Inspection on 03/08/04 for Ladybank

Care Home For Older PeopleLadybank10a Ladybank Birch Hill Bracknell Berkshire RG12 7HAAnnounced Inspection3rd August 2004 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 If Yes refer to Part C 18/11/03LadybankPage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 33rd August 2004 09:20 am Debbie WillcoxID Code095308Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMs Ruth Halliday, ManagerLadybankPage 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 purpose built resource providing 24-hour residential care services, predominantly for people aged 65 and over. The home is made up of 5 units each with an open plan lounge, dining room and kitchen facilities. Branscombe unit provides intermediate care services to eight service users for a maximum period of 6 weeks. 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 announced inspection carried out on a weekday. The inspection comprised of a tour of the building, audit of records, discussions with the manager, the Head of Long Term Care, service users and staff. 3 responses were received from comment cards sent by the CSCI. In the main feedback was positive regarding the conduct of the home. A variation of registration has recently been submitted to the CSCI to increase intermediate care provision from within the home. Cedar unit is currently undergoing refurbishment to create 4 additional intermediate care beds in addition to the 8 beds already provided from this unit. This will be in addition to the 8 intermediate care beds already being provided from Branscombe unit. The management of staff to these two units will be undertaken by the PCT and Bracknell Forest Council. A tour of the extension to Cedar unit was undertaken during this inspection. It was noted as a concern that the communal space provision within this unit is not being extended. It was a concern that to enable 11 people to access the communal lounge could be cramped and not allow for 4.1 sqm per person, as is a requirement within standard 20 of the NMS. However the home has a large lounge on the ground floor of the home and it is planned that this lounge will be made available for intermediate care service users use. There are 2 outstanding requirements and 1 recommendation from the previous inspection. Feedback was given to the registered manager and responsible individual. Choice of Home (Standards 1-6) 5 of these 6 standards were assessed at this inspection. 4 of these 5 standards were assessed at this inspection. Assessed as met. In support of the application recently submitted to the CSCI to vary the categories of registration there is a requirement for the homes statement of purpose to be updated and a copy sent to the CSCI. 3 service user files were viewed at this inspection. Each file contained comprehensive assessments undertaken prior to admittance to the home. Health and Personal Care (Standards 7-11) All 5 standards were assessed at this inspection. 3 of the 5 assessed standards were met. The quality of care planning recording has improved since the last inspection. There was evidence of regular review undertaken for care. Of the 3 files viewed one service user annual review was overdue by 4 months On inspection of the medication storage and administration ion two of the homes units revealed gaps within administration recording. The manager confirmed that the home has regular 3 monthly audit visits from the providing pharmacist. Reports are not maintained within the home of these visits. The inspector will consult with the pharmacist to request copies of reports. There was evidence of competency assessments undertaken for staff as part of their training to administer medication. It is advised that reviews of competency are regularly undertaken. Daily Life and Social Activities (Standards 12-15) All 4 standards were assessed at this inspection. 3 of the 4 standards assessed were met. It was evidenced from observation, records and discussions with service users that opportunities are presented to exercise choice in relation to times for rising and retiring to Ladybank Page 7 bed and routines for daily living as is appropriate. One file viewed contained an assessment of this service users social and leisure interests. The inspector had the opportunity to join a group of service users for the midday meal. There was a mixed reaction in views expressed by services users as to the variety and quality of food provided. There is a choice of two midday meals provided and service users requests are recorded the day before. It was evident that service users are not consulted in the compiling of menus. The manager informed the inspector that this is done on an informal basis. However the manager is looking to address this in providing a more formal assessment of quality assessment. Complaints and Protection (Standards 16-18) 1 of these 3 standards was assessed at this inspection. This standard was assessed as met. It was evident from discussions with two service users that they were aware of how to access the formal complaints procedure. It was evident from discussions with service users and staff that the manager demonstrates and encourages a culture of openness in the recording and dealing with complaints. Environment (Standards 19-26) 7 of these 8 standards were assessed at this inspection. 4 of these 7 standards were found to be met. There is an outstanding requirement from the previous 2 inspections for an action plan to be produced by the registered person detailing timescales for decoration and renewal of fabric and furniture as needed throughout the building. The inspector was informed during the inspection that a plan of works needed has recently been submitted to access funds from the local authority. The main kitchen within the home has recently undergone refurbishment. The unit kitchens remain in need of refurbishment and redecoration. The inspector was informed that a request for funding has been made to enable work to be undertaken. Staffing (Standards 27-30) 3 of these 4 standards were assessed at this inspection. All 3 standards were unmet. It was evidenced from discussions with staff and service users that between the hours of 25pm there is sometimes as little as only 2-3 care staff on duty on the units. This is a cause of frustration for service users who expressed sympathy for the pressure on staff and sometimes neglected to ask for assistance knowing that staff were not available within their unit, as they may have needed to attend elsewhere. This has been highlighted as an area of concern at previous inspections and it will be a requirement that this is addressed as a matter of urgency. There is some way to go before the home will reach the target of 50 of staff qualified to NVQ level 2 or equivalent by 2005. 