Inspection on 26/09/06 for Ladybank

This inspection was carried out on 26th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ladybank 17/09/08

Ladybank 16/01/06

Ladybank 20/09/05

Ladybank 25/01/05

Ladybank 03/08/04

Ladybank 18/11/03

Ladybank 04/09/03

Ladybank 24/03/03

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Ladybank 10a Ladybank Birch Hill Bracknell Berkshire RG12 7HA Lead Inspector Kerry Kingston Unannounced Inspection 26th September 2006 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ladybank DS0000032156.V307430.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ladybank DS0000032156.V307430.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ladybank Address 10a Ladybank Birch Hill Bracknell Berkshire RG12 7HA 01344 459791 Ladybank 01344 303815 Bridgewell Centre 01344 409232 Ladybank 01344 429568 Bridgewell Centre ruth.halliday@bracknell-forest.gov.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Bracknell Forest Borough Council Mrs Ruth Patricia Helen Halliday Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42), Physical disability (19) of places Ladybank DS0000032156.V307430.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th January 2006 Brief Description of the Service: The unit comprises of two elements: Ladybank Residential Unit for residential care of people of both sexes aged 65 years and over. Staff areprovided by Bracknell Forest Borough Council (BFBC), social Services and Housing, for this element of the service. The Bridgewell Centre for Intermediate Care is registered to admit up to 19 service users over the age of 18. The Primary Care Trust and BFBC Social Services provide staffing depending on the preference of the employee, and nursing staff (who are all PCTemployed) work between 9am and 5pm on weekdays, for this element of the service. The intermediate care resource the ‘Bridgewell Centre’ is registered to admit up to 19 service users under the age of 65. Social services provide the staffing for the residential unit and the Primary Care Trust provide nursing staff (between 9am and 5pm on weekdays) for the Bridgewell intermediate care unit. The purpose of the Bridgewell unit is to provide services to promote independence and preventing inappropriate hospital admissions and readmissions. The purpose of Ladybank is to provide long term residential care for older people who are unable to live independently in the community. 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 Forest Borough Council, Social Services and Housing Department. The fees are means tested and are £64.65 - £510 per week. Ladybank DS0000032156.V307430.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A routine unannounced site visit took place between the hours of 10.30am and 7.30 pm on the 26th September 2006, to collect additional information to inform the report for the key inspection. The information was collected from a pre-inspection questionnaire, completed by the manager – all 42 service users were gigen surveys to complete confidentially. Seven were completed and returned to the CSCI Inspection Unit, and further information was collected from these and discussion with two staff, the registered manager, registered responsible person and four service users. A tour of the home, service user and other records were also used to collect information, on the day of the visit. The home consists of two units, one long term residential and one for the rehabilitation of service users, the latter includes nursing staff weekdays. A service local agreement is in place for use of the local GP pracitce and district nursing services area vailable out of hours if needed. Ladybank and Bridgewell are two very different services with one registration, the key inspection report therefore reflects the differences in some outcome groups. What the service does well: What has improved since the last inspection? Everyone has a care plan, but they must ensure the social care element as well as the healthc are element is completed in the Bridgewell Centre. The residents have more to do and staff are developing more activities for them. Ladybank DS0000032156.V307430.R01.S.doc Version 5.2 Page 6 The home is trying to find ways to make sure that more residents want to be involved in how the home is run. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ladybank DS0000032156.V307430.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ladybank DS0000032156.V307430.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 and 6 The quality in this outcome area is adequate. Service users have their needs assessed and the home is able to meet their needs although the method of recording this could be clearer. Service users have enough information to help them decide if they want to live in the residential part of the home, but this could be improved. This judgement has been made using the available information, including a visit to the service. EVIDENCE: Seven Service User assessments were looked at, three from Ladybank and four from the Bridgewell centre. Community Social Services teams and the residential home assess some service users and some in the Bridgewell Centre are admitted on the basis of a hospital assessment. Those service users who are assessed by community teams and by the registered manager have all the necessary areas of care assessed, these include social and personal care information. Those who have a hospital assessment have all their medical needs covered by specific health Ladybank DS0000032156.V307430.R01.S.doc Version 5.2 Page 9 needs assessments nutritional score/food record chart but it does not include emotional well being /social needs /family background or personal needs. Some service users are offered a trial period in the home but this is not always possible because of the individual circumstances of the service users. Service users do not have a contract/written statement of terms and conditions, in either of the units. The Statement of Purpose and Service User guide need some up-dates to ensure that they reflect the current situation. On the assessments looked at it is not always clear that the home is able to meet the individual’s needs. The manager advised that service users, generally, have a meeting four weeks after admission and notes state that it is an appropriate placement (i.e. home can meet the individuals’ needs) notes of these meetings were not available on the files looked at. Service users in the long-term unit are properly cared for and those admitted to the rehabilitation unit are, generally, enabled to return home in an appropriate time span. The pre-inspection questionnaire noted that the Bridgewell Centre had 125 admissions in one year and whilst a small percentage return to hospital or access other accommodation, most return to their homes. Three service users said that they had enough information on which to make a decision about the home, prior to admission but also said that it could have been better. Three of the seven service user surveys returned said that the pre-admission information was ‘enough’ and three noted that it was not enough. Ladybank DS0000032156.V307430.