Inspection on 24/03/03 for Ladybank

INSPECTION REPORTCare Home For Older People Ladybank 10a Ladybank Birch Hill Bracknell Berkshire RG12 7HA 24th & 25th March 2003 ESTABLISHMENT INFORMATION Name of establishment Ladybank Address Ladybank, 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 Date First registered Date of latest registration certificateDo additional conditions of registration apply ?NOIf Yes Refer to Part CDate of last inspection7/2/02LadybankPage 1 Date and Time of Inspection Visit Name of Inspector Name of Inspector Name of Inspector Name of Inspector 1 2 3 4 Debbie Willcox Ruth Lough Lorna Sommerville (Pharmacy Inspector)ID Code 095308Name of Lay Assessor (if applicable) Name of Interpreter/Signer (if applicable)LadybankPage 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 residential resource for people aged 65 years and over. The unit also provides intermediate care resources within the homes Branscombe unit. The home is situated close to South Hill Park, local shops and amenities are within a short distance. The home is made up of 5 units each with open plan lounge, dining room and kitchen facilities. The home is owned and managed by Bracknell District Council, Social Services and Housing Dept.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.) The inspection of this home forms part of the registration process and all requirements will be conditions of registration. This service has been inspected for the first time against National Minimum Standards introduced from 1st April 2002. As a result, this report may contain a substantial number of recommendations and requirements. If so, the number of these should fall significantly at the next inspection when the provider will have had time to take account of the new legislation and standards and to take action to meet them. This inspection took place over a two day period with feedback given to the manager and service manager on the third day. An Immediate requirement was issued in relation to the breakdown of the call bell system, which had been out of action for 5 days. In spite of engineer attendance the source of the problem was unclear at the time of the inspection. The requirement made within the immediate requirement notice was for a risk assessment to be carried out and an action plan produced detailing actions to limit risk to service users. This was complied with within the timescale set. The manager later informed the inspector when the call bell system had been fixed which was within 24-hours of the last day of the inspection. It was apparent from this inspection that Staffing vacancies and the difficulties experienced in the recruitment of staff was having an impact on the home. The home endeavours to maintain a minimum of one staff member on duty within each unit. The home currently operates with a high use of agency staff. Rotas indicated that some agency staff work a shorter shift than those of permanent staff resulting in periods of the day when some staff are needing to cover more than one unit at a time. During the inspection it was observed that staff take breaks together leaving all units unattended. This was considered un-safe practice when considering the high frailty levels within the home. The manager responded appropriately to this observation by immediately notifying staff of the need to stagger breaks from there on in. Time was spent talking to service users and staff. Service users spoke positively about the care received and spoke highly of the staff teams kindly manner and empathetic approach. The atmosphere within the home was warm and friendly. The manager and staff are dedicated and committed to providing quality care.LadybankPage 6 Requirements from last Inspection 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 7 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 14 OP3 Care management and homes assessments to detail assessment of all areas detailed within this standard. Regular reviews to be provided for service users on interim placements. A review to be carried out on all current service users needing two staff for all manual handling transfers. In conjunction with a review of staffing levels to ensure that the home has adequate staffing hours to meet the needs of these service users throughout the 24-hour period. Care plans to be developed to cover all areas assessed within standard 3 involving the service user or representative in the formulation and review of care plans. Policy in the event of death, to include the need to retain medication for a period of 7 days after the death of a service user. Individuals leisure and activities interests be documented within care plans. 6 16(m)(n) OP12 Monitoring of activities provided be recorded and attendance monitored to ensure home is meeting needs of service users. A programme of maintenance and renewal of fabric and decoration of the premises to be 30/05/03 30/05/03214(2)OP330/04/03314OP430/05/03415OP730/04/03513(2)OP1130/04/03723(b)(d)OP1930/05/03 Page 8Ladybank produced including an audit of furniture in need of repair or replacement. A copy sent to the NCSC. Bathroom tiles broken and missing to be replaced. Toilets heavily stained to be de-scaled. 9 23 16 10 Schedule 4 OP24 10. OP21 All wooden commodes to be replaced. A record to be kept of the furniture brought by a service user into the room occupied. Adequate hand washing facilities such as antibacterial liquid soap and paper towels to be provided throughout all bathroom, toilets and laundry. A review of staffing levels to be undertaken using the recommended Department of Health guidance to ensure that staffing levels in respect of service user needs are appropriate. Information and documents in respect of persons working within the home including recruitment and documents as detailed within NMS Schedules 2 & 4, to be kept in the home for inspection purposes. An annual development plan for the home is provided. A quality assurance survey is undertaken involving stakeholders as detailed within this standard. A system to be implemented for recording receipt of valuables deposited by service users for safekeeping and their return. Formal supervision to be provided for care staff at least 6 times per year. A maximum and minimum thermometer should be placed in the medicine refrigerator. Maximum and minimum temperatures need to be monitored and recorded daily, in order to check whether the required range of 2-8 degrees Celsius is being maintained. 