3 staff files held within the home was viewed at this inspection. These were incomplete and it was difficult to assess compliance with this standard. The main staff files are held centrally within Bracknell Forest Councils personnel department. It will be a requirement that these files are made available for inspection at the announced inspection visits as had been previously agreed with all unitary authorities and the CSCI.LadybankPage 8 Management and Administration (Standards 31-38) 7 of these 8 standards were assessed at this inspection. 4 of these 7 standards were assessed as met. It has been evidenced through the observation of records and observation of interactions between the manager, staff and service users that the manager has cultivated an open and transparent culture within the home that upholds service users rights and protection. She is highly valued by both service users and staff. A variety of records detailing health and safety monitoring were viewed and found to be in order and evidencing regular health and safety audit.LadybankPage 9 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 action 1 23 OP25 A review of lighting throughout the building to be undertaken to ensure compliance with recognised standards. The registered person to produce an action plan detailing timescales for decoration and renewal of fabric and furniture needed throughout the home. 01/03/04223(2)(b)(c)OP1901/03/04Action 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 Standard 1 OP27 It is strongly recommended that consideration be given to providing a separate telephone line and administrative support to the intermediate care unit.LadybankPage 10 CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)LadybankPage 11 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 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 1 23 OP25 A review of lighting throughout the building to be undertaken to ensure compliance with recognised standards. This requirement is outstanding from the previous inspection. The registered person to produce an action plan detailing timescales for decoration and renewal of fabric and furniture needed throughout the home. This requirement is outstanding from the previous 2 inspections. 01/11/04223(2)(b)(c)OP1901/11/0434,5OP1An updated statement of purpose to be submitted to the CSCI in support of the recent 01/09/04 application to vary categories of the homes registration. The medication administration record to be signed by the person administering the medication immediately after medication has been given. Service users wishes concerning terminal care and arrangements after death to be assessed and recorded. Adequate staffing levels to meet the assessed needs of service users to be maintained throughout the 24-hour period. Immediatel y413(2)OP9512(3) 15OP1101/11/04618OP27OngoingLadybankPage 12 717, 18OP29Staff files to be made available for inspection at announced inspection visits as agreed with the CSCI and unitary authorities within the Berkshire area.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 OP27 It is strongly recommended that consideration be given to providing a separate telephone line and administrative support to the intermediate care unit. Service users views sought in the compiling of seasonal menus.2OP15* 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 13 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 NO YES YES YES YES NO NO YES YES YES NO YES YES NO NO YES YES NO YES 8 0 0 NA NA YES YES 25 1 03/08/04 09.20 8LadybankPage 14 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 15 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 (£) 350 To (£) 1,616Any charges for extras If yes, please state what the extras are:YESCHIROPODIST, HAIRDRESSER, NEWSPAPERS, TOILETRIES, TRANSPORT 2 Key findings/Evidence Standard met? In support of the application recently submitted to the CSCI to vary the categories of registration there is a requirement for the homes statement of purpose to be updated and a copy sent to the CSCI.LadybankPage 16 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? 3 service user files were viewed at this inspection. Each file contained comprehensive assessments undertaken prior to admittance to the home.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 records, observation and discussions with service users and the managerStandard 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? Files contained evidence of opportunities to visit the home prior to admission and evidence of 4-6 weekly reviews after admission before a placement is made permanent.LadybankPage 17 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? It is proposed to increase the homes intermediate care provision from 8 to 19 beds after completion of current refurbishment underway. Rehabilitation facilities are sited in dedicated space. Specialist services are provided via occupational therapists and physiotherapists. On completion of new unit it is planned that all intermediate care staff will be employed by Bracknell Forest Council domiciliary care department and nursing staff employed by the PCT. The unit manager will remain as the registered person for the building and will take responsibility for the auditing of health and safety, fire safety procedures, Complaints procedures and quality assurance monitoring. The Head of Long Term Care will take responsibility for the monitoring