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Inspection on 30/06/05 for Ladycross House Care Home

Also see our care home review for Ladycross House Care Home for more information

This inspection was carried out on 30th June 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

It should be noted that only some issues were examined during this inspection. Two Service Users were spoken to during the inspection, and both said that they were very well cared for by staff, and that they had considerable confidence in the staff and in the managers of the Home. They were able to say that activities were regularly provided on a weekly basis. Service Users said that they held the key to their bedrooms, and one regularly used it to maintain her privacy and the security of her belongings. They also said that they held the key to the lockable space provided within their bedroom. The inspection found that the staff at the Home keep a good record of Service Users health needs.

What has improved since the last inspection?

Since the last inspection the Registered Providers have provided training for staff in the administration of medication. It was found that risk assessments had been carried out on all Service Users. The nutritional needs of Service Users were also now being regularly reviewed. The Acting Manager ensured that only those Service Users who fitted the criteria of the Home were admitted. Service Users plans of care were kept under regular review, including their health care needs. Complaints made by Service Users, or by their relatives, were now dealt with in line with the Derbyshire County Council complaints procedure. Laundry equipment was now maintained in working order.

What the care home could do better:

The Registered Providers and Acting Manager need to ensure that the statement of purpose is appropriately completed and that a Service Users Guide is provided to all Service Users. They also need to provide all Service Users with a complete statement of terms and conditions of occupancy or contract for staying in the Home. The documentation maintained by the Acting Manager on each Service Users health and personal care needs considerable attention to ensure it is up to date and relevant to each Service User. This included keeping a record of all mealsprovided to each Service User. The Acting Manager needed to also improve the standard of record keeping of the administration of medication. There was evidence to indicate that Service Users were not spoken to about their funeral plans. Service Users also said that staff did not wait to be invited into their bedrooms, tending to just knock and walk in. Service Users said that a choice of meal was not provided at all meal times. It was noted during the inspection of April 2004 that staff were in need of training in the use of restraint, but this had not been provided. Five Requirements were identified in Service Users bedrooms and around the Home that needed attention. An Immediate Requirement notice has been given to the Registered Providers to ensure that staff call monitors are made available as soon as possible. An Immediate Requirement notice had also been given to the Registered Providers in 2003 concerning the need for repair the leaking roof and poorly maintained exterior woodwork, but this had not been addressed. Staffing levels were found to be below acceptable standards during this inspection and this had been the case previously in March 2005. Lastly, the Registered Providers, or designated representative, was found not to be visiting the Home on an unannounced basis on at least a monthly basis. In addition to these items a further three Recommendations were made concerning providing information about Advocacy Services, about arrangements concerning the provision of seating in bedrooms for two people, and about the suggestion that the Registered Providers provide staffing in line with the Residential Forum.

CARE HOMES FOR OLDER PEOPLE Ladycross House Care Home Travers Road Sandiacre Nottingham NG10 5GF Lead Inspector Steve Smith Unannounced Inspection 30 June 2005 10:20 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 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 C52 C02 S35743 Ladycross House V235957 300605 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Ladycross House Care Home Address Travers Road, Sandiacre, Nottingham, NG10 5GF 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) 01629 580000 Derbyshire County Council Sara Topham (Acting Manager) Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Ladycross House Care Home C52 C02 S35743 Ladycross House V235957 300605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: N/A Date of last inspection 23 March 2005 Brief Description of the Service: Ladycross House Care Home provides personal care 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 and 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 dinnig 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. Ladycross House Care Home C52 C02 S35743 Ladycross House V235957 300605 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in just under 6.5 hours. Discussion was held with two Assistant Managers and some of the Home’s records were examined. Two Service Users were spoken to and the bedrooms in one wing and some of the public areas of the Home were examined. What the service does well: What has improved since the last inspection? What they could do better: The Registered Providers and Acting Manager need to ensure that the statement of purpose is appropriately completed and that a