Inspection on 18/11/03 for Ladybank

INSPECTION REPORTCare Home For Older People Ladybank 10a Ladybank Birch Hill Bracknell Berkshire RG12 7HA 18th November 2003 ESTABLISHMENT INFORMATION Name of establishment Ladybank Address 10a Ladybank, Birch Hill, Bracknell, Berkshire, RG12 7HA Email Address Name of registered provider(s)/Company (if applicable) Bracknell Forest Borough Council Name of registered manager (if applicable) Mrs Ruth Patricia Helen Halliday Type of registration Care Home No. of places registered (if applicable) 39 Tel No: 01344 424642 Fax No:Category(ies) of registration, with (number of places) Old age, not falling within any other category (39) Registration number H010000475 Date First registered 2nd July 2003 Was the home registered under the Registered Homes Act 1984 Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 2nd July 2003 NO If Yes Refer to Part C 04/09/03LadybankPage 1 Date of Inspection Visit Time of Inspection Visit Name of Inspector Name of Inspector Name of Inspector 1 2 318th November 2003 09:20 am Debbie WillcoxID Code095308Name of Inspector 4 Name of Lay Assessor (if applicable) Lay assessors are members of the public independent of the NCSC. They accompany inspectors on some inspections and bring a different perspective to the inspection process Name of Specialist (e.g. Interpreter/Signer) (if applicable) Name of Establishment Representative at Ruth Halliday the time of inspectionLadybankPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspection Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: Part E: E.1. E.2. E.3. Compliance with additional conditions of registration (if applicable) Lay Assessors Summary (where applicable) Providers Response Providers comments Action Plan Providers AgreementLadybankPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the National Care Standards Commission (NCSC), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the NCSC in respect of Ladybank. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the NCSC regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Report of the Lay Assessor (where relevant) · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.LadybankPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Ladybank is a purpose built resource providing 24-hour residential care services, predominantly for people aged 65 and over. The home is made up of 5 units each with open plan lounge, dining room and kitchen facilities. Branscombe unit provides intermediate care services to eight service users for a maximum period of 6 weeks. There are plans to extend this service to include Cedar unit. Refurbishment is planned for Cedar unit with work scheduled to start in January 2004. Four additional en-suite bedrooms will be added to this 8-bedded unit. This will require an application to the NCSC for a major variation of registration due to the increase in the number of beds. The home is situated close to South Hill Park, local shops and amenities are within short walking distance. The home is owned and managed by Bracknell District Council, Social Services and Housing Department.LadybankPage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.)LadybankPage 6 This was an announced inspection of Ladybank taking place between the hours of 09.20 ­ 16.45. The inspection comprised of a tour of the building, discussion with service users and discussion with two relatives visiting the home. Time was also spent with the manager and staff. The inspector was able to examine a variety of documents. The quality of interaction between staff and service users was warm, empathic and supportive. In the main service users spoke positively about the quality of care provided. The home continues to struggle with a lack of consistency within the senior staff team due to long term sickness and redeployment. This has impacted on the regularity of staff supervision, service user annual reviews and reviewing of care plans. It is hoped this situation will be improving in the very near future with the return of a residential care officer who had been redeployed to assist in another home. Feedback was given to the Registered Manager and the Responsible Individual the following week after the inspection.Choice of Home (Standards 1-6) 5 of these 6 standards were assessed at this inspection. All 5 standards assessed were met. A care management assessment is undertaken on all service users prior to admission to the home. The homes manager endeavours to be involved jointly in assessments prior to admission. Branscombe unit provides intermediate care services to eight service users. There are plans to extend this service to include Cedar unit. Refurbishment is planned for Jan 2004. Files viewed within the intermediate care unit evidenced a thorough referral and assessment process in place. Health & Personal Care (Standards 7-11) All 5 standards were assessed during this inspection. 3 of these 5 standards were met. Case tracking was undertaken for 4 service users. As highlighted at previous inspection visits improvements are needed in the standard of care planning. Assessment of needs has improved prior to admission to the home. However care planning documents do not clearly identify action plans for meeting individual needs One service user admitted within the last 6 months has a history of falls. His care plan and risk assessment did not refer to this and so no action plan for prevention of falls had been developed. The manager is in the process of enabling staff to understand the role of keyworker and is hopeful that keyworkers will take on the role of reviewing care plans. Daily Life and Social Activities (Standards 12-15) All 4 standards were assessed at this inspection. All 4 standards were met. The monitoring and recording of social activities provided and undertaken has improved. The senior member of staff with the delegated responsibility for organising activities has embraced this role with enthusiasm and commitment. Service users evidenced their enjoyment of a recent visual arts reminiscence art project accessed via a local charity within the home.LadybankPage 7 Complaints and Protection (Standards 16-18) 2 of the 3 standards were assessed at this inspection. Both standards were met. There was evidence that this home takes complaints seriously and investigations are undertaken and recorded appropriately. Bracknell Forest Council undertakes complaints monitoring. Environment (Standards 19-26) All 8 standards were assessed at this inspection. 