systems for supervision of staff as part of her responsibilities undertaken within regulation 26 monitoring.LadybankPage 18 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 quality of care planning recording has improved since the last inspection. There was evidence of regular review undertaken for care. Of the 3 files viewed one service user annual review was overdue by 4 monthsStandard 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) 12 23 Key findings/Evidence Standard met? Above information provided by the manager within the pre-inspection questionnaire. Evidence of regular visits from GPs.LadybankPage 19 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 2 Key findings/Evidence Standard Met? On inspection of the medication storage and administration ion two of the homes units revealed gaps within administration recording. The manager confirmed that the home has regular 3 monthly audit visits from the providing pharmacist. Reports are not maintained within the home of these visits. The inspector will consult with the pharmacist to request copies of reports. There was evidence of competency assessments undertaken for staff as part of their training to administer medication. It is advised that reviews of competency are regularly undertaken. 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? Evidence from observation and discussions with service users.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? It was evidence from pre-assessment documents and care planning information that service users wishes in event of terminal illness or death is not assessed and recorded.LadybankPage 20 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 3 Key findings/Evidence Standard met? It was evidenced from observation, records and discussions with service users that opportunities are presented to exercise choice in relation to times for rising and retiring to bed and routines for daily living as is appropriate. One file viewed contained an assessment of this service users social and leisure interests.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 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? Evidenced from observation and discussions with service users.LadybankPage 21 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. 2 Key findings/Evidence Standard met? The inspector had the opportunity to join a group of service users for the midday meal. There was a mixed reaction in views expressed by services users as to the variety and quality of food provided. There is a choice of two midday meals provided and service users requests are recorded the day before. It was evident that service users are not consulted in the compiling of menus. The manager informed the inspector that this is done on an informal basis. However the manager is looking to address this in providing a more formal assessment of quality assessment.LadybankPage 22 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 10 9 1 0 0 0 95 3 Key findings/Evidence Standard met? Above information was provided by the manager within the pre-inspection questionnaire. It was evident from discussions with two service users that they were aware of how to access the formal complaints procedure. It was evident from discussions with service users and staff that the manager demonstrates and encourages a culture of openness in the recording and dealing with complaints.LadybankPage 23 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. 0 Key findings/Evidence Standard met? Not inspected on this occasion.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 Key findings/Evidence Not inspected on this occasion. Standard met? YES 0 0LadybankPage 24 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? There is an outstanding requirement from the previous 2 inspections for an action plan to be produced by the registered person detailing timescales for decoration and renewal of fabric and furniture as needed throughout the building. The inspector was informed during the inspection that a plan of works needed has recently been submitted to access funds from the local authority. The main kitchen within the home has recently undergone refurbishment. The unit kitchens remain in need of refurbishment and redecoration. The inspector was informed that a request for funding has been made to enable work to be undertaken.LadybankPage 25 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. 2 Key findings/Evidence Standard met? Cedar unit is currently undergoing refurbishment to create 4 additional intermediate care beds in addition to the 8 beds already provided from this unit. This will be in addition to the 8 intermediate care beds already being provided from Branscombe unit. A tour of the extension to Cedar unit was undertaken during this inspection. It was noted as a concern that the communal space provision within this unit is not being extended. It was a concern that to enable 11 people to access the communal lounge would be cramped and does not allow for 4.1 sqm per person, as is a requirement within standard 20 of the NMS. However the home has a large lounge on the ground floor of the home and it is planned that this lounge will be made available for intermediate care service users use. It is a requirement that the registered person produces calculations as to the square metres available per person is produced.Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 0 Key findings/Evidence Standard met? Not inspected on this occasion.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 had an assessment of the premises undertaken by a qualified occupational therapist. The manager has produced a response to the recommendations listed within the report provided by the OT. Some of the recommendations have been and plans in place to meet others.LadybankPage 26 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite NO YES NO 35 0 2 0 X 301 0 X X3 Key findings/Evidence Standard met? Above information was provided by the manager within the pre-inspection questionnaire. The soon to be updated statement of purpose to include the number of rooms and sizes of rooms contained within the extension to Cedar unit.LadybankPage 27 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. 