Inspection on 18/02/09 for Ladesfield

This inspection was carried out on 18th February 2009.

CSCI found this care home to be providing an Good service.

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

Ladesfield 25/03/08

Ladesfield 27/07/07

Ladesfield 18/07/06

Ladesfield 06/01/06

Ladesfield 14/07/05

Ladesfield 18/01/05

Ladesfield 06/10/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

CARE HOMES FOR OLDER PEOPLE Ladesfield Vulcan Close Borstal Hill Whitstable Kent CT5 4LZ Lead Inspector Lisbeth Scoones Unannounced Inspection 18/20 February 2009 09:45 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 Ladesfield DS0000037645.V373847.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. Ladesfield DS0000037645.V373847.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ladesfield Address Vulcan Close Borstal Hill Whitstable Kent CT5 4LZ 01227 261090 01227 266201 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) Kent County Council Manager post vacant Care Home 35 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Ladesfield DS0000037645.V373847.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 2. Dementia (DE) - maximum number 10. The maximum number of service users to be accommodated is 35. Date of last inspection 25th March 2008 Brief Description of the Service: The premises, which were purpose built in the 1970s, comprise a three storey detached property set in its own grounds in a quiet area in the outskirts of Whitstable Town. This is a non-smoking environment. The ground and the first floor are registered for 25 older people, 3 of which are respite beds. All bedrooms are single accommodation, none are en-suite but all bedrooms have a wash hand basin. Every bedroom has a call point designed to help residents summon help should it be needed. The second floor of the building is registered for accommodating 10 people with dementia. All rooms are single accommodation with a washbasin. This unit is secure and kept locked at all times. People can only access the garden area in the company of a member of staff. Ladesfield also has two assessment beds for those people who require support from the intermediate care team prior to return to live independently in the community. Recently two mental health assessment beds have been made available. There is a secure and secluded garden area to the rear of the property. Kent County Council are the Registered Providers. The manager is in charge of the day-to-day operation supported by the senior team leader and a number of Ladesfield DS0000037645.V373847.R01.S.doc Version 5.2 Page 5 team leaders. The current weekly fee is £364.79. Information on the Home services and the CSCI reports for prospective residents are detailed in the Statement of Purpose and Service User Guide. Ladesfield DS0000037645.V373847.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. Judgements have been made with regards to each outcome area in this report, based on records viewed, observations and verbal responses given on the day. These judgements have been made using the Key Lines of Regulatory Assessment (KLORA), which are guidelines that enable The Commission for Social Care Inspection (CSCI) to be able to make an informed decision about each outcome area. This unannounced inspection took place over two days on 19th and 20th February 2009. The second day was an arranged visit to meet with the person employed by the home as the manager, this person is not yet registered with CSCI. The inspection process comprised discussions with the manager, senior team leader, team leader, administrator and other staff. An accompanied tour of the building was made during which many residents were met and spoken with. Documentation was examined in respect of care plans, risk assessments, staff rotas, staff files, training records, medication records, complaints file, accident records and other relevant documents. At all times the staff were helpful and co-operative. The inspection process was further informed by a current AQAA (annual quality audit and assessment) completed by the manager. This provided additional information of the progress made in meeting and raising the standards. Prior to the inspection, comment cards were sent to residents and staff to give their view on the service. Five residents and four members of staff responded. Comments thus received are incorporated in the report. The CSCI has received two complaints since the previous inspection. These were investigated by the manager and satisfactorily concluded. An incident raised by the manager is being investigated under safeguarding vulnerable adults procedures and has not yet been concluded. Since the previous inspection, the acting manager left and a new manager was appointed. She is currently in the process of becoming registered with the CSCI. What the service does well: Ladesfield DS0000037645.V373847.R01.S.doc Version 5.2 Page 7 The requirements and recommendations made at the previous inspection have been acted upon. The inspection process evidenced that as a result outcomes for residents have improved. Staff are provided with Equality and Diversity training which is further promoted through the supervision process. A relative said, Everything/everyone focuses on the residents. Staff are very supportive of each residents individuality and self worth. Staff interacted with the residents in a kind, supportive, patient and respectful and manner. Residents on comment cards said, This is a cheerful, warm and comfortable home. This is pleasant place to live. Very happy. Staff help me through it when I am not happy. Residents praised the choice and quality of the meals provided. The food is very good. I have a small appetite but staff always find me something nutritional. Visitors are made welcome to the home. The home welcomes residents and relatives views on the services the home provides. A new feedback form has been introduced to that effect. Residents are involved in the staff recruitment process. What has improved since the last inspection? What they could do better: Residents with a visual or mental health impairment, may benefit from a Service User Guide and menus presented in large print or pictorial format. The new computerised care planning system would provide an opportunity for a consistent person centred approach to care planning. Ladesfield DS0000037645.V373847.R01.S.doc Version 5.2 Page 8 In respect of residents dignity, the home should ensure that equipment used by district nurses is discreetly stored. The home should ensure that residents are provided with a programme of activities of their choice. The home should develop a system that ensures that all staff are provided with mandatory training at the time when due. The home should ensure that residents accommodation meet their needs. The home should continue to review its staffing levels to ensure that residents needs are met at all times. 