Inspection on 04/09/03 for Ladybank

INSPECTION REPORTCare Home For Older People Ladybank 10a Ladybank Birch Hill Bracknell Berkshire RG12 7HA 4th September 2003 ESTABLISHMENT INFORMATION Name of establishment Ladybank Address 10a Ladybank, Birch Hill, Bracknell, Berkshire, RG12 7HA Email Address Name of registered provider(s)/Company (if applicable) Bracknell Forest Borough Council Name of registered manager (if applicable) Mrs Ruth Patricia Helen Halliday Type of registration Care Home No. of places registered (if applicable) 39 Tel No: 01344 424642 Fax No:Category(ies) of registration, with (number of places) Old age, not falling within any other category (39) Registration number H010000475 Date First registered 2nd July 2003 Was the home registered under the Registered Homes Act 1984 Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 2nd July 2003 NO YES 25/03/03 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 34th September 2003 10:00 am Debbie Willcox Lesley AtkinsID Code095308Name of Inspector 4 Name of Lay Assessor (if applicable) Lay assessors are members of the public independent of the NCSC. They accompany inspectors on some inspections and bring a different perspective to the inspection process Name of Specialist (e.g. Interpreter/Signer) (if applicable) Name of Establishment Representative at Ruth Halliday the time of inspectionLadybankPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspection Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: Part E: E.1. E.2. E.3. Compliance with additional conditions of registration (if applicable) Lay Assessors Summary (where applicable) Providers Response Providers comments Action Plan Providers AgreementLadybankPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the National Care Standards Commission (NCSC), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the NCSC in respect of Ladybank. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the NCSC regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Report of the Lay Assessor (where relevant) · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.LadybankPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Ladybank is a purpose built resource predominantly for people aged 65 and over. The home is made up of 5 units each with open plan lounge, dining room and kitchen facilities. The unit also provides intermediate care resources within the homes Branscombe unit. There are plans to refurbish Cedar unit to provide 24 hour nursing care. The home is situated close to South Hill Park, local shops and amenities are within a short 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.) This was an unannounced inspection of the home carried out between 10.00am and 15.00pm. Throughout the inspection time was spent with the manager, staff and several service users. Feedback was given to the manager throughout the inspection. The atmosphere in the home was found to be warm and friendly. Service users spoken to expressed satisfaction with the quality of service received. The home currently has five staffing vacancies and two senior staff members on sick leave with another senior on a temporary placement to another home. An agency staff member has been purchased to assist the manager with the running of the home and another staff member is acting up into a senior post. The home is under pressure due to these staffing shortages, however it was a credit to the manager and the current staff team that the home was found to be coping and the team morale was good. As highlighted within the last inspection it is apparent that there is insufficient administration support to enable the manager to meet the national minimum standards and ensure that outstanding requirements are met. Again, it will be a requirement that Bracknell Forest Council review staffing levels within the home to reflect the needs of the service and ensure adequate administrative support. Work is soon to commence to refurbish Cedar unit into an intermediate care unit with nursing providing short-term intensive rehabilitative services.LadybankPage 6 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. No. Regulation Standard Required actions Timescale for action 1 16(m)(n) OP12 Individuals leisure and activities interests to be documented within care plans. Monitoring of activities provided be recorded and attendance monitored to ensure the home is meeting current needs of service users. NOT INSPECTED ON THIS OCCASION. 2 23(b)(d) OP19 A programme of maintenance and renewal of 30/05/03 fabric and decoration of the premises to be produced including an audit of furniture in need of repair or replacement. A copy to be sent to the NCSC. All wooden commodes to be replaced. Information and documents in respect of persons working within the home including recruitment and documents as detailed within NMS Schedules 2 & 4, to be kept in the home for inspection. An annual development plan for the home is provided. A maximum and minimum thermometer should be placed in the medicine refrigerator Maximum and Minimum temperatures need to be monitored and recorded daily, in order to check whether the required range of 2-8 degrees Celsius is being maintained. The medicines policy should be expanded to cover the procedures involved with receipt and disposal of medicines. A section (or a separate policy) should be written to cover all aspects of self-medication including the risk assessment process for service users. 30/06/03 30/05/03 30/05/033 423OP2119 OP29 Schedule 2 &45 624 13(2)OP33 OP930/06/03 22/04/03713(2)OP930/05/03LadybankPage 7 Action is being taken by the National Care Standards Commission to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)LadybankPage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements and recommendations are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action 1 16(m)(n) OP12 Individuals leisure and activities interests to be documented within care plans. Monitoring of activities provided be recorded and attendance monitored to ensure the 01/11/03 home is meeting current needs of service users. This requirement remains outstanding from the inspection carried out in March 2003, an additional timescale has been given for compliance. 