Inspection on 25/03/08 for Ladesfield

This inspection was carried out on 25th March 2008.

CSCI found this care home to be providing an Adequate 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 18/02/09

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Ladesfield Vulcan Close Borstal Hill Whitstable Kent CT5 4LZ Lead Inspector Lisbeth Scoones Unannounced Inspection 25th March 2008 09:30 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.V360425.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.V360425.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 Care Home 35 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (35) of places Ladesfield DS0000037645.V360425.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The total number of service users accommodated at one time should not exceed 35. To include up to ten (10) persons in the category Dementia Elderly (DE)(E) accommodated on the top floor. 5th September 2007 Date of last inspection Brief Description of the Service: The premises which were purpose built in the 1970s, are 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, 5 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 an assessment bed for those people who require support from the intermediate care team prior to return to live independently in the community. 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 team leaders. The current weekly fees for the service at the time of the visit start at approximately £351.00 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.V360425.R01.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 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced inspection took place during one day on 25th March 2008. The inspection process comprised discussions with the acting manager, senior team leader, team leader and other staff. An accompanied tour of the building was made during which the inspector met and spoke with many residents. Documentation was examined in respect of care plans, risk assessments, staff rotas, staff files, training records, medication records and other relevant documents. At all times the staff were helpful and co-operative. The inspection process was further informed by an up to date AQAA (annual quality audit and assessment) prepared by the acting manager. This provided additional information of the progress made in raising the standards. 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. The inspection process evidenced that outcomes for residents have improved in respect of the management of the home, admission and care planning, the environment, medication, staff training and supervision. The CSCI has received no complaints about the service since the previous inspection. An incident raised by the acting manager is being investigated under safeguarding vulnerable adults procedures and has not yet been concluded. What the service does well: Following the previous inspection, the acting manager submitted an improvement plan with timescales outlining how the home would improve and meet the requirements. This inspection confirmed the action taken. Staff interacted with the residents in a kind, supportive, patient and respectful and manner. Ladesfield DS0000037645.V360425.R01.S.doc Version 5.2 Page 6 Residents praised the choice and quality of the meals provided. Visitors are made welcome to the home. Staff have been trained in meeting the needs of people with a diagnosis of dementia. What has improved since the last inspection? The previous inspection made 17 Requirements and 5 recommendations. The majority of these have been met resulting in improved outcomes for the residents. A new management team has been installed and good management procedures introduced. The pre-admission assessment process has been reviewed. The home promotes Equality and Diversity as part of the induction and supervision process. A new person-centred care-planning format has been introduced. Care plans are now regularly audited to ensure that these are current and reviewed. Care plans include residents’ choices. Communication with the district nursing team has improved. Nutritional assessments are carried out. Risk of skin breakdown is assessed and acted upon. New medication administration systems have been developed. An activities plan has been introduced. The complaints procedure has been put on display. Safeguarding vulnerable adults training has been provided. The process of providing suitable and safe access to the external grounds has commenced. Staffing levels have been reviewed. Duty rotas now provide clarity as to who is on duty and where. Staff training has improved. The quality assurance systems have been strengthened. Ladesfield DS0000037645.V360425.R01.S.doc Version 5.2 Page 7 Staff supervision has been introduced. Systems have been introduced that ensure that residents are supported in safeguarding their monies. The acting manager informs the CSCI of any reportable event as per Regulation 17. Accidents are evaluated and the appropriate authorities notified. 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. Ladesfield DS0000037645.V360425.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ladesfield DS0000037645.V360425.