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. Ladesfield DS0000037645.V373847.R01.S.doc Version 5.2 Page 9 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 Ladesfield DS0000037645.V373847.R01.S.doc Version 5.2 Page 10 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): 1, 2, 3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective residents are provided with up to date information about the services the home provides. Improved pre-admission procedures assure prospective residents that their needs will be met. The home has 2 assessment beds for those people requiring support from the intermediate care team. EVIDENCE: Seen on display were current copies of the Statement of Purpose and Service User Guide. These documents provide residents with detailed information of the services the home provides. A copy of the recent CSCI inspection report was also seen. Ladesfield DS0000037645.V373847.R01.S.doc Version 5.2 Page 11 No resident is admitted to the home without a comprehensive assessment having been carried out by care management and a senior suitably qualified member of the home. These are carried out to ensure that the home can meet the assessed needs of the prospective resident. The findings of the assessments are used to formulate a care plan. A resident on a comment card said, I spent a week here before coming in full time and I was happy to come. The home has a number of assessment beds for people requiring support from the intermediate care team (2) or the mental health team (2). The manager reported that communication with the ICT and the assessment bed team have improved in respect of delays in accessing professional notes. Ladesfield DS0000037645.V373847.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents mostly benefit from care plans that meet their needs and can be confident that their health care needs, including any changing needs, will be met. Residents are protected by the home’s administration and recording of medication. Residents are treated with dignity and respect for their privacy. EVIDENCE: The previous inspection reported that a new person-centred care-planning format had been introduced. At this inspection it was noted that this format is not yet fully operational, particularly in the dementia care unit. The manager acknowledged that more work needs to be done in this area. New computerised care plans are soon to be introduced. Staff would be trained to use the system and concentrate on the person centred care planning approach. Ladesfield DS0000037645.V373847.R01.S.doc Version 5.2 Page 13 In the dementia care unit it was recommended that, when a respite client returns, previous risk assessments and care plan be updated. A sample of care plans was examined. This evidenced that generally health, social and cultural care needs are recorded. Care plans are supported and informed by a range of risk assessments relating to adequate nutrition, risk of skin breakdown, moving and handling and self-medication. The manager reported that falls and continence assessments are being developed. Residents are weighed regularly and provided with pressure relieving equipment if the risk of skin breakdown is identified. Wherever possible the resident or their advocate had signed the care plan evidencing their input and agreement. Resident’s health care needs in respect of diabetes management, wound care and blood tests are met by a team of district nurses. Visits from the GP, district nurses and other visiting health professionals are recorded in a separate folder for easy access during handovers. The manager reported excellent communication with health professionals. The medication room was visited and a review of medication charts evidenced good recording. Earlier in the year a medication review was carried out. Procedures for as required medication are in place. Good records are maintained for signing medication in and out. A Controlled drug (CD) audit identified a recording discrepancy, which was dealt with on the spot. The manager carries out a regular audit to check compliance. Residents are encouraged to self-medicate. Residents are treated with dignity and respect. A residents relative said, Staff have shown my relative nothing but kindness and understanding and treat him with respect. At the previous inspection it was noted in a resident’s room that equipment used by district nurses was on display, thus compromising resident’s dignity. This was again noted at this inspection. It was recommended that such equipment be stored appropriately. See also standard 19 in relation to the environment. Ladesfield DS0000037645.V373847.R01.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): 12, 13, 14, 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are provided with some organised activities, which could be further improved. Residents benefit from being encouraged to maintain contact with families and friends. Residents enjoy a good, balanced and wholesome diet with special diets being catered for. EVIDENCE: The home no longer employs an activities organiser and when there is time staff provide activities. The manager said that the provision of social and occupational activities is high on the agenda and that more can and must be done in that respect. Staff reported that they often are too busy to provide activities although the manager said that from Monday to Friday staffing levels have recently been increased to allow for this. See also standard 27. Ladesfield DS0000037645.V373847.R01.S.doc Version 5.2 Page 15 Two residents representatives have been nominated to meet with the manager to discuss