Care and Social Services Inspectorate Wales
Care Standards Act 2000
Inspection Report
6 Ridgeway Care Home
6 Ridgeway
Swiss Valley
Llanelli
SA14 8BY
Type of Inspection – Focused
Date(s) of inspection – Wednesday, 11 March 2015
Date of publication – Monday, 18 May 2015
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Summary
About the service
6, Ridgeway Care Home is registered to provide accommodation and personal care for up
to three (3) younger adults with a learning disability. At the time of the inspection there
were two people living at the care home. The Care and Social Services Inspectorate for
Wales (CSSIW) has imposed a condition on the service that no new residents may be
admitted until the service becomes fully compliant with the Regulations.
The care home is a large detached house situated in Swiss Valley, close to the town of
Llanelli. The premises is also the family home of one of the two providers of the service.
The registered manager, who has day to day responsibility for the running of the care
home, is Patricia Thomas. She is also one of the owners of the service and resides at the
property. 6, Ridgeway is a family run business and the family also operate a regulated
domiciliary care agency of which Mrs Thomas is one of the owners.
What type of inspection was carried out?
We (CSSIW) carried out an unannounced focused inspection on 11 th March 2015 in order
to check on progress in previous areas of non-compliance. We will only be making
comment in this report with regard to the non-compliance and any progress made.
During the evening of 14th January 2015, we had reason to carry out a short inspection to
confirm the welfare of people living at the care home. This followed information we
received of a concerning incident which had occurred earlier in the day involving the
registered manager. We were able to confirm that people living at the home were well and
content. There was no separately published report on this brief visit.
What does the service do well?
We did not identify any areas of significant good practice which were over and above the
expectations of the Regulations and National Minimum Standards. However, the purpose
of the inspection was in order to check on progress of previous non-compliance and we
have only commented on these areas.
What has improved since the last inspection?
Non-compliance outstanding following the last inspection in November 2014:
Regulation 13 (4) (c) – Unnecessary Risks
We can confirm that substantial progress has been made with regards to identifying and
eliminating unnecessary risks to people living at the property. Although there is still major
work in progress, we are satisfied that enough has been achieved to meet compliance,
provided the work to outside areas continues this year. We can also confirm that a
substantial lock has been fitted to the COSHH (Control of Substances Hazardous to
Health) cupboard.
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Regulation 25 (1), (2) & (3) – Quality Assurance
At previous inspections we have been unable to evidence that there is a robust quality
assurance system in place. No annual quality assurance report had been produced and
forwarded to CSSIW as required. Following the current inspection we were provided with
a quality assurance report to cover the period March 2014 to March 2015. The document
was satisfactory to enable us to confirm that compliance has been achieved.
What needs to be done to improve the service?
Non-compliance outstanding following the last inspection in November 2014:
Regulation 19 (2) (b) – Fitness of Staff
At previous inspections in March and June 2014, the registered manager was notified that
the service was not compliant with this provision. This was because the registered
manager provided no evidence of completing her own mandatory training updates and
also failed to provide evidence that staff working at the home were appropriately qualified
and all mandatory training up to date. In November 2014, we issued a non-compliance
notice because the registered manager had not addressed the matter. At the current
inspection, we have been unable to confirm that either the registered manager or the two
regular staff have completed mandatory and other relevant training. We cannot therefore
confirm that compliance has been achieved.
Good practice recommendations
We recommended that the registered manager needs to update the Statement of Purpose
to reflect that people living at the property do not currently have access to a garden area.
Also, the registered manager must reflect the current conditions of registration within the
Statement of Purpose.
Once the swimming pool in the rear garden is once again functional, the registered
manager must put detailed risk assessments in place around the use of the pool and
inherent risks of having open water in the garden.
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Quality Of Life
People can be assured that improvements to the environment are in progress which
reduces risks to them when accessing outside areas. At three inspections during 2014,
the service was found to be non-compliant in respect of unnecessary risks to people
living at the property. This was because the registered manager had not replaced a child
lock on the COSHH cupboard for something more substantial and appropriate. This has
now been rectified to ensure against the accidental ingestion of hazardous chemicals.
The non-compliance notice was also issued because the back garden was inaccessible
to people using the service due to piles of debris and a high drop into an empty
swimming pool. Although the swimming pool is still in situ, we acknowledge that a lot of
work has been carried out in the rear garden over the last few months. A large expanse
of fencing has been replaced to ensure the garden is secure. Piles of debris have been
removed and there is major work in evidence in relation to the swimming pool to return it
to a useable facility.
We have been assured by the registered manager that the work will continue in the
garden once the weather allows and we are therefore satisfied that enough has been
achieved to date to confirm compliance. The registered manager has informed us that
people using the service will not be able to access the garden unsupervised during the
on-going work.