3 Key findings/Evidence Standard met? A partial tour of the building was undertaken building was undertaken. As a result of a recent OT report some chairs have been replaced. Rooms viewed were found to be clean, comfortable and service users had been encouraged to bring in personal items if space allowed creating a homely environment.Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 2 Key findings/Evidence Standard met? Table level lighting lamps have been provided to each unit. There is an outstanding requirement for a review of lighting throughout the building to be undertaken to ensure compliance with recognised standards.Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? Evidence from observation.LadybankPage 28 LadybankPage 29 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 2 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 4 19 X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X X1 25 72 Key findings/Evidence Standard met? Above information provided by the manager within the pre-inspection questionnaire. It was evidenced from discussions with staff and service users that between the hours of 25pm there is sometimes as little as only 2-3 care staff on duty on the units. This is a cause of frustration for service users who expressed sympathy for the pressure on staff and sometimes neglected to ask for assistance knowing that staff were not available within their unit, as they may have needed to attend elsewhere. This has been highlighted as an area of concern at previous inspections and it will be a requirement that this is addressed as a matter of urgency.LadybankPage 30 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 3 12 2 Key findings/Evidence Standard met? There is some way to go before the home will reach the target of 50 of staff qualified to NVQ level 2 or equivalent by 2005.Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 2 Key findings/Evidence Standard met? 3 staff files held within the home were viewed at this inspection. These were incomplete and it was difficult to assess compliance with this standard. The main staff files are held centrally within Bracknell Forest Councils personnel department. It will be a requirement that these files are made available for inspection at the announced inspection visits as had been previously agreed with all unitary authorities and the CSCI. 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. 0 Key findings/Evidence Standard met? Not inspected on this occasion.LadybankPage 31 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users financial interests are safeguarded. Staff are appropriately supervised. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 2 Key findings/Evidence Standard met? The manager has a Certificate in Social Services and is currently working towards the registered managers award. It is anticipated that the scoring for this standard will go up to a 3 once this qualification has been obtained.Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? It has been evidenced through the observation of records and observation of interactions between the manager, staff and service users that the manager has cultivated an open and transparent culture within the home that upholds service users rights and protection. She is highly valued by both service users and staff. 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? This standard was partially inspected. There was evidence that service users have access to regular reviews and service user meetings.LadybankPage 32 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. 3 Key findings/Evidence Standard met? The registered manager has access to an annual business and financial plan for the establishment. This is open to inspection.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 0 Key findings/Evidence Standard met? Above information provided by the manager within the pre-inspection questionnaire. This standard was not inspected on this occasion. 1 X 0Standard 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? It was evident that regularity of supervision is improving but has some way to go to achieve the minimum of 6 times per year. It is hoped that the stability within the senior team will enable staff to be provided regularly with this valuable resource. There is a need for annual appraisals to be provided for staff.LadybankPage 33 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? Homes records were seen to be secure. Bracknell Forest Council has a policy on access to records for service users.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? A variety of records inspected including water temperature testing; Fire records; personal appliance testing; hot water valves servicing ­ all were found to be in order. The report detailing the environmental health inspection visit undertaken in December 2003 was found to be without requirements or recommendations. It was evident that there is a need to ensure maternity risk assessments are undertaken.LadybankPage 34 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateDebbie WillcoxSignature Signature Signature11/8/04LadybankPage 35 Public reports It should be noted that all CSCI inspection reports are public documents.LadybankPage 36 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 enter date(s) of inspection here and any factual inaccuracies: Please limit your comments to one side of A4 if possibleLadybankPage 37 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. 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 publicationNOAction 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 plan YESOther: enter details here LadybankPage 38 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.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 D.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 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 39 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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