Inspection on 25/01/05 for Ladybank

Care Home For Older PeopleLadybank10a Ladybank Birch Hill Bracknell Berkshire RG12 7HAUnannounced Inspection25th January 2005 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point 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 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O 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. 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 YES 03/08/04 If Yes refer to Part CLadybankPage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 325th January 2005 13:50 pm Debbie WillcoxID Code095308Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionCaroline Ball, RCO, Wendy Crispin, RCO, Mira Haynes, Head of Long Term CareLadybankPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & 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: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementLadybankPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), 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 CSCI 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 CSCI 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 · 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 residential and intermediate care resource for people aged 65 years and over. The Intermediate care resource the `Bridgewell Centre is registered to admit service users under the age of 65 in certain circumstances. Mimosa and Magnolia units are based within the Bridgewell Centre, which provides intermediate care services to 19 service users for a maximum period of 6 weeks. Staff allocated to this unit are employed by the Primary Care Trust and work within NHS policies and procedures. The purpose of this unit is to provide services to promote independence and preventing inappropriate hospital admissions and re-admissions. Long term Residential care ­ These beds are part of three units named Avondale, Dawn and Eversley. These units are designed to be homely consisting of bedrooms, open plan lounge, dining room and kitchenette. The home is situated close to South Hill Park, local shops and amenities are within a 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 unannounced inspection carried out on a weekday afternoon and evening. This inspection consisted of a tour of the intermediate care units and a partial tour of the residential care units. The inspector had the opportunity to sit in on the handover meeting from am to pm shifts and had opportunities for discussions with service users and staff. All service users spoken with were complimentary regarding the manner and conduct of staff. One service user accessing respite care services said; `You cant get better than this, I have all I need and more. Feedback from this inspection was given to the Service Manager and the duty officer in charge of the pm shift. The unit manager was not present during this inspection. Choice of Home (Standards 1-6) 5 of these 6 standards were assessed at this inspection. All 5 standards were met. A recently updated statement of purpose was submitted to the CSCI. The files of 2 service users recently admitted to the home were viewed. There was evidence of a comprehensive care management assessment on each file. Care planning documentation held within the residential care unit including the quality of information stored has improved consistently over the last 2 inspection visits to the home. Health and Personal Care (Standards 7-11) 4 of these 5 standards were assessed at this inspection. 3 of the 4 standards assessed were met. It was evident that chiropody services are provided for all service users on a regular basis. Optician, hearing checks and dental services are accessed as and when a need for treatment is identified rather than regular planned preventative checks undertaken. A GP visits the home on a weekly basis. Daily Life and Social Activities (Standards 12-15) 2 of these 4 standards were assessed at this inspection. Both standards assessed were met. Discussions with service users evidence that staff seek to promote choice in all aspects of daily living. Regular reviews and unit meetings enable service users to express their wishes and views in relation to their care. Complaints and protection (Standards 16-18) 2 of these 3 standards were assessed at this inspection. Both standards assessed were met. It was evident from discussions with staff that service users are enabled to access postal voting and staff have on occasions in the past assisted service users to polling stations to vote. The service manager informed the inspector that the local authority on behalf of service users purchases Age Concern advocacy services. Environment (Standards 19-26) 5 of these 8 standards were assessed at this inspection. 3 of the 5 standards assessed were met. The unit kitchens remain in need of refurbishment and redecoration. The homes service manager informed the inspector that refurbishment of the home other than the intermediate care units is planned to take place from April 2005 onwards - within this financial year. The Capital bid has so far been agreed. A new pager system has been installed since the last inspection. Ladybank Page 7 Staffing (Standards 27-30) 2 of these 4 standards were assessed at this inspection. 1 of the 2 standards assessed was met. Staff recruitment is currently in progress, especially noticeable within the intermediate care unit. Some staff are in the process of transferring from the residential care units to the intermediate care team. There is presently a high use of agency staff throughout the units. The rotas evidenced consistent staffing levels throughout the am and pm shifts. There was evidence seen of new staff induction within the intermediate care unit. This consisted of an induction checklist. A discussion took place with the intermediate care coordinator. Standard 30.2 had been partially met however in order to meet this standard, further work will be needed to ensure that staff are provided with a more comprehensive induction process compliant with TOPSS foundation standards. Management and Administration (Standards 31-38) 5 of these 8 standards were assessed at this inspection. 4 of the 5 standards assessed were met. The home has been through a period of transition with the implementation of and now further development of the intermediate care units. It has been observed that throughout this process the unit manager for residential care and the nurse coordinator for the intermediate care unit have both been positive in their approach and jointly supportive of each other in the implementation of these changes within Ladybank. It was evident that this approach has enabled staff and service users to cope with and move forward positively during this period of change. Service users evidenced that they have been kept informed and consulted during this process.LadybankPage 8 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY 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. