Inspection on 17/10/06 for Ladycross House Care Home

This inspection was carried out on 17th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ladycross House Care Home 05/05/09

Ladycross House Care Home 24/02/06

Ladycross House Care Home 30/06/05

Ladycross House Care Home 23/03/05

Ladycross House Care Home 23/04/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Ladycross House Care Home Travers Road Sandiacre Nottingham NG10 5GF Lead Inspector Claire Williams Key Inspection 17th October 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ladycross House Care Home DS0000035743.V315286.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ladycross House Care Home DS0000035743.V315286.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ladycross House Care Home Address Travers Road Sandiacre Nottingham NG10 5GF Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0115 9098400 0115 9098402 Not given www.derbyshire.gov.uk Derbyshire County Council Sara Topham Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Ladycross House Care Home DS0000035743.V315286.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th February 2006 Brief Description of the Service: Ladycross House Care Home provides personal care and accommodation for 35 Older People. The Home is owned by the Derbyshire County Council and is situated in the town of Sandiacre on the outskirts of Nottingham. It is within easy reach of the M1 motorway and the A52 to Derby and Nottingham. The Home provides ground floor accommodation in four wings, each with its own lounge and dining area. There is a separate communal room situated near to the main entrance. All bedrooms are single occupancy. There is separate bath, shower and toilet provision. The Home also has a separate smoking area. The home is currently having refurbishments completed to the roof area and internally to upgrade the bedrooms. Information about the service is provided in the Statement of Purpose and Service User Guide; both of these documents were made available to residents. Information included on the pre-inspection questionnaire received on 04/09/06 stated that the fees for the home were £348 per week. Items not covered in the fees include hairdressing, chiropody, toiletries, transport and holidays. Ladycross House Care Home DS0000035743.V315286.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, carried out by one inspector, and lasted 7 hours. A review of the evidence available prior to the site visit was undertaken, for example, the pre inspection questionnaire, resident surveys (10 surveys received) and notification of incidents, are used to identify areas to be examined during the site visit. The information available was used to identify those residents whose care was to be cased tracked. Records such as care plans (as part of the case tracking process, which is used to help determine how the home meets the needs of individual residents) were examined during this inspection. Time was spent taking with residents and staff on duty and observing the daily routine. Some bedrooms were viewed during this visit and a brief tour of the building was undertaken. Other records such as medication records, staff files and service certificates were also examined. An assessment was also made of the progress by the registered persons to address the requirements made at previous inspections. The registered manager was not on duty therefore the assistant manager Margaret Haines assisted with the inspection. The inspector contacted the Registered manager after the visit in order to provide feedback and to discuss any outstanding issues. Following consultation with these people, it was agreed that they would be referred to as ‘residents’ for the purpose of this report. What the service does well: Ladycross House provides a comfortable and homely environment for the people who use the service. Residents and families were encouraged to personalise their rooms with their own possessions. The staff team are committed to providing a good standard of care for residents, and are provided with good training opportunities to enable them to develop their skills and knowledge. Residents responded positively about the standard of care provided and comments received included “The staff are very caring” “they will do anything you ask of them”. Visitors spoken with also commented, “the staff are marvellous and do their best”. Management and staff recognise the importance of providing opportunities for the people living in the home to join in with activities and entertainment. Social events and activities were organised and provided variety and social stimulation for residents. The importance of maintaining links with family, friends and the local community was also recognised and supported. Ladycross House Care Home DS0000035743.V315286.R01.S.doc Version 5.2 Page 6 Residents were offered a choice and variety of meals, and resident’s commented that they enjoyed the meals. What has improved since the last inspection? What they could do better: Information is still not available on the contract/ terms and conditions of residency in relation to the services that are not covered by the weekly fees to live in the home. This information must be provided so that residents and their families are aware of what the fees cover and what items they have to pay for independently. The care planning of individuals needs, abilities and preferences should be improved in order to ensure all elements are covered so that staff can be aware of the support required by individuals. The plans should be reviewed on a monthly basis to ensure they reflect individual’s current needs. Risk assessments need to be monitored accordingly in accordance with the guidance or an explanation recorded of what action should be taken. All assessments and information on individuals should be reviewed at least annually to ensure it is still valid. A delegate of the provider needs to ensure that visits and reports are completed on a monthly basis by undertaking as assessment of the standards at the home in order to fulfil the requirements of the regulations. Ladycross House Care Home DS0000035743.V315286.R01.S.doc Version 5.2 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. Ladycross House Care Home DS0000035743.V315286.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ladycross House Care Home DS0000035743.V315286.