4 of the 8 standards were met. Some areas of the home are in need of decoration and furniture in need of replacement. A survey of the building and furniture and furnishings has recently been undertaken. An assessment of the premises has recently been undertaken by Occupational Therapists. A number of recommendations have been made as a result of this assessment. It will be a requirement of this inspection that an action plan is produced in response to the recommendations listed within this report. Staffing (Standards 27-30) All 4 standards were assessed at this inspection. 1 of these 4 standards was met. It was evident from discussions with staff that between the hours of 2-5pm staffing levels are sometimes reduced. This results in staff needing to cover more than one unit at a time. Staff commented on how this can impinge upon time for activities with service users. Many of the telephone calls coming into the main office are for the busy intermediate care unit. Residential care staff are dealing with telephone calls and queries related to the intermediate care unit. It will be recommended that a separate telephone line and administrative support be provided for the intermediate care unit. Staff are inducted in accordance with the TOPSS foundation standards. Recruitment record keeping has improved within the home. There is a need to ensure that gaps in employment are identified and copies of current work visas held within the home. Management and Administration (Standards 31-38) 7 of these 8 standards were assessed at this inspection. 2 of these 7 standards were met. The manager is currently working towards the registered Managers Award. It was evident from discussions with service users and staff that the manager is highly regarded. Staff evidenced that the manager works hard to cultivate a team atmosphere and staff feel valued by her management style. 4 service users personal allowance accounts were viewed. A record of transactions is undertaken with dual signatures obtained for each transaction. The manager was advised of the need to ensure that all valuables including post office account books are clearly recorded as held for safekeeping. Health and safety statutory training is provided via Bracknell Forest Council. During the inspection staff were observed on two occasions to be transporting service users in wheelchairs without footplates. It will be a requirement that staff undergo training in safe use of wheelchairs.LadybankPage 8 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. No. Regulation Standard Required actions Timescale for actionAction is being taken by the National Care Standards Commission to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)LadybankPage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements and recommendations are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action 1 15 OP7 Service users care plans to clearly identify care need, action to be undertaken by staff in meeting care need and detail intended outcome. Care plans to be reviewed at least once a month to reflect changing care needs and current objectives for health and personal care. All service users to access annual reviews. Medication policy to be updated to include the management of homely remedies. Policy to be dated with a date set for review of this document. An action plan to be produced detailing response to recommendations made within occupational therapist report following assessment of the premises. 01/03/04215(2)(b)(c)OP701/03/04313(2)OP901/03/04423OP2201/03/04523OP25A review of lighting throughout the building to be undertaken to ensure compliance with 01/03/04 recognised standards. Including the provision of table-level lamp lighting. Gaps in employment to be identified within application forms. Registered person to ensure that references are authenticated. 01/03/04619 schedule 2 &4OP29LadybankPage 10 717(1)(a) schedule 4(9)(a) 13OP35Receipt of all valuables held for safe keeping by the home to be clearly recorded. All staff to be provided with training in the safe use of wheelchairs. The registered person to produce an action plan detailing timescales for decoration and renewal of fabric and furniture needed throughout the home as identified within recent survey produced.01/03/048OP3801/03/04923 (2)(b)(c) OP1901/03/04RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s) No. Refer to Good Practice Recommendations Standard * It is strongly recommended that consideration be given to providing a separate telephone line and administrative support to the Intermediate care unit.1OP27* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.LadybankPage 11 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct Observation Indirect Observation Sampling · Pre-inspection Questionnaire · Records · Care Plans / Care Pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting Professionals survey / feedback Tour of Premises Formal Interviews Document reading Additional Inspection Information: Number of Service Users spoken to at time of inspection Number of Relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the Responsible Individual seen CRB check for the Manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of Inspection Time of Inspection Duration Of Inspection (hrs) YES YES YES YES YES NO NO NO YES YES YES NO YES YES NO NO NO YES NO YES 12 2 0 NA NA YES YES 30 X 18/11/03 09.20 9.5LadybankPage 12 The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards for Care homes for older persons have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.LadybankPage 13 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide Range of fees charged From (£) 393.00 To (£) 393.00Any charges for extras If yes, please state what the extras are:YES HAIRDRESSING, CHIROPODY, TOILERIES, ACTIVITIES PAPERS/MAGAZINES 3 Standard met?Key findings/Evidence Evidence from documentation provided to the NCSC.LadybankPage 14 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). N/A Key findings/Evidence Standard met? Not inspected on this occasion.