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 6 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 an assessment bed 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 dated March 2008. These documents provide residents with detailed information of the services the home provides. Ladesfield DS0000037645.V360425.R01.S.doc Version 5.2 Page 10 Since the previous inspection, the pre-admission process has been reviewed. The senior team now requests a full needs led assessment together with a care plan. If the information provided is insufficient to make a judgement whether the home can meet a prospective resident’s needs, the senior team visits the client. Trial visits prior to admission are offered. Since the previous inspection, a screening tool has been developed to assist in determining dependency. This in turn assists in setting appropriate staffing levels. See also standard 27. The previous inspection identified that the lack of information available to staff was of particular concern in the Somerset Suite, which is the secure unit for people with a diagnosis of dementia. This is a respite unit only and this means that there is a high turnover of people coming in and out. This has now been addressed. Since the previous inspection all residents have had a care management review. With these improved systems in place, residents and their representatives are assured that the home can meet the needs of individual residents. The home has an assessment bed for those people requiring support from the intermediate care team. Senior staff spoken with were enthusiastic about this new development and the additional support received. Such support includes the input from an Admiral nurse and other community based staff. It is too early to comment on the outcome of this initiative. Ladesfield DS0000037645.V360425.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 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 mostly treated with dignity and respect for their privacy. EVIDENCE: Since the previous inspection a new person-centred care-planning format has been introduced. Care plans are reviewed weekly and now demonstrate that the care needs and intervention are appropriately evaluated. Following training and regular meetings, staff said they are encouraged and supported in getting involved in care planning. Ladesfield DS0000037645.V360425.R01.S.doc Version 5.2 Page 12 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 and self- medication. Residents are weighed regularly and provided with pressure relieving equipment if the risk of skin breakdown is identified. Wherever possible the resident had signed the care plan evidencing their input and agreement. However, staff are not provided with sufficient information as to the action to take when a resident is loosing weight. For a resident with a continence need, insufficient information was recorded for staff to provide the care. 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 now recorded in the designated section of the care plan. A visiting district nurse said that the home had much improved since the new management team had taken over. “Staff speak up for the residents”, she said. Training in respect of blood glucose monitoring is being piloted by the district nurses with a view that staff have a better understanding of looking after residents with diabetes. As referred to in standard 6, the home has an assessment bed for those people requiring support from the intermediate care team. Such support includes the input and staff training from an Admiral nurse (specialising in dementia care in the community). Following the previous inspection, a pharmacist inspection was carried out. This inspection evidenced the action taken following that visit. A review of medication charts evidenced good recording. Medication reviews are carried out. Procedures for ‘as required’ medication have been introduced. A system has been introduced for staff to use when a resident goes out for the day. As a result the resident does not miss any prescribed medication while being away from the home. A form has been introduced for that purpose. It was noted in a resident’s room that equipment used by district nurses was on display, thus compromising resident’s dignity. It was recommended that such equipment be stored appropriately. Ladesfield DS0000037645.V360425.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. 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 employs an activities organiser who at the time of the inspection was off sick. Staff were interacting with the residents in a pleasant and cheerful manner. Residents said they enjoyed talking to the staff. Residents mentioned they much enjoyed the Easter Bonnet party. A member of staff showed photographs of that event. A resident’s room was full of ‘things’ he had made himself. “I like being active” he said. Ladesfield DS0000037645.V360425.R01.S.doc Version 5.2 Page 14 At the time of the inspection, residents in the Somerset Suite were awaiting the completion of the secure garden. Until this is completed residents have no access to the garden. See also standard 19. In the dementia unit staff were noted to interact with the residents in a patient and enabling manner. A resident took an interest in an activities board and reminiscence board on display. A resident was reading the newspaper. In order for staff to be aware of a resident’s psychological, spiritual and cultural needs, residents are asked to complete a social care plan questionnaire and map of life. An activity timetable has been developed and staff are encouraged to record all activities on individuals sheets. Family and friends are welcomed at any time and people are able to have visitors when they want. Relatives all spoke highly of the staff and said that they were always made welcome. 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 have been revamped and that ‘proper’ choices are now provided at suppertime. The kitchen was recently inspected by the Environmental Health inspector. Both (new) chefs have a certificate in Intermediate Food Hygiene. Since the previous inspection, residents in the Somerset Suite are provided with fresh drinking water. Ladesfield DS0000037645.V360425.