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection 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)STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Ladybank Page 9 Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements 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. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action Service users wishes concerning terminal care and arrangement after death to be assessed and recorded. Outstanding from the previous inspection. Original timescale 01/11/04 The bathroom located within Magnolia unit to be fitted with an assisted bathing hoist or replaced with a bath that is accessible to all service users. All newly appointed members of staff within the intermediate care unit to receive induction training to TOPSS specification within 6 weeks of appointment.112(3) 15OP1131/03/05223OP2101/06/05318OP3031/03/05 and ongoingRECOMMENDATIONS 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). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * 1 OP8 The registered person to enable all service users to access to hearing, sight and dental checks on a regular basis.* 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 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 NO YES YES NO NO NO YES NO YES NO YES YES NO NO NO YES NO YES 6 0 0 NO NO NA NA X 2 25/01/05 13:50 5.15LadybankPage 11 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people 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 12 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 (£) X To (£) XAny charges for extrasYES 3If yes, please state what the extras are: Key findings/Evidence Standard met? An up to date statement of purpose has recently been provided to the CSCI.LadybankPage 13 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). 0 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? The files of 2 service users recently admitted to the home were viewed. There was evidence of a comprehensive care management assessment on each file.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? Evidence obtained from discussions with service users, duty officer and examination of records.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? Evident from discussions with service users that opportunities to visit the home prior to admission are provided. Reviews are conducted 4-6 weekly after admission before a placement is made permanent and within 48 hours after an emergency admission.LadybankPage 14 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? The homes intermediate care provision `The Bridgewell Centre has recently increased from 8 to 19 beds within 2 units recently re-named: Magnolia and Mimosa. It was evident that rehabilitation facilities are sited within designated space. Specialists services are provided by occupational therapists and physiotherapists each providing 18 hours to the unit per week. It was disappointing that with the addition of a recently built extension adding 4 rooms to one unit a shower facility was not provided within each en-suite toilet room, when it was evident there was space to do so. All staff to this unit are employed by the PCT. Training is accessed by both the PCT and Local authority. There was evidence seen of new staff induction. This consisted of an induction checklist. Further work will be needed to ensure that staff are provided with induction compliant with TOPSS foundation standards. (see standard 30) The intermediate care service was seen to be well utilised.LadybankPage 15 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. 3 Key findings/Evidence Standard met? The files of 2 service users recently admitted to the home were viewed at this inspection. It was evident that care planning documentation and the quality of recording has improved significantly since the last inspection. Care plans are much more detailed. There is however a need for all documents to be dated and the name of the person completing care plans to be detailed.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 taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) X X2 Key findings/Evidence Standard met? It was evident that chiropody services are provided for all service users on a regular basis. Optician, hearing checks and dental services are accessed as and when a need for treatment is identified rather than regular planned preventative checks undertaken. It was evident that a GP visits the home on a weekly basis.LadybankPage 16 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. 0 Key findings/Evidence Standard Met? Not inspected on this occasion.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? It was evident from observation and discussions with service users that staff actively promote service users privacy, dignity and independence.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? There has been an outstanding requirement for care planning documentation to detail the wishes of service users wishes in the event of terminal illness or death to be recorded. It was evident from the assessment of 2 service users files that neither had this information recorded.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. 0 Key findings/Evidence Standard met? Not inspected on this occasion.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? Evidenced from observation of visitors to the home and discussions with service users.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? Discussions with service users evidence that staff seek to promote choice in all aspects of daily living. Regular reviews and unit meetings enable service users to express their wishes and views in relation to their care.LadybankPage 18 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. 0 Key findings/Evidence Standard met? Not inspected on this occasion.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 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 CSCI Percentage of complaints responded to within 28 days Key findings/Evidence Not inspected on this occasion. X X X X X X X 0Standard met?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? It was evident from discussions with staff that service users are enabled to access postal voting and staff have on occasions in the past assisted service users to polling stations to vote. The service manager informed the inspector that the local authority on behalf of service users purchases Age Concern advocacy services.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 POVA lists YES X 3Key findings/Evidence Standard met? It was evident that staff has access to training in protection of vulnerable adults.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 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? The unit kitchens remain in need of refurbishment and redecoration. The homes service manager informed the inspector that refurbishment of the home other than the intermediate care units is planned to take place from April 2005 onwards - within this financial year. The Capital bid has so far been agreed. A new pager system has been installed since the last inspection. 