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? A care manager undertakes assessments prior to admission. The homes manager endeavours to be involved jointly in assessments prior to admissions. One service user recently admitted to the home had been assessed by both a care manager and the unit manager. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? Case tracking was undertaken for 4 service users. 2 service users had recently been admitted to the home. 1 had been admitted for interim care. It was evident from a recent admission that a lack of information provided by a local hospital had resulted in an inappropriate placement. The manager responded this to appropriately with relevant specialist intervention called upon to intervene.Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? The home provides trial visits for prospective service users. A review is undertaken 6 weeks after admission to the home before the placement becomes permanent.LadybankPage 15 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff to deliver short-term intensive rehabilitation and enable service users to return home. 3 Key findings/Evidence Standard met? Branscombe unit provides intermediate care services to eight service users for a maximum period of 6 weeks. There are plans to extend this service to include Cedar unit. Refurbishment is planned for Cedar unit with work scheduled to start in January 2004. Four additional en-suite bedrooms will be added to this 8-bedded unit. This will require a request for a major variation of registration due to the increase in the number of beds. Files were viewed evidencing the referral and assessment process in place. Prior to admission prospective service users are assessed by an Occupational Therapist, Physiotherapist and Nurse based within the hospital. Upon admission to the home the Care Coordinator undertakes further assessments including Mental Test Scoring, Bathel assessment and Waterlow pressure assessment.LadybankPage 16 LadybankPage 17 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 1 Key findings/Evidence Standard met?LadybankPage 18 One service user admitted the day before the inspection for interim care was found to be anxious and having difficulty settling in. Contact sheets contained information as to care given since admission to the home. However no care plan had been compiled prior to admission and assessment details were not made available for staff to view. The manager informed the inspector that normal practice would be for assessment information to be placed within service users file also containing daily notes. As highlighted at previous inspection visits improvements are needed in the standard of care planning. Information is currently taken from the pre-admission assessment and from this information a checklist of tasks to be undertaken on behalf of service users is compiled and staff tick when these tasks are undertaken. However there is no identified plan of care, which identifies service users care needs with a detailed action plan as to how individual needs are to be met with an identified outcome. One service user admitted within the last 6 months has a history of falls. His care plan and risk assessment did not refer to this history of falls and no action plan for prevention of falls had been developed. The manager informed the inspector that care plans are reviewed. The manager was advised that a system to evidence this was needed to ensure compliance with this standard 7.4 The manager has developed detailed risk assessments clearly identifying level of risk and control measure in place and identifying who takes responsibility. The manager is in the process of enabling staff to understand the role of a keyworker and is hopeful that keyworkers will take on the role of reviewing care plans. Care plans do not evidence when reviewing of care plans is undertaken. It was apparent that not all service users are being provided with annual reviews. One service users file evidenced that this service user had not had access to a review since September 2001. The manager identified that due to a lack of stability within the senior staff team it has been difficult for the home to keep up to date with record keeping and reviews.LadybankPage 19 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. Number of incidents where service users have been taken to Accident and Emergency during last 12 months Number of service users with pressure sores at time of inspection (from information taken from care notes)8 03 Key findings/Evidence Standard met? GP visited the home during the inspection. Visits are undertaken by the GP weekly. One service user admitted the day before was complaining of back pain and did not have pain-relieving medication available. The GP was consulted and medication obtained on behalf of this service user.Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 2 Key findings/Evidence Standard Met? A medication policy has recently been developed for the home. This document covers the Receipt, administration re-ordering and return of medication. There is a requirement for this document to be dated and a date set for review. A policy for the administration and recording of homely medicines must be developed in the care home.Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with and examination by health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? There was evidence from team meetings that values around ensuring privacy and dignity for service users is reinforced at team meetings.LadybankPage 20 Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 3 Key findings/Evidence Standard met? Policy in place.LadybankPage 21 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 3 Key findings/Evidence Standard met? A senior member of staff has the delegated responsibility for coordinating social activities. This is undertaken with enthusiasm and commitment. A monitoring book detailing activities arranged and list of attended by who has been developed. Service users spoken to evidenced how much they have enjoyed a recent visual arts reminiscence art project accessed via a local charity within the home.Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences 3 Key findings/Evidence Standard met? During this inspection time was spent with two visiting relatives who evidenced that they are enabled to visit the home at anytime of the day.Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? Evidence from observation and discussions with service users. Service users evidenced choice of times for rising and going to bed. Service users are entitled to bring personal possessions with them when moving into the home.LadybankPage 22 Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet which is suited to individual, assessed and recorded requirements and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Service users evidenced that choice of food is offered. All service users spoken to commented positively on the quality of the food provided. Service users birthdays are celebrated with a birthday cake.LadybankPage 23 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple clear and accessible complaints procedure which includes the stages and time-scales for the process and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to NCSC Percentage of complaints responded to within 28 days 9 9 0 0 0 0 100 3 Key findings/Evidence Standard met? Evidence that complaints are taken seriously and responded to appropriately. Complaints and compliments are recorded. Outcome of complaints investigations also recorded in detail. Bracknell Forest Council carries out complaints monitoring.Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. N/A Key findings/Evidence Standard met? Not inspected on this occasion.LadybankPage 24 Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial, or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES 0 3Key findings/Evidence Standard met? The home has a whistle blowing policy. Staff evidenced knowledge of this policy. Evidence from complaints recording evidenced that allegations of misconduct are investigated and responded to appropriately.LadybankPage 25 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 2 Key findings/Evidence Standard met? Some areas of the home are in need of decoration and furniture in need of replacement. A survey of the building and furniture and furnishings has recently been undertaken. An action plan detailing timescales for work to be undertaken is needed. In January 2004 work will commence on Cedar unit to extend and create 4 extra en-suite bedrooms. Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 3 Key findings/Evidence Standard met? The home is made up of 5 units. Each unit has a lounge/diner and kitchenette. Kitchenettes are in need of refurbishment. The ground floor has a large communal lounge.LadybankPage 26 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 3 Key findings/Evidence Standard met? Wooden commodes have recently been replaced. The recent Occupational Therapist assessment report identified the need for the provision of grab rails in toilets with integral toilet roll holders and replacement toilet seats with sideways stoppers.Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons including a qualified occupational therapist, with specialist knowledge of the client groups catered for and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 2 Key findings/Evidence Standard met? An assessment of the premises has recently been undertaken by Occupational Therapists. A number of recommendations have been made as a result of this assessment. It will be a requirement that an action plan is produced in response to recommendations listed within this report.LadybankPage 27 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite NO YES NO 35 0 2 0 2 332 0 2 03 Key findings/Evidence Standard met? Information provided with the pre-inspection questionnaire No change since the last inspection.LadybankPage 28 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user, which is furnished and equipped to assure comfort and privacy and meets the assessed needs of the service user. 2 Key findings/Evidence Standard met? Some Sofas and armchairs are in need of repair or replacement. The recent Occupational Therapist report identified a need to provide a selection of riser/recliner armchairs and the raising of existing sofas and chairs to enable ease of transfer for service users. One service user without carpet in his room told the inspector that he would prefer carpet rather than the vinyl flooring currently in place and that his family had considered purchasing carpet on his behalf. The manager was made aware of this service users request.Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 2 Key findings/Evidence Standard met? Some areas of the home were found to be dimly lit such as lounges and corridors. This could be an issue for service users with a visual impairment. It will be a requirement of this inspection that an audit of lighting throughout the building be undertaken to ensure compliance with recognised standards (lux 150). This audit should include the assessment of need for table-level lamp lighting for service users use throughout communal areas and bedrooms. Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? Evidence from observation.LadybankPage 29 LadybankPage 30 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours 5 X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff Key findings/Evidence 6 17 X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X XX 30 X Standard met? 2LadybankPage 31 The current senior team is depleted with staff on long term sickness. This has had a knock on effect on the general record keeping within the home, reviews and the provision of supervision being undertaken. 3 new staff have recently been employed as sessional workers. It was evident from discussions with staff that between the hours of 2-5pm staffing levels are sometimes reduced. This results in staff needing to cover more than one unit at a time. Staff commented on how this can impinge upon time for activities with service users. Many of the telephone calls coming into the main office are for the busy intermediate care unit. Residential care staff are dealing with telephone calls and queries related to the intermediate care unit. It will be recommended that a separate telephone line and administrative support be provided for the intermediate care unit. Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 4 12 2 Key findings/Evidence Standard met? 3 senior staff are currently undertaking NVQ level 3, promoting independence. 2 care staff are working towards NVQ 3 in care. Given current evidence available the home is not on target to achieve the target of 50 of staff qualified by 2005.LadybankPage 32 Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 2 Key findings/Evidence Standard met? 3 staff files were viewed, staff who have recently been employed. Work is currently in progress to ensure that all staff files contain information required within schedule 2 and 4. Not all information required within care homes regulations was available within these files. However it was evident that improvements are ongoing. One staff file viewed was a recently employed member of staff. The file contained a photocopy of a visa, which was unrecognisable, and thus no date for expiry of this visa evident. The manager informed the inspector that this visa had expired and a new visa issued but as yet the home had not obtained a copy of this. There was evidence of CRB checks undertaken. Application forms were contained within staff files. These forms do not clearly identify gaps in employment. It will be a requirement that forms are updated to ensure compliance with regulations. References from previous employers were not recorded on headed notepaper or company stamp provided. It was evidenced that the manager obtains evidence of employment checks carried out by employment agencies providing staff to the home.Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme, which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? The home uses a corporate induction checklist detailing procedures and guidelines relating to terms, conditions and health and safety. A TOPSS induction booklet is given on day one of employment. 5 induction workshops sessions are arranged for all social care staff. Copies of the GSCC codes of conduct are given within induction packs and staff sign receipt of these. Agency staff are inducted and evidence of a checklist was produced. There was evidence of team meetings and meeting minutes viewed.LadybankPage 33 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 2 Key findings/Evidence Standard met? The manager is currently working towards the NVQ 4 Registered Managers Award.Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? It was evident from discussions with staff and service users that the manager is highly regarded. Staff evidence that the manager works hard to cultivate a team atmosphere and staff feel valued by her management style.Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. N/A Key findings/Evidence Standard met? Not inspected on this occasion.LadybankPage 34 Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure that there is effective and efficient management of the business. 2 Key findings/Evidence Standard met? Inventories of personal belongings are currently being compiled for all service users. Bracknell Forest Council undertook a recent financial audit of these accounts and recommendations were made. One recommendation was that the manager carries out regular audits and evidences when these occur.Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders 1 X X2 Key findings/Evidence Standard met? 4 service user personal allowance accounts were viewed. Each service user has a residents cash account record book. Dual signatures are recorded against each transaction A post office account book was found to be held on behalf of a service user within the home. No record was found detailing the receipt of this book and the manager was advised to ensure that receipt of all valuables including post office and cheque books are clearly recorded.Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 2 Key findings/Evidence Standard met? Care staff evidenced 1-1 formal supervision is provided for staff. However a recently employed staff member had not received formal supervision in 5 months of employment. It is hoped that once stability has returned within the senior team the provision of supervision will be less sporadic.LadybankPage 35 Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? All Bracknell Forest council policies and procedures are currently under review. Personnel procedures have been updated and procedural guidance manuals issued to managers.Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable, the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? The manager has developed individual and general risk assessments which are in place. It was evident from discussions with the manager and staff that statutory training such as manual handling, food hygiene and health & safety is provided. Assessments are undertaken on staff administering medication. During the inspection it was observed on two occasions staff transporting service users in wheelchairs without footplates. It will be a requirement that staff undergo training in safe use of wheelchairs.LadybankPage 36 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateDebbie WillcoxSignature Signature SignatureLadybankPage 37 PART D(where applicable)LAY ASSESSORS SUMMARYLay Assessor Date Public reportsSignatureIt should be noted that all NCSC inspection reports are public documents.LadybankPage 38 PART EE.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 18/11/03 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleLadybankPage 39 Action taken by the NCSC in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. E.2 Please provide the Commission with a written Action Plan by , which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESOther: enter details here LadybankPage 40 E.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.E.3.1 I of Ladybank confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or E.3.2 I of Ladybank am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.LadybankPage 41 - 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. 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