expenditure of the voluntary fund. A small shop has just been opened. Residents care plans include a social care plan questionnaire and map of life. This provides staff with important information about residents interests. The activity timetable has recently been reviewed and will be piloted. Staff are encouraged to record all activities. Such records however do not reflect whether the activity was enjoyed or actively participated in. When there is time, staff do quizzes and play Bingo. A Wii game has recently been purchased. A resident said she would like more activities. A residents relative said how much the Christmas activities had been enjoyed. Music and singing is especially welcome. A comment was made that it was sad that the home no longer had the service of a minibus so that residents can get out and about. In the Somerset Suite, the Notice board is not used to its full potential and the manager said that more activities need to be provided. The Service User Guide gives information in respect of religious services available. The home provides opportunities for residents to practice their religion. A communion service is held once a week and a catholic priest visits the home. Since the previous inspection, the secure garden has been completed. The garden however lacks interest and colour. The manager reported in the AQAA that plans are in place to involve the residents in planting the garden with tactile plants and aromatic herbs. Family and friends are welcomed at any time and people are able to have visitors when they want. It was noted that small seating areas have been arranged around the home so that people can sit in privacy. Overall comments about the meals were positive. Residents are provided with a choice of varied, wholesome meals, which include fresh fruit. The manager said that menus are regularly reviewed in accordance with residents wishes. Staff training in respect of meeting residents nutritional needs is being sought. The kitchen is due for some modernisation and quotes are being obtained to meet EHO requirements. Whilst all residents are provided with fresh drinking water, staff reported that the kitchenette on the first floor is hardly used as there is no drinking water available. Staff collect jugs of water from the main kitchen. This was discussed with the manager. Ladesfield DS0000037645.V373847.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents feel confident to air their views and their complaints are listened to and acted upon. Residents are protected from harm and staff are trained to safeguard vulnerable adults EVIDENCE: A copy of the complaints procedure is on display in the entrance hall and on the residents notice board. The complaints folder was examined and demonstrated that all complaints are taken seriously, recorded and acted upon. A resident spoken with said she had no complaints. Another resident said she would always speak to the manager if there were a concern. A resident on a comment card said, I had problem, which was dealt with straight away. The training matrix identified that for some staff there has been a delay in receiving adult protection training. Two team leaders have recently completed the training the trainer course in respect of safeguarding vulnerable adults and training can now be provided in-house. Staff spoken with demonstrated a good awareness of what constitutes abuse and knew what to do if this was ever Ladesfield DS0000037645.V373847.R01.S.doc Version 5.2 Page 17 witnessed or suspected. Staff are further trained in the Mental Capacity Act 2005. In relation to safe recruitment procedures, see standard 29. The manager makes effective use of the safeguarding vulnerable adults procedures in raising issues of concern that affect the well-being of the residents. Ladesfield DS0000037645.V373847.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a pleasant, homely environment that is continually improved and maintained. Residents have access to safe gardens that could be made to look more interesting. The suitability of some bedrooms needs to be reviewed in respect of space and safe moving and handling. Residents live in a clean and hygienic environment. EVIDENCE: The Somerset Suite based on the top floor, which provides respite care for people with a diagnosis of dementia, is comfortable, pleasant, spacious and light. This is a secure unit and people are not able to gain access to the gardens without the support of staff. Since the previous inspection, residents Ladesfield DS0000037645.V373847.R01.S.doc Version 5.2 Page 19 now have access to a safe and secure garden. As already mention in standard 12, the garden is to be made more user friendly with raised flowerbeds and other features of interest. Staff at the Somerset unit said that they take residents out into the garden. Improvements continue to be made to the rest of the home. Since the previous inspection, some carpets and bedroom furniture have been replaced. The majority of the bedrooms on the ground and first floor are small. Whilst this does not pose a problem for ambulant residents, for those who are wheel chair bound and need a hoist and two members of staff to transfer, it may do. With the increasing dependency of some of the residents, the suitability of the chosen or available bedroom needs to be considered. The size and lay out of the bedroom needs to be included in the moving and handling risk assessments. See also standard 3 in respect of pre-admission assessments. The manager said there is a good team of domestic staff consisting of 5 people who are responsible for cleaning and laundry. Bedrooms and communal areas were clean, tidy and free from unpleasant odours. A relative said, Domestic staff are diligent about their duties. Since the previous inspection, a sluice room has been made available in the Somerset Unit and is no longer used as a laundry room. Foot operated clinical waste receptacles have been made available. Bins in communal areas have been replaced. An infection control audit has been carried out. The team leaders conduct a recorded monthly audit of the home. Staff are provided with infection control training, though for some this was overdue. See also standards 30 and 38. Ladesfield DS0000037645.V373847.