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 The quality in this outcome area is good. The home provides excellent health and generally good personal and social care. Bridgewell needs to ensure that the personal and social care needs of service users are included in the care planning process. This judgement has been made using available information, including a visit to the service. EVIDENCE: In Ladybank the residential unit, service users health, personal care and social needs are incorporated into individual care plans. In Bridgewell, the rehabilitation unit the care plans describe healthcare needs but lack personal and social care plans. The length of stay is variable, usually between six and twelve weeks. A staff member said that personal care and daily living skills are dealt with by the occupational therapists but these plans relate only to specific pieces of work rather than overall personal and social care issues. It was not clear from the care plans how people like to be helped with personal care or what their usual routines are. Monthly reviews are not always recorded as completed. The manager is confident, that reviews are routinely completed on Ladybank DS0000032156.V307430.R01.S.doc Version 5.2 Page 11 a monthly basis, in both units and she will ensure that the recording systems are used to keep records are up-to-date. Health care needs in both units are well met, good and detailed records are kept of appointments, referrals and medical interventions. The Bridgewell Centre is staffed by a team of generic intermediate care assistants (health and social care), occupational therapists, physiotherapist, and nursing staff during ‘office hours’. The team also has dedicated input from speech and language therapist, dietician, pharmacist. There is out of hours access to district nursing and GPs who will refer service users on to a consultant geriatrician if necessary. The team is lead by the intermediate care nurse manager. When nurses are not on duty service users access health services form the primary health care team, as they do in the residential unit. Service users who are able, are encouraged to self medicate. Medication is stored safely and risk assessments and competence assessments are carried out. The recording of the checking of service users who self medicate was not consistent and the recording procedure was not always used. Medication administration records seen, for medication administered by staff, were accurate. The pre-inspection questionnaire noted that there had been no medication errors since the last inspection. All staff complete training prior to administering medication and staff competent to give medication are identified. Three service users said that they received very good or excellent care, they know who to talk to if they were concerned about anything and felt that they are listened to and action is taken as necessary. Six of the seven service user surveys received noted that they were always listened to and their views were acted upon. Four service users said staff were very good and treated them with respect. Staff were observed interacting positively and respectfully with service users (both units). The home ensures that adequate assessments are completed and good quality care plans are developed from them. These ensure that all individual needs are met, including any equality and diversity issues. Ladybank DS0000032156.V307430.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. The quality in this outcome area is good. The home offers a good standard of daily life and social activities which it continues to develop and improve, the recording of activities is sometimes inconsistent with the practice. This judgement has been made using the available information, including a visit to the service. EVIDENCE: The activities records for seven service users showed that activities are not always specifically recorded. In the Bridgewell Centre activities form part of the daily therapy but are not always recorded. Three service users said that they had enough to do, two of those felt that they preferred to ‘do their own thing and this was respected by the staff’. The ‘generic’ activities log noted eight activities for the month of September, only three were for more than one service user. These were a church service, a visit by a specifically trained pet dog and a current affairs morning, there are plans for an imminent ‘auction’. The main sitting area has a computer and a piano for use by service users. One lady said that she sometimes plays the piano and have an ‘impromptu’ singsong and the computer is also used, on occasion. A hairdresser attends the home and there were records of some service users being taken out individually for a walk in the local area. The registered person and the Ladybank DS0000032156.V307430.R01.S.doc Version 5.2 Page 13 registered manager described how activities had increased since the last inspection and one staff member is now allocated the responsibility to organise activities. The manager stated that generic activities are not always recorded and are not included on individual records as a matter of course. The home appears to welcome visitors, fifteen visitors signed into the home during the inspector’s visit. One was seen speaking with the staff, who were making time for them and appeared to be very accommodating. Many people were visiting Bridgewell and there are no restrictions with regard to time or numbers of visitors. Three service users said that their families and friends were made welcome and felt comfortable to visit them. Service users felt that their views are listened to