30/06/03823OP2130/06/0330/04/031123OP2630/05/031218OP2730/06/0319 13 Schedule 2 OP29 &4 24 OP3330/05/031430/06/031524OP3330/07/0316Schedule 4. 9 (a)(b) 18(2)OP3530/04/0317OP3630/05/031813(2)OP922/04/03LadybankPage 9 1913(2)OP9The medicines policy should be expanded to cover the procedures involved with receipt and disposal of medicines. A section (or a separate policy) should be written to cover all aspects of self-medication including the risk assessment process for service users.30/05/032013(2)OP9Eye preparations should not be used for more than 28 days once opened, if stated on the Immediate label. Expired containers should be returned to the pharmacy and a new supply opened. All controlled drugs to be stored in the controlled drugs cabinet. Water temperature checks to include sinks within service users rooms. Immediate Immediate21 2213(2) 13OP9 OP38RECOMMENDATIONS 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 Recommendation Action Standard * Consideration is given as to how the home will provide services users with opportunities to feedback their views about services provided through group discussions as well as ensuring regular formal reviews. Strongly recommended that the contract with CHANNEL be reviewed to ensure adequate timescales set for response to call bell system failures. Dose changes to the medication record charts should be signed and dated by the prescriber if possible. If not they should be clearly amended to show the change, who authorised it and the date. Pill cutters should be cleaned between use for different service users and at the end of the medication round if used.1OP332OP383OP94OP9* 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 10 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 Visiting Professionals survey / feedback Tour of Premises Formal Interviews Document reading Date of Inspection Time of Inspection Duration Of Inspection (hrs) YES YES YES YES YES YES NO NO YES NO YES NO YES YES NO NO YES NO YES 24/03/03 09:30 17The 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 in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable.LadybankPage 11 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 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. Range of fees charged From (£) X To (£) XAny charges for extrasYES 3Key findings/Evidence Standard met? Statement of purpose and service user guide viewed. Service user guide to contain most recent inspection report.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). 3 Key findings/Evidence Standard met? A new document has recently been developed for service users providing a statement of terms and conditions. This document is in draft. A discussion took place as to the wordiness of this document and the need to ensure it is service user friendly.LadybankPage 12 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. 2 Key findings/Evidence Standard met? Copies of care management assessments completed prior to admission viewed. The home has developed a home assessment form. Both of these assessment documents need to include all items listed within standard 3. Care planning documents within the home did not clearly link with the care management assessment information. There is a small number of service users placed on what is termed by the home as shortterm interim placements. Some of these service users have come into the home as emergency placements and have been residing within the home for several months whilst a permanent placement is found. There is no set limit to determine to length of stay for these placements. A discussion took place with the manager as to the need to ensure that these service users are provided with the opportunity for regular reviews involving their care 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. 2 Key findings/Evidence Standard met? There are six service users needing 2 staff for all transfers. One of these service users has not had a review since 1999. As well as a need within the home to ensure that all service user reviews are up to date, there is also a need for a review of staffing levels within the home to ensure that the home is able to adequately meet the current needs of the homes service user group throughout the 24-hour period. With the proposal to create another intermediate care unit with nursing care, the service manager informed the inspector that staffing levels at night would increase once this new unit is operational.Standard 5 (5.1 ­ 5.3) The registered person ensures that the 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? Evidence obtained from policies, procedures and discussion with the manager. Some potential service users are enabled to use the respite service prior to a permanent admission. The home has a policy that a review takes place for all service users within 4-6 weeks of placement.LadybankPage 13 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? Care coordinator does not carry out assessment visits prior to placement. Some service users are admitted as an emergency with as little as 24-hours notice. 