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. 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 have received safeguarding vulnerable adults training. EVIDENCE: Since the previous inspection, the complaints process has been reviewed. A copy of the complaints procedure is on display in the entrance hall and in residents’ bedrooms. 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. Staff confirmed that they have received safeguarding vulnerable adult training and that they were aware of what to do if abuse was ever witnessed or suspected. Staff are further trained in the Mental Capacity Act 2005. The previous inspection report recorded a high incidence of incidents and accidents and that these had not been appropriately addressed. Through risk assessments and audit, record keeping and staff training this is now managed effectively. See also standard 38. Ladesfield DS0000037645.V360425.R01.S.doc Version 5.2 Page 16 The Registered Provider is Kent County Council and as such all staff are fully subject to all checks such as Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA). See also standard 29. The acting manager makes effective use of the safeguarding vulnerable adults procedures in raising issues of concern that affect the well-being of the residents. Since the previous inspection systems have been introduced to safeguard residents’ monies. See also standard 35. Ladesfield DS0000037645.V360425.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 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. Not all residents have access to safe and comfortable outdoor communal facilities. Residents live in a clean environment but infection control risks were identified that could put residents at risk. EVIDENCE: The previous inspection reported extensive renovation work having been carried out to the top floor, which accommodates people with a diagnosis of dementia admitted for respite care. The unit provides a comfortable, pleasant and light environment. Ladesfield DS0000037645.V360425.R01.S.doc Version 5.2 Page 18 Since the previous inspection, communal areas of the home have been recarpeted and some curtains replaced. The toilet areas have been redecorated. The laundry area has been upgraded. The manager showed those areas that still need decorating and upgrading. This would include new furniture and beds. At the previous inspection, concern was expressed about the suitability of the top floor for accommodating people with dementia. This is a secure unit and people are not able to gain access to the gardens without the support of staff. Since that inspection, a safe and secure garden area has been identified. This area is currently fenced off and has not been planted up yet. The manager said that this area will soon be made available for residents to use and is to be made user-friendlier with railings, benches, raised flowerbeds and other features of interest. The manager further said that the staffing structure has been reviewed in order to provide sufficient staff to take residents out into the garden. Overall bedrooms and communal areas were clean and tidy and apart from one free from unpleasant odours. However, the standard of cleanliness in one of the bathrooms was poor. Whilst there is a sluice room on the ground floor, no such facility is provided in the Somerset Suite. The laundry room doubles up as a sluice room used for cleaning commode pots. Staff confirmed that they sometimes use the sluice room on the ground floor. This is an unacceptable practice and presents a risk of cross-infection. The sluice room on the ground floor has a hole in the ceiling, which needs seeing to. A clinical waste bag was lying on the floor in a resident’s room and should be in a stand. Many bins in communal areas had either no lid or were open. Clinical waste bins were not of the foot-operated type. In respect of infection control training, see also standards 30 and 38. Ladesfield DS0000037645.V360425.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. 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 not fully protected by the home’s recruitment procedures. EVIDENCE: The manager said that staffing levels are determined daily on the basis of dependency. As already referred to in standard 3, dependency assessments carried out on admission would inform the number of staff needed to care for residents’ needs. Rotas seen reflect the staff on duty per unit and per shift. The home has two separate units with designated staff. The larger unit based on the ground and first floor has three staff on duty for the 7 – 2 and 2 – 9 shifts, although an additional member of staff is also on duty at key times within these shifts. There are also two waking night staff. In the smaller Somerset Suite, the staffing levels are dependent upon the number of people staying at any current time. At the time of the inspection there were 2 staff members on duty. There is also one waking member of staff Ladesfield DS0000037645.V360425.R01.S.doc Version 5.2 Page 20 allocated. There is a sleep-in team leader who is available during the night hours if required. The manager said that a big recruitment drive is under way. Currently vacancies are covered by relief and agency staff. Staff spoken with said that currently these staffing levels are adequate. Residents spoken with said that they were well looked after and staff were kind and courteous. There are designated kitchen, cleaning and admin staff. There are 18 members of staff with an NVQ in Care and currently another 8 are in the process of obtaining the qualification. All staff are undertaking the common induction training in line with