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 4 (Standard 6 is not applicable in this home) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission procedure ensures individual needs are assessed providing staff with sufficient information to plan care. Residents have access to information that informs them about what they can expect from living at this home. EVIDENCE: The Registered manager has updated the Statement of purpose and Service user guide, and these documents now contain all of the required information. Residents have access to these files, as they are located in each lounge area. If residents wanted their own individual copy then this would be facilitated. A contract is in place but this document has not yet been updated to include reference to the additional services that have to paid for, that are not included in the fees. The Registered manager stated that she is still waiting for an electronic version of the document so that she can then amend these details. The files of three residents were looked at in detail during this site visit. Each resident had a Community Care assessment completed prior to moving into the home. Due to the refurbishment there have not been any recent admissions to Ladycross House Care Home DS0000035743.V315286.R01.S.doc Version 5.2 Page 10 the home. The Registered manager stated that she has an assessment, which she would complete on any new referrals in order to ensure the home can meet their needs. The inspector had the opportunity to speck with some visitor’s who stated that they had visited several homes and chose this home for their relative as they “felt it would meet their needs”. In discussions with people living at the home some people stated that they initially visited the home for respite and then made the decision to move in on a permanent basis “because they really liked it, and the staff were caring”. Information from the surveys generally supported that residents considered that they had received enough information to decide if the home was the right place for them to live. Ladycross House Care Home DS0000035743.V315286.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lack of full and detailed care planning does not provide staff with the information they need to satisfactorily meet residents’ needs. The medication practices generally ensure that resident’s health needs are met. EVIDENCE: Residents spoken with commented postively about living at Ladycross House and stated “the staff team were good, ‘I am looked after well’. Residents said that they were able to discuss any isuses or concerns with the staff or the manager. Observtaions suported that generally peoples privacy and dignity were respected and staff were observed routinely knocking on bedroom and bathroom doors, and speaking with residents in a respectful and polite manner. The inspector did note one instant whereby service users dignity could be compromised and this was discussed with the assistant manager. Each file examined contained an updated care plan, which was completed in adequate detail in order to guide staff on the delivery of care. However the inspector did note that two care plans did not refer to the support indivduals required with their oral or foot care which could result in staff not being aware Ladycross House Care Home DS0000035743.V315286.R01.S.doc Version 5.2 Page 12 of any potential need in this area. There was some variation in respect of the paperwork in indivduals files for example: Two of the three files contained detailed night plans which is good practice as they include the indivduals perferences in respect of rising and retiring. The third file conatined a 24 hour preferred rountine which is also good practice. However there was limited evidence to support that these documents had been reviewed since their implementation dates in 2005. There was some information within all three care plans of indivduals likes and dislikes in respect of food and hobbies. The assistant manager is currently completing a profile on each person in order to gather information about their likes and dislikes and about their backgrounds. This information is for the provider but it would be also be beneficial to place a copy in the indivduals file for information. There was evidence to support that elements of the care plan had been reviewed on an monthly basis in two files. The third file had not routinly been reviewed monthly. These findings were discused with the assistant manager and later with the Registered manager who stated that these shortfalls maybe a result of the current refurbishment taking place which has impacted on both the residents and the staff team due to the time element of moving individuals to empty rooms so that each bedroom could be redecorated Discussion with residents and staff indicated that residents needs were being met, and staff had a good knowledge of each persons abilties, needs and preferences. Risk assessments were in place in all three files but these were not reviewed in accordance with the guidance or statements on the assessment. For example a Tissue viability assessment stated to reassess weekly but the dates of the reassessment was monthly. Residents spoken with confirmed access to healthcare facilities such as opticans, chiropodist and GPs as they required them. The medication systems were examined. Systems were in place to check and record the receipt of medication into the home; for identifying the medication record with the resident, and for identifying staff initials on the records. A review of the medication records supported that medication had been given to residents as prescribed. Storage of medication was satisfactory. The inspector noted that one handwritten medication instruction had not been signed by a second person to validate it. The assistant manager confirmed that staff had received medication training previously and that refresher training was planned for the future. Ladycross House Care Home DS0000035743.V315286.