Service Users Guide is provided to all Service Users. They also need to provide all Service Users with a complete statement of terms and conditions of occupancy or contract for staying in the Home. The documentation maintained by the Acting Manager on each Service Users health and personal care needs considerable attention to ensure it is up to date and relevant to each Service User. This included keeping a record of all meals Ladycross House Care Home C52 C02 S35743 Ladycross House V235957 300605 Stage 4.doc Version 1.40 Page 6 provided to each Service User. The Acting Manager needed to also improve the standard of record keeping of the administration of medication. There was evidence to indicate that Service Users were not spoken to about their funeral plans. Service Users also said that staff did not wait to be invited into their bedrooms, tending to just knock and walk in. Service Users said that a choice of meal was not provided at all meal times. It was noted during the inspection of April 2004 that staff were in need of training in the use of restraint, but this had not been provided. Five Requirements were identified in Service Users bedrooms and around the Home that needed attention. An Immediate Requirement notice has been given to the Registered Providers to ensure that staff call monitors are made available as soon as possible. An Immediate Requirement notice had also been given to the Registered Providers in 2003 concerning the need for repair the leaking roof and poorly maintained exterior woodwork, but this had not been addressed. Staffing levels were found to be below acceptable standards during this inspection and this had been the case previously in March 2005. Lastly, the Registered Providers, or designated representative, was found not to be visiting the Home on an unannounced basis on at least a monthly basis. In addition to these items a further three Recommendations were made concerning providing information about Advocacy Services, about arrangements concerning the provision of seating in bedrooms for two people, and about the suggestion that the Registered Providers provide staffing in line with the Residential Forum. 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 C52 C02 S35743 Ladycross House V235957 300605 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Ladycross House Care Home C52 C02 S35743 Ladycross House V235957 300605 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2 and 3. The statement of purpose and Service Users Guide do not contain the relevant information to provide Service Users with clear information of the provision of services by the Home. Assessments of need were always provided when new Service Users were admitted to the Home. EVIDENCE: These Standards were not inspected on this visit to the Home. However, following a review of documentation and discussion with the Assistant Manager it was apparent that the Home’s statement of purpose did not meet the details laid down by Schedule 1 of the Care Homes Regulations or National Minimum Standard 1. The details need to be personalised to this Home. This issue has been outstanding since 2003. During a tour of the premises, the Assistant Manager looked for the Service Users Guide in two bedrooms, but none could be found. All Service Users need to be given a Service Users Guide to the Home. Again, this issue has been outstanding since 2003. Ladycross House Care Home C52 C02 S35743 Ladycross House V235957 300605 Stage 4.doc Version 1.40 Page 9 Following discussion with the Assistant Manager it became apparent that the Acting Manager and Registered Providers had not provided a statement of terms and conditions of residency/contract that meets the requirement set by Regulation 5 of the Care Homes Regulations or National Minimum Standard 2.2. This also had been an outstanding issue since 2003. The Assistant Manager said that when a new referral was made to the Home, that an assessment of need of the potential Service User was made by a Care Manager of the local authority, the Home’s owners. The assessment was made whether the potential Service User was sponsored by the Social Services Dept or was a self-funding Service User. Standard 6 does not apply to this Home. Ladycross House Care Home C52 C02 S35743 Ladycross House V235957 300605 Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 & 11. The care provided to Service Users appeared to be good, however, Service Users’ health and personal care needs were not being fully met, as there was insufficient information in care plans. EVIDENCE: Ladycross House Care Home C52 C02 S35743 Ladycross House V235957 300605 Stage 4.doc Version 1.40 Page 11 To help assess Standard 7, the Service User Plan, the Inspector examined the records of four Service Users, for the purpose of case tracking. It was found that only some of the basic information was provided for each Service User. All of the files had the initial assessments made by the Care Managers who placed each Service User within the Home. Two of the files had the up to date assessment of need of the Service User, although these documents were not dated, and two of the files had no current plan of care in them at all. None of the files had the Contract/Statement of Terms and Conditions of Residency made between the Registered Providers and the Service User within them. All of the files contained risk assessments for each of the Service Users. However, there was no indication that Service Users or their representatives had been asked about the limitations that might need to be placed upon their choice, freedom