Inspection on 15/09/05 for Ladycroft Respite Service

This inspection was carried out on 15th September 2005.

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

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

Other inspections for this house

Ladycroft Respite Service 04/06/09

Ladycroft Respite Service 20/06/07

Ladycroft Respite Service 16/12/05

Ladycroft Respite Service 17/11/04

Ladycroft Respite Service 29/04/04

Similar services:

Whitwood House

Whitwood Hall

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

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

CARE HOME ADULTS 18-65 Ladycroft Respite Service Ladycroft Wath-Upon-Dearne Rotherham Lead Inspector Alan Bartrop Unannounced 15 September 2005 11:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ladycroft Respite Service 20050915 Ladycroft UN Stage4 S56502 V210199 J55.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Ladycroft Respite Service Address Ladycroft, Wath-Upon-Dearne, Rotherham Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01325 301331 Milbury Care services Limited Yvonne Brown Care home only 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places Ladycroft Respite Service 20050915 Ladycroft UN Stage4 S56502 V210199 J55.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Manager, Mrs Yvonne Brown, achieves a NVQ Level 4 in Management and Care by 2005. 2. The two separate groups of Service Users who will attend Ladycroft, those with physical and sensory needs and those with significant behaviour challenges, must access the facility separately based on dependence and risk assessment and management procedures. 3. The Registered Manager must have at least fifty percent of her contracted hours in a supernummary capacity in order to fulfill her managerial responsibilities. This will be reviewed by the Commission after three months of registration, and the allocated time amended accordingly if required. Further reviews may take place at three monthly intervals if necessary. 4. It has been agreed that Ladycroft can be registered without the provision of an emergency alarm system. This situation will be monitored and a call alarm system will be required if any individual Service User assessments identify that it is needed, or a need for such a system is identified through accident and incident reporting and notifications. 5. Service Users must not commence utilising Ladycroft respite care services until a Local Authority assessment and care plan is provided and an initial assessment has been completed by the Registered Manager. Date of last inspection 17-Nov-2004 Ladycroft Respite Service 20050915 Ladycroft UN Stage4 S56502 V210199 J55.doc Version 1.40 Page 5 Brief Description of the Service: Ladycroft offers respite services for up to six people with learning disabilities. It is a purpose built bungalow situated in a quiet area in Wath upon Dearne, near Rotherham. The accommodation consists of four single bedrooms, which are accessible to people in wheelchairs, each with an en-suite toilet facility and tracking to aid mobility. One assisted bath, and one shower are also provided. The home has two lounges, a separate dining room and a kitchen and laundry. Two self-contained flats form part of this home. These can provide accommodation for individuals for up to six months. The home has an enclosed grassed garden area to the side and rear of the home. A car park is provided. All areas of the home are accessible to people in wheelchairs. Ladycroft Respite Service 20050915 Ladycroft UN Stage4 S56502 V210199 J55.doc Version 1.40 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out when the manager was off duty. The inspection was facilitated by Thomas Buckingham who was the acting senior on duty. The inspection involved a tour of the building, inspection of records and discussion with staff. Service users were not interviewed as they were all at the day centre. The service had been discussed with one family of a service user previously and they felt that both their son they benefited from the respite. What the service does well: What has improved since the last inspection? What they could do better: There is still a delay between reporting repairs and them being completed. Ladycroft Respite Service 20050915 Ladycroft UN Stage4 S56502 V210199 J55.doc Version 1.40 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ladycroft Respite Service 20050915 Ladycroft UN Stage4 S56502 V210199 J55.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Ladycroft Respite Service 20050915 Ladycroft UN Stage4 S56502 V210199 J55.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 5 Service users and their relatives receive a copy of the terms and conditions of the home which both the home and the relatives sign. EVIDENCE: Terms and conditions were seen in the files that had been signed by all parties. There were assessments of the service users needs and risk assessments relating to relevant aspects of their daily lives. There were contracts in the files from the provider authorities that stated the care needs of the residents Ladycroft Respite Service 20050915 Ladycroft UN Stage4 S56502 V210199 J55.doc Version 1.40 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 9 Service users are supported in their daily lives and there is a provision for them to take risks as assessed by a formal risk assessment. EVIDENCE: Risk assessments were seen in the files that related to different aspects of the resident’s care and the different activities that they liked to do. The daily records of care provided detailed the different activities that the resident had done, these related to the care needs identified in the care plan. Assessments are carried out prior to the resident’s admission to the home and these were available for inspection. Ladycroft Respite Service 20050915 Ladycroft UN Stage4 S56502 V210199 J55.