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of suitable activities are provided, which met the leisure and recreational interests of residents. The meals offered both choice and variety and catering for any special dietary needs. EVIDENCE: The routines at Ladycross House were planned around the resident’s needs and wishes. Residents spoken with confirmed that they make choices about their daily lives, and are encouraged to remain as independent as possible. Residents were actively involved in choosing activities; trips, menus and entertainment, and half of the residents had gone out on a trip to Matlock and Chatsworth at the time of the inspection. The assistant manager informed the inspector that two residents attend the ‘residents forum’, which meets every three months to discuss any issues about living in the local care homes owned by Derbyshire local authority. Not all of the residents choose to join in with the activities or trips, and the staff respects their wishes. Residents in their feedback confirmed that regular activities take place, including exercises, bingo, board games and in house entertainment, and individuals spoken with commented that they were satisfied with the activities provided at the home. The hairdresser continues to visit the home regularly. Ladycross House Care Home DS0000035743.V315286.R01.S.doc Version 5.2 Page 14 Throughout this site visit the remaining residents were observed occupying themselves listening to music, watching the television, and one resident was assisted to take her books back to the local library. The visitors spoken with confirmed that they can visit anytime and are always made to feel welcome and are offered refreshments when they visit. They commented that the staff team kept them well informed of their relatives well being. The inspector was invited to have a lunchtime meal. The Residents spoken with commented that the meals provided met their preferences and they confirmed that choices were available at all times. There was sufficient dining space for residents, and dining tables were well presented with tablecloths, napkins, cutlery, condiments, glasses and jugs of water. The lunchtime meal was served in a relaxed manner, and staff support was provided for those residents who needed assistance. Residents confirmed that they were happy with the quantity and quality of the food they received at the home, and commented that ‘the meals were very nice’. A brief tour of the kitchen was undertaken, and all food was stored appropriately and fridge and freezer temperatures were generally recorded daily, but the inspector did note several gaps in this record. The assistant manager stated that a record was maintained of the food taken by residents and that in particular improvements had been made to the recording at weekends. The inspector provided the assistant manager with a copy of the publication devised by the CSCI on “improving meals for older people in care homes” which was devised following consultation with older people. Ladycross House Care Home DS0000035743.V315286.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A satisfactory complaints procedure was in place with some evidence that people felt that their views were listened to and acted upon. Staff had a good knowledge and understanding of adult protection issues which protects residents from harm. EVIDENCE: The home has a complaints procedure and feedback confirmed that residents are aware of this procedure. Residents in their feedback stated that they “were confident that any concerns they raised would be dealt with, without any hesitation”. The complaints procedure was available to all residents and relatives and was included in the Service User Guide, which all residents have access to. The inspector was informed that one complaint had been received since the previous inspection and this was partially upheld. The records examined had been completed satisfactory. Residents were protected from potential harm through staff knowledge and training. The required polices and procedures were in place, and staff spoken with had a good understanding of these procedures and confirmed that they had attended safeguarding vulnerable adults training. New staff members undertake an introduction to safeguarding adults as part of their induction training. Ladycross House Care Home DS0000035743.V315286.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The areas being used by the residents was of a good standard providing residents with an attractive and homely place to live. EVIDENCE: As mentioned previously the home is undergoing a full refurbishment which is why no admissions have been made for a period of time to allow for residents to utilise empty bedrooms whilst their designated bedroom is redecorated and fitted with new furniture. This work has had an impact on the residents but generally they think the home will look better and “be improved” once it has been completed. The work includes maintaince of the roof and external areas such as the patio area, which will have new slabs laid in order to improve access for residents, in addition to the full internal refurbishment. The inspector had the opportunity to view some bedrooms that had already been completed. Residents had been consulted about the new colour of their rooms and they had personalised them to suit their individual tastes. The Ladycross House Care Home DS0000035743.V315286.R01.S.doc Version 5.2 Page 17 residents are provided with one chair in their bedroom, and would be provided with an additional chair if they requested this, and if there was sufficient space for this provision. The Service user guide details what furniture is available in each bedroom. The areas used by the residents were clean and free of any odours and residents and visitors confirmed that this is the normal standard. These areas were homely and provided a comfy environment for the residents to enjoy. The Aids and adaptations identified in the previous inspection report have been replaced with new equipment. Only one bath hoist remains and this will be replaced in the future. All equipment had been maintained within the specified timescales. Suitable laundry facilities were provided, and service users commented on the good standard of laundry service. The assistant manager confirmed that the call system had been reviewed and will be further reviewed on the completion of the refurbishment. At the time of the visit all of the call systems appeared to be working satisfactory. Ladycross House Care Home DS0000035743.V315286.