or decision-making. It was found that only two of the files contained a review of care carried out by the Social Services Dept or by the Home itself. No files had evidence to show that the Service Users had seen their own file or agreed its contents or had seen and signed the review of care. Regular recording was provided in each file, although the Acting Manager had not signed each record to indicate that she had read the contents, on at least a monthly basis. All four files were easy to read and the Acting Manager kept the files in a safe location in the Home. None of the files had a confidential section within them, and they were also very poorly organised, even though some of the files had section dividers. Lastly, no Service User was provided with confirmation, in writing from the Registered Providers, to say that the services provided at Ladycross House were suitable to meet the Service User’s assessed needs in respect of their health and welfare. It was found that the records of Service Users health needs were appropriately maintained. However, the record of meals taken by Service Users was not being kept. The records kept on this issue need to indicate which Service User had what meal, across at least the midday and evening meals, and be kept for at least 3 years. Two Service Users were interviewed during this inspection. Both said that they were unaware of the records kept in their name by the Home. One had been in the home 8-years, the other 2-year, but both said they had never been shown their records. The record of medication given to Service Users was well maintained, although the following errors in the record were found: Ladycross House Care Home C52 C02 S35743 Ladycross House V235957 300605 Stage 4.doc Version 1.40 Page 12 1. When medication cannot be given to a Service Users, staff do not use the codes given at the foot of the Medication Administration Record (MAR) sheet. 2. When the MAR sheet says against a medication ‘None supplied this month’, the Acting Manager needs to indicate whether the Home is giving medication using supplies previously given or whether the medication has been stopped. 3. The Acting Manager had added prescriptions/medications to the MAR sheet, but had not indicated that a Doctor had authorised this. The Acting Manager needs to indicate that this is the case on the MAR sheet, sign the sheet and have this backed up by a second signature from another member of staff. 4. Creams are applied to Service Users by staff but this is not recorded on the MAR sheet. The record of creams applied is kept in the staff room. The records for 3 Service Users were examined. It was found that the creams were applied inconsistently. For example, for one Service User the MAR sheet said that a cream was to be applied twice a day. The staff record showed that this was applied in the main once a day, frequently missed altogether and only occasionally applied twice a day. The Assistant Manager said that medication was always given to Service Users by staff, but that Service Users could manage their own inhalers. Those Service Users who were only in the Home for short-term care would normally manage their own medication. Two Service Users were spoken to about life in the Home. They said that staff were very good at listening to their views on how they liked to be cared for and staff would carry out their wishes. Their care needs were always met with dignity and respect. As a result, they said they felt very safe in the Home, and appeared to have a strong sense and appearance of well-being. One of the Service Users said that her plans for her funeral had been made and that the Acting Manager was aware of this. However, the second Service User said that staff at the Home were unaware of her funeral plans, as staff had never asked her about this. Ladycross House Care Home C52 C02 S35743 Ladycross House V235957 300605 Stage 4.doc Version 1.40 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 standard(s) 12, 13, 14 & 15. Service Users’ preferred lifestyles were respected by the Home. Service Users were given a wholesome and appealing diet in pleasant surroundings although the choice of meal was very restricted. EVIDENCE: The two Service Users spoken to said that they could go to bed and get up at times of their own choosing. They also said that they could choose or change their bath times. One of the Service Users said that they could bath alone, without staff being present, if they wished to do so. The two Service Users said that no one at the Home influenced them on how to spend their money. The Service Users were aware of who their keyworker was and understood their role in the Home and with themselves. The Service Users also said that activities were regularly provided within the Home. This included events such as skittle evenings, bingo, visits by a guitarist, and trips out. They said that these events were available on a weekly basis. Service Users said that they could go out into town if they so wished, and one said she did this regularly. Relatives and friends were able to visit at any time, and could be seen in the privacy of Service Users bedrooms. When the Service Users were in their bedrooms they said that staff always knocked and some Ladycross House Care Home C52 C02 S35743 Ladycross House V235957 300605 Stage 4.doc Version 1.40 Page 14 times waited to be invited in, but mostly paused and came in. They said that their mail was always delivered unopened, and they were aware of the Home’s rules on smoking. Two Service Users were asked if they were aware of Advocates