10 hours of physio and 10 hours of occupational therapy are provided to this unit weekly via NHS staff. Placements within this unit are for a maximum of six weeks. There are plans to create another intermediate care unit with nursing within the home.LadybankPage 14 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 health care needs are fully met. · 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? Care plans viewed did not adequately reflect the assessment details provided prior to admission. Care plans documents viewed are task oriented and lack details of identified needs, action plan and intended outcomes. Risk assessment documents recently developed clearly identified risks. A photograph is needed on each service users file. A senior officer is assigned to each unit and takes responsibility for a monthly review of care plans. There was no evidence that service users are involved in the drawing up and reviewing of care plans. Most service user annual reviews are long overdue. One service user with high dependency needs has not had a formal review since 1999.LadybankPage 15 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. No. of incidents where service users have been admitted to Accident and Emergency since last announced inspection No. of service users with pressure sores at time of inspection (from information taken from care notes)29 03 Key findings/Evidence Standard met? It was unclear how many of the 29 admissions to hospital were to accident and emergency. The home has recently developed a policy raising staff awareness of tissue viability, prevention of and detection of pressure sore areas. Evidence of a request for a psychological assessment being sought for one service user. GP carries out weekly visits of the home. Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt of 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? This standard was inspected by the NCSCs pharmacy inspector. The medicines refrigerator does not have a maximum and minimum thermometer. Temperatures are sometimes recorded although not every day. Some eye drops which had been opened for more than 28 days were found in the refrigerator. Some Fentanyl patches were found in the medicines trolley ­ these should be stored in the controlled drugs cabinet. The medicines policy does not cover the areas of receipt or disposal of medicines and there is no written policy for self-medication and how service users are assessed. The pill cutters had traces of powder on them and did not appear to have been cleaned after use. Dose changes on the medication record charts were not signed or dated.LadybankPage 16 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, 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, following death. 4 Key findings/Evidence Standard met? Observation of interactions between staff and service users and discussions with service users evidenced that service users are treated with respect, warmth and empathy. Evidence from observation that rights to privacy are upheld. Discussion with staff evidenced a strong commitment to providing quality care that promotes independence and dignity. The home has a mobile telephone enabling service users to make calls in private. Screening is provided for those service users sharing a room. 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. 2 Key findings/Evidence Standard met? Evidence obtained from observation, policy and discussions with staff and manager. Policy needs to include the need to keep medication for a period of 7 days after death.LadybankPage 17 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. 2 Key findings/Evidence Standard met? Evidence obtained from discussion with staff and manager and care planning documents. A senior staff member has taken on the role of activities organiser. Activities have been organised within the home such as visiting theatre groups, coffee morning and parties. It was noted that there are no organised activities outside of the home. From discussion with staff and manager difficulties with staffing levels and frailty levels were cited as the main reasons for this. Although activities and leisure interests are recorded within the initial assessment there was no evidence of these within care plans. There is a need to record leisure and activities choices within care plans as well as documented evidence of activities organised and monitoring of choice and attendance. There was evidence through observation and discussion of service user choices being upheld as to times when rising in the morning and on going to bed.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? Evidence of visitors to the home. Service users spoken to evidenced being able to go out with relatives whenever they wanted to. The home has a welcoming atmosphere.LadybankPage 18 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 that the home is flexible and service users are afforded choice with daily routines.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 congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Kitchen was clean and well organised. The inspectors ate a meal with service users on the second day of the inspection. The meal was found to be well presented, nutritious with fresh vegetables. There was evidence of choice offered and recorded. It was a residents birthday and sherry was offered with the midday meal. A birthday tea with cake is provided to celebrate birthdays. A discussion took place with the manager who informed the inspector that seasonal menus would shortly be implemented.LadybankPage 19 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 since the last announced inspection 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 Percentage of complaints responded to within 28 days 13 X X X 1 100 3 Key findings/Evidence Standard met? Evidence that this home takes complaints seriously and complaints are responded to appropriately. Staff evidenced training in complaints handling.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. 