and they have as much choice /control over their daily lives as is possible. Six of the seven service user surveys returned stated that their views were always listened to. The home has regular resident meetings and has plans to develop them to ensure that as many service users as possible have access to the meetings and the minutes of the meetings. They plan to produce the minutes in different communication formats and find ways of involving and interesting more of the service users, so that more people participate. Current minutes reflect that the home shares information, seeks service users views and attempts to involve service users in the day-to-day running of the home. The home has an adequate menu, which is reviewed with input from service users and the dietician who will also advise on special diets. Two assistant cook posts are, currently, vacant. Staff who work in the kitchen have food hygiene training certificates, as do some care staff who work on the units. Service users are asked to discuss menus at resident meetings and asked if they like the food. Alternatives are offered on a daily basis. Three service users spoken to said that they liked the food, a further service user said it was ‘wonderful’. One lady said ‘not so good’ and one service user said it was ‘sometimes ok’ and ‘sometimes not’. Two comments from service user surveys said that the cooking was sometimes poor. Service users choose their lunchtime and evening meal in the morning and one was observed being given an alternative meal as she had changed her mind about her selection. One service user was observed being given his special diet. The manager advised that Ladybank can easily get the help of dietician who works mainly in Bridgewell and she also will advise on the content of the general menu, to ensure its’ nutritional value. All service users spoken to said that they are able to have drinks/snacks whenever they wanted (including during the night.) The night logs noted service users being given cups of tea and biscuits, as requested. Ladybank DS0000032156.V307430.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The quality in this outcome area is good. Service users are generally, confident and able to voice their concerns, which are taken seriously. Service users are kept safe from harm or abuse. This judgement has been made using available information, including a visit to the service. EVIDENCE: The complaints books for Ladybank and Bridgewell are kept separately. Ladybank has a detailed recording of all complaints received and appropriate action is taken quickly. There are two recorded complaints since the last inspection. The manager views complaints as positive and constructive in improving care. Three service users said that they know how to make complaint, four of the seven service user surveys noted that they were always clear how to complain and two noted that they were usually clear about how to make a complaint. Two staff were able to describe how to respond and deal with any complaints. Bridgewell complaints are well recorded but some are not written into the complaints book. Two complaints were recorded in daily notes but there was no corresponding entry in the complaints book. A serious complaint received had been entered in the book and acknowledged, although the timescale was not mentioned in the letter, the complaint procedure handbook was sent with the letter and this details time for responses but there was no timescale noted for the investigation to take place. The lady who made he complaint had left Ladybank DS0000032156.V307430.R01.S.doc Version 5.2 Page 15 the home because of the issues she had raised, the manager was not aware of the content of the complaint. All service users spoken to felt safe, staff are trained in the Protection of Vulnerable Adults issues and two staff were able to clearly describe how they would deal with any concerns they had with regard to abuse of service users. The Commission for Social Care Inspection have received no complaints or notifications of Vulnerable Adults issues since the last inspection. Ladybank DS0000032156.V307430.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The quality in this outcome area is good. The home is adequately maintained and is clean and hygienic This judgement has been made using available information, including a visit to the service. EVIDENCE: The buildings are clean, hygienic and well maintained. The manager outlined plans to replace carpets and other scheduled maintenance. Four of the seven service user surveys noted that the home is always fresh and clean and two noted that it is usually fresh and clean. One service user survey commented that the incontinence bins overflow, the manager acknowledged that there had, recently, been a problem with regard to the emptying of the bins, but this has been resolved with the organisation that is contracted to empty the bins. Two Staff confirmed that they have received infection control training. All sluice facilities and waste disposal facilities are in place. Bedrooms seen are personalised and service users confirmed they were able to bring some of their own things to the home, if they wanted to. The manager said that service Ladybank DS0000032156.V307430.R01.S.doc Version 5.2 Page 17 users are able to have their room re-decorated, in a colour scheme of their choice, after a month or so, if they are to remain in the home permanently. Ladybank is comfortable and homely, whilst Bridgewell reflects the transient nature of the service users, with less personalisation of the environment. Ladybank DS0000032156.V307430.