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents benefit from being cared for by staff who are well trained and supervised. Residents are protected by the home’s recruitment procedures. EVIDENCE: The manager reported that there have been significant staff vacancies at all levels. A number of care staff vacancies have now been filled. Staffing levels are determined daily on the basis of dependency. Rotas seen reflect the staff on duty per unit and per shift. The home has two separate units with designated staff. Staffing levels at the larger unit based on the ground and first floor have recently been increased. See standard 12 in respect of activities. Staff spoken with said they enjoyed the work but that staffing levels are not always adequate. This issue was discussed with the manager. Two waking staff members cover the night shift. There is a sleep-in team leader who is available during the night hours if required. In the smaller Somerset Suite, the staffing levels are dependent upon the number of people and their dependency. At the time of the inspection there Ladesfield DS0000037645.V373847.R01.S.doc Version 5.2 Page 21 were 2 staff members on duty. One waking staff member covers the night shift. The manager said that the home is continually recruiting new staff. Currently vacancies are covered by relief and agency staff. There are designated kitchen, cleaning, maintenance and admin staff. Over 50 of staff have or are in the process of obtaining an NVQ in Care. All staff have undertaken the common induction training in line with Skills for Care as an update for current skills. In respect of recruitment, three staff files were examined. It demonstrated sound recruitment procedures. Good documentation was noted including POVAfirst and CRB checks, interview notes, evidence of induction and other training and two written references. One reference was addressed to Whom it may concern. This was discussed with the manager. As part of the appraisal process, personal action and development plans have been devised. A training matrix is now in place. Whilst all staff are provided with mandatory training, the training matrix identifies that some of the training is overdue. Apart from in-house moving and handling and safeguarding vulnerable adults training, staff need to apply for all other training. At times such training is delayed due to insufficient places being available. This could result in staff not having the up to date training the home strives their staff to attend. Delays identified relate to infection control and Equality and Diversity. This issue was discussed with the manager who is to take this up with the training department. Specialist training is provided such as dementia care and challenging behaviour, Equality and Diversity and palliative care. Team leaders undertake a 16-week medication training. This training is also available to care staff. Ladesfield DS0000037645.V373847.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The management of the home provides leadership, guidance and direction to staff to ensure that residents receive consistent quality care. The home is run in the residents’ best interests. Residents’ financial interests are safeguarded. Staff are appropriately supervised. Residents’ health, safety and welfare are promoted. Ladesfield DS0000037645.V373847.R01.S.doc Version 5.2 Page 23 EVIDENCE: The temporary senior management team transferred in July 2008 and a new manager was appointed. She is currently in the process of applying for registration with the CSCI to become the registered manager. A new senior team leader was appointed in September 2008. Both managers took part in this inspection. The manager is approachable and operates an open door policy. A staff member said that the manager is a good listener and makes changes. The manager is well aware of those areas where improvements can and should be made. The manager has been trained in budget and business planning and demonstrated a commitment to provide strong management leadership. There are clear lines of accountability within the organisation and the home. The Operations Manager meets with the manager monthly for supervision and monitoring. The home welcomes residents and relatives views on the services the home provides. A new feedback form has been introduced to that effect. Residents are involved in the staff recruitment process. Due to lack of interest, residents meetings now take place quarterly. Questionnaires are sent out and an annual quality audit undertaken. The manager ensures that she or a member of the senior team sees all residents every day and encourages feedback. Exit questionnaires have been introduced for all short-term residents. The previous inspection reported the introduction of safe systems for the management of residents monies and belongings whilst staying in the home. For this purpose, residents have been provided with a lockable facility in their room. Where the home is involved with looking after residents’ monies, a robust safeguarding system is in place. Staff receive regular recorded supervision. benefit they get from this. Staff spoken with confirmed the The AQAA confirmed that all equipment and services have been serviced or tested as recommended by the manufacturer or other regulatory body. Dates of last review or certificate were supplied. Accident records are well maintained and evaluated. Incidents of a challenging nature are recorded on ABC charts. The manager informs the CSCI and other authorities of any reportable event. Staff are provided with all mandatory training such as fire safety awareness, moving and handling, food hygiene, infection control and First Aid. See standard 30. Ladesfield DS0000037645.V373847.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 3 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 x 2 2 3 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 x 3 3 x 3 Ladesfield DS0000037645.V373847.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 Regulation Requirement Timescale for action 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 Ladesfield DS0000037645.V373847.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Ladesfield DS0000037645.V373847.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!