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 17 The staff do not keep a record of what individual residents eat. EVIDENCE: There are menus written out in weeks but there is no record kept of what food was provided on any individual day. Because of the way the meals are planned it is possible that a balanced diet is not offered over a period of a full week. Resident’s choices are not recorded. The menu is not presented in a pictorial format, this makes it very difficult for the residents to use it. Ladycroft Respite Service 20050915 Ladycroft UN Stage4 S56502 V210199 J55.doc Version 1.40 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20 None of the service users hold and administer their own medication. Medication records were not accurately kept. EVIDENCE: The record for booking medications in and out was not easily read and needs replacing so that the record can be easily read. There were gaps in the medication administration record & request. There was no code to show that the resident did not come into the home until the evening which led to mistakes being made by the staff making the record. Medication was appropriately stored with each service user’s medication being kept in a separate container. Ladycroft Respite Service 20050915 Ladycroft UN Stage4 S56502 V210199 J55.doc Version 1.40 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed during this inspection. EVIDENCE: Ladycroft Respite Service 20050915 Ladycroft UN Stage4 S56502 V210199 J55.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 30 The home was clean and hygienic. EVIDENCE: The tour of the building found that all areas had been cleaned and were in a tidy state. All the toilets and bathrooms had hand washing facilities. The home was well ordered and the equipment was stored out of the way of residents when they returned that evening. Residents personal belongings were kept in their bedrooms. Ladycroft Respite Service 20050915 Ladycroft UN Stage4 S56502 V210199 J55.doc Version 1.40 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36 Staff confirmed that there was a good range of training opportunities. EVIDENCE: Staff stated that there were training courses offered in a wide variety of subjects. Staff discussed the imminent start of their National Vocational Qualification level 2 training. Staff have received mandatory training and there are plans to update this as necessary. Ladycroft Respite Service 20050915 Ladycroft UN Stage4 S56502 V210199 J55.doc Version 1.40 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 The views of the families are received and implemented by the staff. EVIDENCE: There are a series of parties held each year where families and service users are invited and it is at these events that their views are put forward. Some families write into the staff putting their ideas forward for any changes in the care for their residents. The families are informed of any reviews that are held to discuss the care of the individual and they can put their ideas forward to the review. Ladycroft Respite Service 20050915 Ladycroft UN Stage4 S56502 V210199 J55.doc Version 1.40 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x 2 Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x 3 Standard No 11 12 13 14 15 16 17 x x x x x x 2 Standard No 31 32 33 34 35 36 Score x x x x x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ladycroft Respite Service Score x x 2 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x x x 20050915 Ladycroft UN Stage4 S56502 V210199 J55.doc Version 1.40 Page 18 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. Standard 5 17 20 20 Regulation 4 16 13 13 Requirement Service Users and their families be given a copy of the terms and conditions of the home Records be maintained of what the residents eat New and clear medication booking in and out forms be produced and used No gaps be left in the Medication Administration record Timescale for action 1 January 2006 1 November 2005 1 November 2005 1 November 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 17 20 Good Practice Recommendations The menu be produced in pictorial format so that the residents can use it A code be used on the Medication record that shows a resident was admitted in the evening Ladycroft Respite Service 20050915 Ladycroft UN Stage4 S56502 V210199 J55.doc Version 1.40 Page 19 Commission for Social Care Inspection First Floor Barclay Court Heavens Walk Doncaster South Yorkshire DN4 5HZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ladycroft Respite Service 20050915 Ladycroft UN Stage4 S56502 V210199 J55.doc Version 1.40 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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