3 Key findings/Evidence Standard met? Evidence from discussion with the manager of a referral to a care manager for advocacy support for a service user who does not have family or other support with finances. Service users are enabled to vote.LadybankPage 20 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 Protection of Vulnerable Adult lists since last announced inspection YES03 Key findings/Evidence Standard met? Vulnerable adults training provided for staff. Most of the senior team have recently attended and the Unit Manager will shortly be attending. Policy in place.LadybankPage 21 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 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. · Service users live in safe and 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 such as the units kitchens and bathrooms are becoming shabby and in need of refurbishment. Several areas of the home such as corridors are in need of decoration. Walls within staff toilets are in need of rendering and decoration. Some of the furniture within service users rooms are in need of repair or replacement. The inspector was given a copy of planned maintenance proposals for 03/04, which detailed plans to upgrade `Avondale unit kitchen including new sink and mixer tap. `Cedar kitchen units, worktops and flooring will be replaced. It will be a requirement of this inspection that a cyclical programme of decoration and renewal of fabric and decorations of the premises is produced as well as an audit of furniture in need of repair or replacement throughout the home. See standard 24. Standard 20. (20.1 ­ 20.7) 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.m for each service user. (To be applied from 1st April 2007 for homes existing prior to 1st April 2002 which do not meet this standard). 3 Key findings/Evidence Standard met? Each of the 5 units has an open plan lounge, dining room and kitchen. Downstairs there is a large comfortable and homely communal lounge.LadybankPage 22 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 2 Key findings/Evidence Standard met? Tiles are in need replacement within two bathrooms. Domestic staff maintain a clean homely environment. Several toilets throughout the home are badly stained and in need of de-scaling. The home has a large number of wooden commodes in need of replacement. Some are worn and without varnish. Due to the porous nature of the wood these harbour infection and are difficult to clean. 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. 3 Key findings/Evidence Standard met? The home has several manual hoists and one electric hoist. There are Grab rails within corridors and in some bathrooms. Hospital beds are provided for those service users assessed as needing them. The inspector was informed that an assessment of the premises is to be carried out by an Occupational therapist arranged for the end of April.LadybankPage 23 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Single rooms with at least 10 sq.m usable space Single rooms below 10 sq.m usable space Single rooms accommodating wheelchair users At least 12 sq.m Less than 12 sq.m Shared rooms at least 16 sq.m Shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Number of single bedrooms with en suite Number of single rooms without en suite Number of double rooms with en suite Number of double rooms without en suite NO YES NO 0 34 0 4 3 30 1 1 0 4 03 Key findings/Evidence Standard met? Evidence of room sizes provided by the manager. 30 single rooms fall below 10sqm the smallest rooms measuring 9.2sqm. Careful consideration needs to be given to the allocation of these rooms. One room previously used as a double has been provided for a service user who needs the use of a wheelchair and a hoist for all transfers.LadybankPage 24 Standard 24 (24.1 ­ 24.8) The home provides 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? The inspector was informed of the planned renewal of carpets within some rooms and corridors. There was evidence that service users are enabled to bring in items of their own furniture and possessions. There was evidence that some rooms have been furnished and decorated according to individual choice. The home does not have an Inventory detailing those items brought into the home belonging to individual service users.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. 3 Key findings/Evidence Standard met? Evidence obtained from observation.Standard 26 (26.1 ­ 26.9) The premises are kept clean and 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. 2 Key findings/Evidence Standard met? Infection control policy in place. There is a need for all bathrooms, communal toilets and laundry to have antibacterial liquid soap and paper towels provided. Domestic staff work hard to maintain a clean fresh smelling environment. The home has a much valued laundry assistant. The laundry room contained one commercial washing machine and one small domestic sized machine. One commercial gas tumble dryer and a domestic sized machine for use when the large one may be out of action.LadybankPage 25 LadybankPage 26 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 and 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 6 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 Key findings/Evidence 33 0 X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X X1 Standard met? 1LadybankPage 27 The home has several staff vacancies resulting in a high use of agency staff. Evidence from rotas show that agency staff are sometimes booked for shorter shifts than permanent staff. The result of this is that on some occasions staff are needing to cover more than one unit. It was apparent from discussions with staff that this can cause difficulties especially when another agency staff member does not turn up for work or an emergency arises within the home. Freezing of a 24-hour admin post has had a knock on effect, creating increased workloads for senior staff. Evidence from discussions with the manager indicated that the high level of staffing vacancies has affected the frequency and quality of management monitoring and the regularity of supervision for staff. The home has had a practice where all staff go off on breaks at the same time. This leaves service users vulnerable especially if they are unable to reach a call bell if needed. This was considered un-safe practice and the staggering of staff breaks discussed with the manager who responded by instructing staff accordingly. There are currently 6 service users in need of 2 staff for all transfers. It will be a requirement of this inspection that a review of staffing levels for the home and a review as to the current needs of these service users is undertaken to ensure that the home is staffed adequately to meet their needs. See also standard 7.Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered 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 5 25 3 Key findings/Evidence Standard met? 3 staff are about to commence NVQ level 3 training in May 2003. Induction according to TOPSS standards have been produced and the inspector was informed that 2 staff recently recruited have used this new format.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. 1 Key findings/Evidence Standard met? There were no staffing files that could be inspected as these are currently held within the central human resources department. Regulation and standards clearly detail the need for records to be maintained within the care home for all staff working within the home.LadybankPage 28 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? There was evidence of induction and a new format produced incorporating the TOPSS standards. Evidence of training recorded, however there is a need to ensure that all statutory training is provided and attended within recommended timescales.LadybankPage 29 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 responsibility 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 Unit Manager has a Diploma in Social work and informed the inspector that she will be working towards the Registered Managers Award. This will provide the manager with a management qualification as required by 2005. Upon completion of this award it is hoped that the scoring for this standard will rise to a 3.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? Throughout this inspection the manager adopted a positive open and transparent approach. This view of the manager was also evidenced from discussions with the staff team and service users. Staff also described the manager as approachable and expressed confidence in her abilities to respond to and deal with problems.LadybankPage 30 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 the success in meeting the aims and objectives and the statement of purpose of the home. 2 Key findings/Evidence Standard met? There is currently no annual development plan for the home. No quality assurance reviews are undertaken involving stakeholders such as GPs, district nurses, care managers etc. The home does not provide formal opportunities for service user feedback through individual or group discussions. The service manager has developed a quality questionnaire, which is on display within the home.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. 3 Key findings/Evidence Standard met? Budgetary system in place. Insurance certificates were not held within the home at the time of the inspection. The inspector informed the manager of the need to display these within the home.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 users. 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 Key findings/Evidence Financial records viewed. Standard met? 2 0 0 0The home does hold a record of receipt and return of valuables apart from a note on the daily log and the occasional VAT receipt given.LadybankPage 31 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? The home has been through a difficult period with staff shortages, this has had a knock on effect as to the provision of and regularity of formal supervision. Evidence from discussions with staff and records seen demonstrate that formal supervision is sporadic. The unit manager does receive regular supervision via the service manager.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? The home ha been updating policies and procedures to meet changes in legislation and meet the needs and challenges of the services provided.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? Water temps testing at present does not include sinks in service users rooms. There was an immediate requirement made in relation to the call bell system, which had been out of action for 5 days. A risk assessment and action plan was asked for detailing how the risk to service users would be reduced whilst waiting for the system to be fixed. This was complied with, within the timescales set. It will be requirement of this inspection that the contract with CHANNEL be reviewed to ensure an adequate response time is guaranteed in response to all reports of a system failure.LadybankPage 32 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLadybankPage 33 PART D(where applicable)LAY ASSESSORS SUMMARYLay Assessor Date Lead Inspector Date Public reports Debbie WillcoxSignatureSignatureIt should be noted that all NCSC inspection reports are public documents.LadybankPage 34 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 enter date(s) of inspection here and any factual inaccuracies: Please limit your comments to one side of A4 if possibleLadybankPage 35 Action taken by the NCSC in response to provider comments: Amendments to the report were necessaryComments 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 accurate Note: 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 12/04/03 , 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 requiredAction plan was received at the point of publicationAction plan covers all the requirements in a timely fashionAction plan did not cover all requirements and required further discussionProvider has declined to provide an action planOther: enter details here LadybankPage 36 E.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.E.3.1 I of 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 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 DateLadybankPage 37 - 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!