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Quality Of Staffing
We cannot assure people that they will receive care from staff who are appropriately
trained and competent to deliver the service safely. At previous inspections in March,
June and November 2014, we found no evidence that the registered manager had
completed her mandatory training updates. As the registered manager is the main care
provider and is the only carer on the premises at night and at weekends this is extremely
concerning. As the staff are supplied by the family run domiciliary care agency, all
training is carried out at the agency premises by three senior staff who are accredited
trainers.
The registered manager has also historically accessed her training via the agency and
their accredited trainers. The registered manager informed us that they had completed
their training (except manual handling) by use of power point presentations on a memory
stick in her own time at home. These presentations are used for training agency staff
who are supervised during the training by accredited trainers and complete workbooks.
Completion of the power point presentations at home is not considered to be good
practice and is not in line with domiciliary agency policy. The manager and training
coordinator at the agency confirm that any offsite training must be authorised by their
accredited trainers and supervised by competent and appropriately qualified staff and
there are no records of any such requests for offsite training.
On 11th March 2015, the registered manager provided CSSIW with dates of when they
stated that they completed mandatory training updates. The topics covered were as
follows:
Protection of Vulnerable Adults
November 2014
Medication
December 2014
Food hygiene
December 2014
Infection control
December 2014
Handling information
December 2014
Manual handling
August 2014
However, CSSIW were not provided with confirmation that the training had been
completed or that it had been assessed and validated by an appropriately qualified
trainer and assessor. No certificates were provided to confirm this training.
On 31st March 2015, we received an email from the registered manager with some
certificates attached for training completed online and one for manual handling. These
were as follows:
Medication
14.3.15
Dignity and Respect
15.3.15
Safeguarding Vulnerable Adults
15.3.15
Health and Safety
16.3.15
Person Centred Care
16.3.15
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Manual Handling/Risk Assessment
16.8.14
However, CSSIW were not provided with confirmation that the training had been
assessed and validated by an appropriately qualified trainer and assessor. The person
who endorsed the certificates was not accredited and authorised to do so as an
employee of the domiciliary agency. This has been reported to the agency and is
currently being investigated.
It is a requirement for the registered manager to be registered with the Care Council for
Wales and to provide evidence to them upon re-registration that they have completed the
required level of training.
We also received no evidence that the regular staff working at the home were
appropriately qualified in all expected areas. At the current inspection, we have been
unable to confirm that either the registered manager or regular staff have completed
mandatory and other relevant training. We cannot therefore confirm that compliance has
been achieved. Regulation 19 (2) (b) – Fitness of Staff
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Quality Of Leadership and Management
People cannot be assured that there is a robust quality assurance system in place to
identify areas of good practice and also of necessary improvement. The registered
manger has not produced an annual quality assurance report and forwarded to CSSIW
as required.
Although at the last inspection in November 2014 we were satisfied that quarterly
compliance visits were being carried out since the absent provider had delegated this
responsibility to an employee of the domiciliary agency. The reports from these visits
were reasonably adequate, considering the small size of the care home. However, the
registered manager has not used these reports, along with any other regular quality
audits, complaints, compliments and customer satisfaction surveys to produce an annual
quality assurance report. Following the current inspection we were provided with a
quality assurance report which was adequate to achieve compliance in relation to
Regulation 25 (1), (2) & (3).
We discussed with the registered manager the need to update the Statement of Purpose
to reflect that people living at the property do not currently have access to a garden area.
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Quality Of The Environment
Not being considered at the current inspection. However, we can confirm that major
work continues in the rear garden of the property which will improve the quality of the
environment and its impact on people using the service.
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How we inspect and report on services
We conduct two types of inspection; baseline and focussed. Both consider the experience
of people using services.
Baseline inspections assess whether the registration of a service is justified and
whether the conditions of registration are appropriate. For most services, we carry out
these inspections every three years. Exceptions are registered child minders, out of
school care, sessional care, crèches and open access provision, which are every four
years.
At these inspections we check whether the service has a clear, effective Statement of
Purpose and whether the service delivers on the commitments set out in its Statement
of Purpose. In assessing whether registration is justified inspectors check that the
service can demonstrate a history of compliance with regulations.
Focused inspections consider the experience of people using services and we will
look at compliance with regulations when poor outcomes for people using services are
identified. We carry out these inspections in between baseline inspections. Focussed
inspections will always consider the quality of life of people using services and may look
at other areas.
Baseline and focused inspections may be scheduled or carried out in response to concerns.
Inspectors use a variety of methods to gather information during inspections. These may
include;
Talking with people who use services and their representatives
Talking to staff and the manager
Looking at documentation
Observation of staff interactions with people and of the environment
Comments made within questionnaires returned from people who use services, staff
and health and social care professionals
We inspect and report our findings under ‘Quality Themes’. Those relevant to each type of
service are referred to within our inspection reports.
Further information about what we do can be found in our leaflet ‘Improving Care and
Social Services in Wales’. You can download this from our website, Improving Care and
Social Services in Wales or ask us to send you a copy by telephoning your local CSSIW
regional office.
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