who could support them if this became necessary in the Home. However, both were unaware of this and said that if they needed assistance they would look for this from their families. Information about Advocates could be supplied in the Service Users Guide to the Home. Service Users said that breakfast was available through the early part of each morning, and that this could be taken in their bedroom if they so chose. A choice was available at breakfast but at other meal times no choice was provided, although in the past a choice had been available. Ladycross House Care Home C52 C02 S35743 Ladycross House V235957 300605 Stage 4.doc Version 1.40 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 standard(s) 16 & 18. EVIDENCE: These Standards were not inspected on this visit to the Home. However, both Service Users spoken to said that if they wished to make a complaint they could do so to the Acting Manager or to the Assistant Managers, in all of whom they had considerable confidence. Both Service Users were very confident that their concerns would be appropriately addressed, although neither had chosen to make a complaint, up to the time of this inspection. Ladycross House Care Home C52 C02 S35743 Ladycross House V235957 300605 Stage 4.doc Version 1.40 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 standard(s) 19, 20, 21, 22, 23, 24, 25 and 26. Generally, the Home was adequately maintained throughout, however, significant improvements were needed to ensure all Service Users lived in a well-maintained environment. EVIDENCE: During this inspection only a sample of bedrooms were examined, together with some of the communal space provided. The Home was found to be spacious, with ample communal space, although with numerous corridors to Service Users bedrooms. The lounges appeared comfortable, but the dining areas were closely laid out with little space between tables for Service Users to gain access. The bedrooms inspected provided limited space for Service Users although looked to be comfortable. However, the bedrooms only had one comfortable chair, and two bedrooms inspected suffered with a poor odour. The electric light provided in some of the bedrooms was poor and not of 150 Lux (approx 100 watts). However, all Service Users were offered a key to their bedroom door, which was lockable on both the inside and outside of the bedroom. It was also found that Service Ladycross House Care Home C52 C02 S35743 Ladycross House V235957 300605 Stage 4.doc Version 1.40 Page 17 Users were offered the key to the lockable space provided within each bedroom. In the public toilets examined, the pull cord to summon staff assistance was found wrapped around handrails. In Yellow Wing, a light shade was needed in one of the public toilets. In baths examined, a chair hoists were provided to offer assistance into the baths, but the hoist could not be locked into position before hoisting or lowing the Service Users in to the bath. This issue was first noted during the inspection of 23 April 2004. As part of the inspection the staff call was operated, but no staff member responded to it. It transpired that all staff call monitors, worn by staff, had broken and had been sent for repair. No spare staff call monitors were available in the Home. An urgent ‘Immediate Requirement’ notice was issued to the Acting Manager for the staff call monitors to be made available to staff by Monday 4 July 2005. During the inspection of 23 March 2005, the condition of the woodwork on the outside of the home was found to be very poor. The roof to the home was also found to be leaking. An ‘Immediate Requirement’ notice was made for all this work to be addressed but to date none of it has been met. Ladycross House Care Home C52 C02 S35743 Ladycross House V235957 300605 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 The Registered Providers were not providing sufficient care staffing to meet the assessed needs of the Service Users. EVIDENCE: Staffing rotas for weeks beginning the 12, 19 and 26 June 2005 were examined. These showed that management, day care and night care staffing amounted to 504.75 hours, 494.5 hours and 486.25 hours each week respectively. However, according to the Residential Forum, staffing should have been provided at 628 hours each week if 17 Service Users were judged to be at the ‘Medium’ level of need and 18 at the ‘Low’ level of need. Alternatively, if all 35 Service Users were judged to be at the ‘Low’ level of need then staffing should have been provided at 593 hours each week. Both of these figures are above the level of care staffing provided by the Registered Providers. The above figures were calculated including the Manager’s working time, but the Residential Forum requirement does not include the Manager’s working time within staffing requirements. When rescheduling the rota the Registered Providers need to take this into account. Ladycross House Care Home C52 C02 S35743 Ladycross House V235957 300605 Stage 4.doc Version 1.40 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 Lack of senior management input to the Home means that the needs of Service Users were not appropriately addressed. EVIDENCE: These Standards were not formally inspected during this inspection. While reviewing the inspection report of March 2005, the Assistant Manager said that senior managers of the Local Authority do not regularly visit and ‘inspect’ the Home on an unannounced basis, in line with Regulation 26. If the Home had been visited in line with this Requirement no documentation had been left in the Home. This issue