2 23(b)(d) OP19 A programme of maintenance and renewal of fabric and decoration of the premises to be produced including an audit of furniture in need of repair or replacement. A copy to be sent to the NCSC. This requirement remains outstanding from the inspection carried out in March 2003, an additional timescale has been given for compliance. All wooden commodes to be replaced. This requirement remains outstanding from the inspection carried out in March 2003, an additional timescale has been given for compliance. 01/12/0301/11/03323OP21LadybankPage 9 419 OP29 Schedule 2 &4Information and documents in respect of persons working within the home including recruitment and documents as detailed within NMS Schedules 2 & 4, to be kept in the home for inspection. This requirement remains outstanding from the inspection carried out in March 2003, an additional timescale has been given for compliance.01/11/03524OP33An annual development plan for the home is provided. This requirement remains outstanding from the inspection carried out in March 2003, an additional timescale has been given for compliance. 01/12/03613(2)OP9A maximum and minimum thermometer should be placed in the medicine refrigerator Maximum and Minimum temperatures need to be monitored and recorded daily, in order to check whether the required range of 2-8 degrees Celsius is being maintained. This requirement remains outstanding from the last inspection in March 2003. An additional timescale has been given for compliance.01/10/03713(2)OP9A section of the homes medication policy (or a separate policy) should be written to cover all aspects of self-administration of medication including the risk assessment process for service users. This requirement remains outstanding from the last inspection carried out in March 2003, an additional timescale has been given for compliance.01/11/03818OP27An audit of staffing levels and administrative support for the home to be undertaken by Bracknell Forest Council to ensure that permanent administrative staffing levels reflect the needs of this size of home and to allow the home to be properly managed.01/12/03LadybankPage 10 RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s) No. Refer to Good Practice Recommendations Standard ** Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.LadybankPage 11 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct Observation Indirect Observation Sampling · Pre-inspection Questionnaire · Records · Care Plans / Care Pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting Professionals survey / feedback Tour of Premises Formal Interviews Document reading Additional Inspection Information: Number of Service Users spoken to at time of inspection Number of Relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the Responsible Individual seen CRB check for the Manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of Inspection Time of Inspection Duration Of Inspection (hrs) YES NO NO YES YES NO NO NO YES NO YES NO YES YES NO NO NO YES NO YES 10 0 0 NA NA NO NA X 1 04/09/03 10.00 10LadybankPage 12 The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards for Care homes for older persons have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.LadybankPage 13 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service Users assessed and referred solely for intermediate care are helped to maximise their independence and return home.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide Range of fees charged From (£) X To (£) XAny charges for extrasYESIf yes, please state what the extras are: 2 Key findings/Evidence Standard met? The homes Service user guide is in the final stages of development needing the addition of pictures. This document will need to contain most recent inspection report.LadybankPage 14 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). N/A Key findings/Evidence Standard met? Not inspected on this occasion.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 2 Key findings/Evidence Standard met? The home strives to undertake an assessment in addition to the care management assessment prior to admittance to the home. Although the care management assessment form indicates an in depth assessment it was recognised that an assessment may have been carried out some length of time before actual placement and may not fully reflect the current needs of service users. The homes assessment form is still in need of updating to ensure compliance with the list of criteria within standard 3.Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 2 Key findings/Evidence Standard met? The home currently has four empty beds ready for relocation of those service users currently living on Cedar unit in preparation for refurbishment of this unit. 9 service users living within the home are on interim placement, it is envisaged that two of these service users will become permanent. One service user has been on temporary placement for 5-6 months. For the 7 service users who will be moving on to other placements, only one has monthly reviews. The manager informed the inspectors that arrangements will be made to ensure that monthly reviews will be held for all service users who are waiting for permanent placement elsewhere. OT assessments have recently been carried out on service users needing 2 staff for transfers.LadybankPage 15 Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? The home has a policy that a review is undertaken of placement after 4-6 weeks from admission.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? Evidence from observation and discussions with the care coordinator for this unit. Weekly, 10 hours of physiotherapy and 10 hours of occupational therapy are provided to this unit.LadybankPage 16 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. 