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A stable, experienced, motivated and competent staff team cares for the residents. The recruitment procedures safeguard residents from any potential risks. EVIDENCE: Feedback received from the residents surveys suggested that generally residents felt that they received care and support when they needed it, as sufficient staff were available. Residents spoken with expressed no concerns about the number of staff on duty. The visitors spoken with stated, “more staff could be provided as they always seem to be rushing around”, but they also commented “their relative received a good standard of care”. The staff spoken with stated that “at the moment they could manage due to the reduced numbers of the people living in the home”, but they stated that “due to the dependency levels they are often rushed off their feet”, and “do not know how they will cope when the home reaches full occupancy”. Staff felt able to speak with the management team if they felt under pressure and did not have time to meet individual’s needs to a good standard. Discussions with the staff team, confirmed that they had a good knowledge of individuals needs, and staff expressed their commitment and enthusiasm towards ensuring residents had a good quality of care. Staff said they feel supported by both their colleagues and their managers, and feel that they are offered good training opportunities. Residents are supported by a competent and trained staff team, as all staff had been provided with the required training to ensure that they were competent Ladycross House Care Home DS0000035743.V315286.R01.S.doc Version 5.2 Page 19 to do their jobs. The pre-inspection questionnaire stated that of the 21 care staff 14 had achieved a National Vocational Qualification (NVQ) at Level 2 or equivalent, therefore achieving the required 50 target. An additional 2 members of care staff were currently working towards this qualification. New staff members undertake an induction programme, which meets the required specifications. The files for four members of staff were looked at during this inspection, which included a recently employed staff member. Derbyshire County Council has a detailed recruitment and selection procedure, and all recruitment documents are held at the human resource department, then copies are sent to the Registered manager. Not all of the documentation was in the staff files but the pre-inspection questionnaire confirmed that all of the required checks had been undertaken. Ladycross House Care Home DS0000035743.V315286.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from the home being managed by an experienced manager who provides clear leadership throughout the home. EVIDENCE: The Registered manager has many years experience of working with this client group, and has undertaken all of the required training to enable her to fulfil her roles and responsibilities within the home. Positive comments were received from the residents, staff and the visitors about how approachable and supportive she was. There was evidence to support that on an annual basis both residents and their families are sent a quality assurance questionnaire in order to gain their views on the service. There is a report displayed in the reception area of the findings from the previous audit undertaken in January 2006 with recommendations on Ladycross House Care Home DS0000035743.V315286.R01.S.doc Version 5.2 Page 21 how the providers intends to improve the areas identified, which included the provision of activities and the variety of meals. There was evidence to support that a representative of the provider visits the home on a regular basis to see the Registered manager and to carry out a regulation 26 visit, which is an unannounced visit to check on the standards of the home. The Registered manager had copies of the report completed of these visits but the recent copy received was dated 12/7/06. The Registered manager should receive a copy of the reports on a monthly in order to evidence that visits are undertaken as required by this regulation. Systems were in place for safeguarding resident’s monies. The records and the money held on behalf of four residents were cross-referenced and found to be accurate. A system for staff supervision was in place and in discussions with the staff team they confirmed that they did have supervisions with their line manager. Discussion with staff also confirmed that they were offered “good” training opportunities. Staff were up to date with fire training, and the inspector was informed by the relief manager that night staff do receive this training twice a year. The assistant manager and Registered manager confirmed that all staff was up to date with the required mandatory training. The inspector was informed that infection control training was not routinely provided but staff do undertake aspects of this training in their induction, food hygiene training and NVQ. Systems were in place for checking health and safety issues around the building (hot water temperatures, fire safety precautions including emergency lighting). A sample of service/maintenance records was examined (including equipment, gas and electricity services), and these appeared to be satisfactory. Ladycross House Care Home DS0000035743.V315286.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 3 Ladycross House Care Home DS0000035743.V315286.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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. Standard OP2 Regulation 5 Requirement The statement of terms and conditions of residency/contract provided to Residents must meet the criteria set by Regulation 5 of the Care Homes Regulations and National Minimum Standard 2.2. (This issue is outstanding from the inspection report of 2003) All residents must have care plans that set out in detail the action which needs to be taken by care staff to ensure that all aspects of health, personal and social care needs are met. Risk assessments must be reviewed in accordance with the guidance or an explanation recorded on what action should be taken. Regulation 26 visit reports must be available in the home to support that these visits are undertaken at the required frequency. (This issue is outstanding from the inspection report dated 23 April 2004) Timescale for action 31/01/07 2. OP7 15(1) 31/01/07 3 OP8 12(1)a b13(4)c14 (1)a 26 31/01/07 4 OP31 31/01/07 Ladycross House Care Home DS0000035743.V315286.R01.S.doc Version 5.2 Page 24 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 Refer to Standard OP7 Good Practice Recommendations Care plans should be reviewed every month and altered to accurately reflect the needs of the resident. This should involve the resident and be agreed and signed by the resident whenever capable, and/or representative. Night care plans and 24 routines should be reviewed monthly or at least annually and amended if there are any changes. Staff should be reminded to ensure that all handwritten medication instructions should be countersigned by two people in order to validate them Catering staff should record the temperatures of the fridge and freezers on a daily basis to ensure the food is being stored appropriately. Resident dependency should continue to be monitored to ensure staffing levels continue to meet residents needs. 2 3 4 OP9 OP15 OP27 Ladycross House Care Home DS0000035743.V315286.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. 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