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 The quality in this outcome area is good. The home has a competent, well-trained staff team in sufficient numbers to meet the needs of the service users. This judgement has been made using available information, including a visit to the service. EVIDENCE: The home has a staff team of fifty-three, these are split into two teams Ladybank and Bridgewell. A large percentage of the Bridgewell staff team are nurses and therapists working daytime hours only and paid by the primary care trust. The minimum of staff on duty (between 8am and 10pm) is three in Ladybank and four in Bridgewell, in addition a senior care officer is on duty in the home, giving a total of eight. There are four waking night staff and one senior care officer sleeping in. Two comments on the service user surveys said there were not always enough staff, but there has been no change since last inspection and service users spoken to during the inspector’s visit, said that there were always staff to help them if they needed assistance. Staff were observed carrying out all necessary tasks and spending time talking to and interacting with service users, throughout the site visit. Twenty-four of the fifty-three staff are professionally qualified, eight havenearly completed NVQ 2 and three are embarking on NVQ 2/3s. Two staff spoken to confirmed that there are excellent training opportunities and that they are very positively Ladybank DS0000032156.V307430.R01.S.doc Version 5.2 Page 19 encouraged to take them up. One staff member who had been in post for approximately eighteen months was embarking on her professional training, she had participated in all mandatory and numerous basic training courses. Two staff files sampled had the appropriate checks and records. There was a discussion with the manager about her ensuring she was made aware of any information about a staff member that could be significant in her decision to employ them, including nursing staff. Although training is a priority in the home and staff have many training opportunities the manager was advised that training records need to be kept up-to-date and accessible. Ladybank DS0000032156.V307430.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 The quality in this outcome area is good. The home is well managed but the Bridgewell unit is very separate from Ladybank and this causes some confusion with regard to the day-to-day responsibilities of the registered manager. The Health safety and welfare of service users are seen as a priority within the home. EVIDENCE: The manager has been in post for many years, is a qualified social worker and has attained the registered manager’s award and is widely experienced. She was observed interacting with residents who appeared to know her and feel comfortable to talk to her. There is ongoing development and improvement work planned around helping service users to express their views more clearly and being encouraged to become more involved in the running of the home. Rotas reflect the needs of Ladybank DS0000032156.V307430.R01.S.doc Version 5.2 Page 21 the service users and they can rise and retire whenever they wish as there are 4 waking night staff from 10pm until 8am, and daytime staff work between 8am and 10pm. There was a discussion with the registered individual and the registered manager about the management of the home as the two separate units run very differently. The registered manager does not have day-to-day knowledge of the Bridgewell Centre as this is managed by the nurse manager. The manager stated they have a minimum of weekly meetings to discuss service user, staff and environmental issues, and was advised these need to be recorded. Formal management supervision of the nursing manager of the Bridgewell unit is not, currently undertaken by the registered manager but by the intermediate care serivces manager and clinical supervision through the Primary Care Trust. It was not clear what nursing procedures are carried out in the Bridgewell unit and who was responsible for them. Written procedures identifying nursing procedures and who is responsible for them in the Bridgewell Centre need to be available on the unit. The registered manager advised that all invasive procedures and specialised dressings are carried out by the nursing staff or district nurses. The home does not get involved in the general finances of the service users. They do hold small amounts of cash that are recorded on an individual basis, locked in the safe and any entries/withdrawals are signed for by families/the service users or two staff. Service users are encouraged to retain control of their own finances, wherever possible. The home has appropriately referred a service user to the vulnerable adults co-ordinator because there was some concern with regard to the handling of their finances. The issue was resolved satisfactorily. The manager advised the inspector that she audits the cash regularly. The home treats health and safety as a priority, it has a health and safety advisor in the local authority and the manager is the designated health and safety representative in the home. All necessary maintenance checks and actions are completed. There have been a large number accidents and incidents reported but the home includes the reporting of ‘near misses’, to ensure that any necessary risk assessment or avoidance action is undertaken. The number of accident and emergency admissions (fifty five as noted on the Pre-Inspection questionnaire) appeared high but the manager explained that the count included every time someone was sent to hospital to be ‘checked over’, the service users often go straight home again. The home is very conscientious with regard to the safety of the service users. Accident and incident forms are detailed and checked by the manager who comments and looks for any trends or patterns and advises any necessary Ladybank DS0000032156.V307430.R01.S.doc Version 5.2 Page 22 changes to care plans and/or referrals to other professionals such as the ‘falls clinic’. Ladybank DS0000032156.V307430.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 1 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 4 Ladybank DS0000032156.V307430.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP2 OP7 Regulation 5.1(b)(c) 15.1 Requirement To provide service users with a contract/statement of terms and conditions. To ensure that all service users have a written plan as to how their health and welfare needs are to be met. Timescale for action 01/01/07 01/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2. 3 Refer to Standard OP12 OP16 OP31 Good Practice Recommendations To record individual and generic activities provided by the home. To consider using a ‘joint’ complaints procedure/book for both units. To ensure that the manager has clear lines of accountability and responsibility, in respect of both parts of the home. Ladybank DS0000032156.V307430.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ladybank DS0000032156.V307430.R01.S.doc Version 5.2 Page 26 - 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. 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