Skills for Care as an update for current skills. Staff training has been reviewed with the introduction of Skills for Care common induction standards. Equality and Diversity training is promoted. The AQAA states, “It is our aim to ensure that all staff apply for and attend such training during the next year as part of the KCC training plan.” In respect of recruitment, three staff files were examined. Good documentation was noted including interview notes, evidence of induction training and two references. Whilst assurances were given that the home does not employ staff without a POVA, this could not be evidenced from the information available in a staff file. One staff file contained evidence of a POVA and CRB check, another a POVA but no CRB. This person had been employed since February 2007. A third staff file contained no evidence of a POVA or CRB check. This person had only recently been employed and at least a POVA should have been on file. As part of the appraisal process, personal action and development plans have been devised. A training matrix is now in place. This includes safeguarding vulnerable adults and the Mental Capacity Act 2005. All staff are provided with mandatory and specialist training. However, infection control training is overdue for a number of staff. See also standards 26 and 38. Team leaders undertake medication training and staff working in the Somerset Suite are provided with dementia training. Ladesfield DS0000037645.V360425.R01.S.doc Version 5.2 Page 21 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 adequate. 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 but infection control risks must be addressed. Ladesfield DS0000037645.V360425.R01.S.doc Version 5.2 Page 22 EVIDENCE: The home has been managed since August 2007 by an acting manager. She has an NVQ 4 in Care, the Registered Managers’ Award (RMA) and post graduate Diploma in management. On a day-to-day basis she is supported by her deputy, a senior team leader. They respect and like each other and work well as a team. They were present throughout the inspection visit. The post of manager has been advertised and a decision will soon be taken regarding a permanent manager’s post. There are clear lines of accountability in the home. Both the acting manager and senior team leader work ‘hands on’. They know the residents and staff well. Staff and residents said they like the acting manager and her deputy and respect their hard work. Whilst improvement in management is acknowledged, issues identified in respect of staff recruitment (standard 29) and infection control (standards 26, 30 and 38) evidence areas that are currently not well managed. A senior manager visits the service on a monthly basis to audit records, monitor practices and support the acting manager. There is a ‘formal’ manager’s walk around every month. There are systems in place to enable residents to feedback about the service such as resident meetings. Recent residents’ surveys have been undertaken resulting in better meal choices and menu changes. Since the previous inspection, twice monthly family/carers meetings have been introduced to provide residents’ relatives with an opportunity to express their view and influence the service. Exit questionnaires have been introduced for all short-term residents. Since the previous inspection, safe systems have been introduced for residents who look after their monies and belongings whilst staying in the home. For this purpose, they 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. Regular staff supervision is now taking place. Staff spoken with confirmed the benefit they get from this. The AQAA presented at the inspection in July 2007 confirmed that the maintenance of electrical equipment, electrical circuits and gas appliances had been carried out. Accident records are well maintained and evaluated. Incidents of a challenging nature are recorded on ABC charts. The acting manager informs the CSCI and other authorities of any reportable event. Ladesfield DS0000037645.V360425.R01.S.doc Version 5.2 Page 23 Mandatory training is provided including moving and handling, health and safety and fire safety. Infection control training is outstanding. See also standards 26 and 30. Ladesfield DS0000037645.V360425.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 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 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 2 2 x x x x x 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 3 x 2 Ladesfield DS0000037645.V360425.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. 1 Standard OP19 OP20 2 OP26 OP38 18 (1) c (i) 23 (2) (k) Regulation 12 (1) (a) 23 (2) (o) Requirement The registered person must make sure that people have access to external grounds that are suitable for and safe for use by the service users The registered person shall ensure that any necessary sluicing facilities are provided The registered person shall ensure that persons employed at the care home receive training appropriate to the work they are to perform (in relation to infection control) Timescale for action 30/06/08 30/06/08 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 OP7 Good Practice Recommendations That care plans include intervention planned when residents have identified weight loss (b) That care plans identify the intervention plans in dealing with continence care needs That an infection control audit be carried out That all staff files contain evidence of a POVA and CRB DS0000037645.V360425.R01.S.doc Version 5.2 Page 26 (a) 2 3 Ladesfield OP26 OP29 check 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.V360425.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!