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. 0 Key findings/Evidence Standard met? Not inspected on this occasion.LadybankPage 22 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 1 Key findings/Evidence Standard met? Within the intermediate care units there is provision of 2 bathrooms one of these baths in a parker bath. The inspector was informed that the other bathroom is not currently used, as there is no provision of an assisted bathing hoist. This has resulted in only one bathroom being available for 19 people. This standard has not been met, as the National Minimum Standards require that for new extensions - a ratio of 1 assisted bath be provided to 8 service users.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. 0 Key findings/Evidence Standard met? Not inspected on this occasion.LadybankPage 23 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 X 4 2 0 3 X 301 0 X XKey findings/Evidence Standard met? The recently updated statement of purpose includes all room sizes.LadybankPage 24 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. 0 Key findings/Evidence Standard met? Not inspected on this occasion.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? It was noted that some unit lounges have had table lamps provided.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? The partial tour of the building including sluice rooms evidenced a clean and fresh smelling environment.LadybankPage 25 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 X 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 X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X XX X X3 Key findings/Evidence Standard met? Staff recruitment is currently in progress, especially noticeable within the intermediate care unit. Some staff are in the process of transferring from the residential care units to the intermediate care team. There is presently a high use of agency staff. The rotas evidenced consistent staffing levels throughout the am and pm shifts.LadybankPage 26 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 the 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 Key findings/Evidence Not inspected on this occasion. X X Standard met? 0Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? Not inspected on this occasion.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. 2 Key findings/Evidence Standard met? There was evidence seen of new staff induction within the intermediate care unit. This consisted of an induction checklist. A discussion took place with the intermediate care coordinator. Standard 30.2 had been partially met however in order to meet this standard further work will be needed to ensure that staff are provided with amore comprehensive induction compliant with TOPSS foundation standards.LadybankPage 27 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. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 4 Key findings/Evidence Standard met? The home has been through a period of transition with the implementation of and now further development of the intermediate care units. It has been observed that throughout this process the unit manager for residential care and the nurse coordinator for the intermediate care unit have both been positive in their approach and jointly supportive of each other in the implementation of these changes within Ladybank. It was evident that this approach has enabled staff and service users to cope with and move forward positively during this period of change. One service user commented that `The best person to go to if I have a problem is the manager ­ she is so lovely and helpful.LadybankPage 28 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. 3 Key findings/Evidence Standard met? Regular service users reviews are undertaken and unit meetings arranged. The service manager informed the inspector that questionnaires are made available to service users and visitors to the home. Quality assistance audits are undertaken with managers visiting other homes to spend time with service users ascertaining their views.Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? Not inspected on this occasion.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 X X X3 Key findings/Evidence Standard met? This standard was partially inspected. There was evidence of recorded inventory contained within 2 service users files viewed.LadybankPage 29 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. 0 Key findings/Evidence Standard met? Not inspected on this occasion.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? Evidence from observation of records held.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. 3 Key findings/Evidence Standard met? Partially inspected. The inspector was informed that two senior staff have recently trained as manual handling trainers and will cover training of staff across Bracknell Forest Council services.LadybankPage 30 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateDebbie WillcoxSignature Signature Signature02/02/05LadybankPage 31 Public reports It should be noted that all CSCI inspection reports are public documents.LadybankPage 32 PART DD.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 25 January 2005 of Ladybank and any factual inaccuracies: Please limit your comments to one side of A4 if possible I would like to thank you for recognising the work put into setting up the new Bridgwell Centre. I agree the residents have had the minimal disruption from the changes necessary throughout the home, and this could not have been achieved without the commitment of the whole staff team, at all levels. They have all be involved, to varying degrees, whether it was informing, reassuring and moving residents, or being involved in the planning, monitoring and eventual setting up and opening of the new unit. We will continue to promote mutual support for both the units, as we feel the home, the services we provide and the staff groups, are naturally inter-linked if we are to provide a homely environment, and maintain good health and safety procedures. We also recognise differences within the two areas of the unit, and staff training, and staffing levels will reflect the differing needs.LadybankPage 33 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary YESComments 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 accurateYESYESNote: 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. D.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 34 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.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 D.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 35 Ladybank / 25th January 2005Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000032156.V195598.R01© This report may only be used in its entirety. 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