2 Key findings/Evidence Standard met? There was a slight improvement in the standard of recording within care plans and their reflection of the assessed needs of service users, however it was acknowledged that with the gaps within the senior staffing team this is an added burden for the manager to ensure compliance with this standard.Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. Number of incidents where service users have been taken to Accident and Emergency during last 12 months Number of service users with pressure sores at time of inspection (from information taken from care notes) Key findings/Evidence Not inspected on this occasion.X X N/AStandard met?LadybankPage 17 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? Requirement from the last inspection for a maximum and minimum thermometer to be placed within the medicine refrigerator is still outstanding. Medication policy has recently been updated to include requirements to cover procedures involved with receipt and disposal of medicines, however the requirement to include within this policy or a separate policy all aspects of self-administration of medication is still outstanding. Gaps were found in the recording of drugs administered. 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. 3 Key findings/Evidence Standard met? Policy has been updated to include need for the home to retain medication within the home for a period of at least 7 days.LadybankPage 18 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 2 Key findings/Evidence Standard met? There was evidence from discussions with service users and observation that daily living activities are flexible and choices upheld whenever possible. The requirement to document service users activities and leisure interests within care plans and a system for monitoring will be inspected in greater detail at the next inspection.Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences 3 Key findings/Evidence Standard met? Evidence from discussions with service users and staff. The home has a welcoming atmosphereStandard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? Evidence from records and discussions with staff, service users and manager and observation.LadybankPage 19 Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet which is suited to individual, assessed and recorded requirements and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Evidence from observation and discussions with service users.LadybankPage 20 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users legal rights are protected. Service users are protected from abuse.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple clear and accessible complaints procedure which includes the stages and time-scales for the process and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to NCSC Percentage of complaints responded to within 28 days 14 X X X 1 0 100 2 Key findings/Evidence Standard met? It was apparent that this is a home that takes complaints seriously and responds appropriately. The complaints book detailed a variety of complaints. One complaint recorded on 23/08/03 detailed the nature of complaint but there was no record of action taken in response or the outcome. There is a also a need for the complaints book to detail if a complaint is taken to a further stage in the complaints procedure and the name of the investigating officer involved.LadybankPage 21 Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. N/A Key findings/Evidence Standard met? Not inspected on this occasion.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 Standard met? Policy in place. Vulnerable adults training is provided for staff. YES 0 3LadybankPage 22 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 manager informed the inspectors that an audit of home has been undertaken and a 3year plan is being implemented. Various parts of the home are looking shabby and in need of refurbishment. Fabric and furnishings are in need of replacement some chairs used by service users are shabby and low in height. There is a need to ensure an audit is undertaken to ensure seating throughout the home meets the needs of the current service user group. Work will shortly commence to refurbish Cedar unit to provide intermediate care services with nursing. The manager informed the inspectors that in readiness for refurbishment of Cedar unit and the movement of service users onto other units rooms would be decorated in readiness for these service users. Rotting plaster in the staff toilet has been rectified and was as a result of damp coming from the kitchen.LadybankPage 23 Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 3 Key findings/Evidence Standard met? Each unit has an open plan lounge, dining room and kitchenette. The kitchens are outdated, shabby and in need of refurbishment. On the ground floor there is a large and comfortable, homely lounge.Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 2 Key findings/Evidence Standard met? A requirement made at the last inspection for all wooden commodes to be replaced is still outstanding. The manager informed the inspectors this is due to financial resources previously allocated to replace commodes being used to replacement kitchen and laundry equipment.Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons including a qualified occupational therapist, with specialist knowledge of the client groups catered for and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 3 Key findings/Evidence Standard met? The home has several hoists and aids.LadybankPage 24 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 Key findings/Evidence No change from previous inspection. NO YES NO 34 0 4 0 Standard met? 3 3 301 0 4 0LadybankPage 25 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user, which is furnished and equipped to assure comfort and privacy and meets the assessed needs of the service user. 2 Key findings/Evidence Standard met? Although some room sizes are limited service users are enabled to bring in their own furniture and possessions. Regulations require that a record of furniture and valuables belonging to service users is maintained. This is currently being undertaken however the manager is looking to update this record book further to ensure full compliance with regulations. Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 3 Key findings/Evidence Standard met? Evidence from observation.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? Liquid soap dispensers and paper towels have been purchased for all toilets and bathrooms throughout the home.LadybankPage 26 LadybankPage 27 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 Key findings/Evidence X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X XX X X Standard met? 1LadybankPage 28 The home has 5 full time staff vacancies at present for care staff. The senior team is severely understaffed and the home is suffering from a lack of consistency within the senior staff team. Two senior staff members are on long-term sick leave. One Residential care Officer has been posted temporarily to manage another home. One care assistant is currently acting up into the role of residential care office and a full time senior has been employed on a temporary basis via an agency. A 24-hour administrative support post has been deleted from the staff team. The home currently has only 12 hours of admin assistance to the home. This is insufficient considering the size of this home and the administrative support needed to support the manager. It was apparent from this inspection that with the lack of administrative support and the gaps in senior staff support, this has resulted in the manager being put under increased pressure. Although there has been additional administration input into the home this is insufficient for the level of ongoing support needed. The manager is taking work home to keep up to date with her workload and whilst at work is constantly needed to answer the door and the telephone. As a result of the lack of permanent senior staff support and administrative support the manager is struggling to maintain adequate supervision for all staff within the home. This is unacceptable and again it will be a requirement that Bracknell Forest Council carry out a review of staffing levels and administrative support within the home to ensure that this home is adequately staffed and the manager supported to carry out her role and fulfil her responsibilities as registered manager. Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 5 25 3 Key findings/Evidence Standard met? The manager informed the inspectors that a recent personal planning programme for all staff has resulted in a more positive approach for undertaking NVQ qualifications.LadybankPage 29 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. N/A Key findings/Evidence Standard met? It was not possible to inspect this standard, as staffing records are not kept within the home.Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme, which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. N/A Key findings/Evidence Standard met? Not inspected on this occasion.LadybankPage 30 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. N/A 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. N/A Key findings/Evidence Standard met? Not inspected on this occasion.LadybankPage 31 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? A recent quality assurance survey has been undertaken seeking views of service users, relatives and visitors. Information has been collated and a report has been issued. The manager agreed to send a copy to the inspector. A recent meeting has been held to provide consultation for service users and relatives to discuss refurbishment of Cedar unit and the need for some service users to move units. Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure that there is effective and efficient management of the business. N/A 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 Key findings/Evidence Not inspected on this occasion. Standard met? X X X N/ALadybankPage 32 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. N/A 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. N/A Key findings/Evidence Standard met? Not inspected on this occasion.Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable, the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? Water temperature testing is carried out weekly and now includes all outlets accessed by service users. The CHANNEL contract for the homes call bell system has not been reviewed as required at the last inspection. However management are looking at new call bell system for the new unit and reviewing for the rest of the home. Accident books for both staff and service users were viewed. Evidence was seen that manual handling hoists are serviced 6 monthly. It transpired during the inspection that bath hoists had not been serviced since April 2002. The manager was unaware that the contract had been cancelled. Steps were taken during the inspection to rectify this situation.LadybankPage 33 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateDebbie WillcoxSignature Signature SignatureLadybankPage 34 PART D(where applicable)LAY ASSESSORS SUMMARYLay Assessor Date Public reportsSignatureIt should be noted that all NCSC inspection reports are public documents.LadybankPage 35 PART EE.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on enter date(s) of inspection here and any factual inaccuracies: Please limit your comments to one side of A4 if possibleLadybankPage 36 Action taken by the NCSC in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. E.2 Please provide the Commission with a written Action Plan by 29/10/03, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was 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 planOther: enter details here LadybankPage 37 E.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.E.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or E.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation 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 38 - 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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