems found by inspectors, including missing care information, incomplete records and unrecorded water temperatures.
“The systems were not fully effective in identifying all of the areas for improvement we identified during the inspection.” from the report
- 01What has been done to fit temperature-regulating valves or otherwise manage the 21 bedroom hot water outlets that did not have them?
- 02How do you now check that care plans, risk assessments and daily records contain complete and current information?
- 03How are people's fluid targets recorded and checked, and what action is taken when someone does not reach their target?
- 04How are mental capacity assessments now recorded so that each assessment relates to one specific decision?
- 05How does the management team make sure its audits identify problems before they affect people's care?
This was an unannounced inspection covering all five CQC questions, with the home, care and records examined; the report says the previous inspection was in December 2016. This explanation was written from the published report of 5 November 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Ridgeway Manor Residential Care Home
3 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- October 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Ridgeway Manor Residential Care Home →
- November 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
Read what inspectors found at Ridgeway Manor Residential Care Home →
- December 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 29 December 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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