was first identified during the inspection of April 2004 and had not been rectified since that date. Ladycross House Care Home C52 C02 S35743 Ladycross House V235957 300605 Stage 4.doc Version 1.40 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 3 15 2 COMPLAINTS AND PROTECTION 2 3 3 2 3 3 3 3 STAFFING Standard No Score 27 2 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 2 x x x x x x x Ladycross House Care Home C52 C02 S35743 Ladycross House V235957 300605 Stage 4.doc Version 1.40 Page 21 Yes 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. Standard OP1 Regulation 4 Requirement The statement of purpose must meet with the criteria set by Schedule 1 of the Care Homes Regulations and NMS1, and must be personalised to the Home. (This issue has been outstanding since 2003) A Service Users’ Guide to the home must be supplied to every Service User. (This issue has been outstanding since 2003) The statement of terms and conditions of residency/contract provided to Service Users must meet the criteria set by Regulation 5 of the Care Homes Regulations and National Minimum Standard 2.2. (This issue has been outstanding since 2003) The Acting Manager must ensure that all Service Users files contain an up to date copy of their Care Plan. A copy of the Contract/Statement of Terms and Conditions of Residency must be available in each Service Users file. The Acting Manager must ensure that each Service User, or their Timescale for action 25 August 2005 2. OP1 5 25 August 2005 25 August 2005 3. OP2 5 4. OP7 15 25 August 2005 25 August 2005 5. OP7 5 6. OP7 17 Sch 3 25 August 2005 Page 22 Ladycross House Care Home C52 C02 S35743 Ladycross House V235957 300605 Stage 4.doc Version 1.40 7. 8. OP7 OP7 15 14 9. OP8 17 & Sch 4 10. OP9 13 11. OP9 13 12. OP9 13 13. OP9 13 representative, has had the opportunity to discuss their rights to choice, freedom and decision-making while staying in the Home. The outcome must be recorded in each Service Users records. The Service Users plan of care must be signed by the Service User, or their representative. Each Service User’s file must contain information from the Registered Providers to say that the services provided in the Home are suitable to meet the Service User’s assessed needs in respect of their health and welfare. The Acting Manager must ensure that a record is kept of meals provided for each Service User cared for in the Home, keeping the record for at least 3 years. When medication cannot be given to a Service User staff must use the codes given at the foot of all Medication Administrations Record (MAR) sheets. When the MAR sheet says ‘None supplied this month’, the Acting Manager must indicate whether the Home is giving medication using supplies previously given or whether the medication has been stopped. Additional prescriptions can only be added to the MAR sheet if a Doctor has indicated this. This must be marked on the MAR sheet and signed by two members of staff. The record of creams applied to Service Users must be maintained on the MAR sheet. If staff are authorised to apply creams, senior staff must ensure that this is done at the frequency 25 August 2005 25 August 2005 25 August 2005 25 August 2005 25 August 2005 25 August 2005 12 August 2005 Ladycross House Care Home C52 C02 S35743 Ladycross House V235957 300605 Stage 4.doc Version 1.40 Page 23 14. OP11 12 15. OP13 12 16. 17. OP15 OP19 16 23 18. OP19 23 19. OP19 16 20. OP19 23 21. OP19 16 indicated on the MAR sheet, checking that this has been carried out on a daily basis. The Acting Manater must ensure that all Service Users are spoken to about their funeral plans and that these are recorded within each Service Users file. The Acting Manager must ensure that staff are aware of the need to knock and await a response from the Service User before entering bedrooms. The Acting Manager and care team need to decide which Service Users this must apply to, given Service Users differing abilities. The Acting Manager must provide a choice at all meals provided in the Home. The woodwork on the outside of the premises must be maintained in a good state of repair. The roof must be repaired. (This issue is outstanding from the inspection report of 2003. All main light bulbs in Service Users bedrooms must provide 150 lux of light (100 watts). If the Service User requests a different level of lighting, this must be recorded within their personal record. The odour in the bedrooms indicated during the inspection must be removed. If appropriate this could include the replacement of the carpet with a linoleum floor covering. The pull cord to summon staff must not be wrapped around handrails thus making them inoperative. In Yellow Wing, the light in one of the public toilets must be provided with a lightshade. C52 C02 S35743 Ladycross House V235957 300605 Stage 4.doc 23 September 2005 12 August 2005 12 August 2005 Immediate Reqmt. 12 August 2005 2 September 2005 12 August 2005 12 August 2005 Ladycross House Care Home Version 1.40 Page 24 22. OP19 23 23. 24. OP22 OP27 23 18 25. OP31 26 Bath hoists must be replaced with units that lock into position. (This issue is outstanding from the inspection dated 23 April 2004) The Acting Manager must obtain replacement staff call monitors by 4 July 2005. The Registered Providers must ensure that staffing levels are maintained to meet the health and welfare needs of service users. (This issue is outstanding from the inspection report dated 23 March 2005) Monthly visits by the Registered Providers or designated representative, complying in full with Regulation 26, must take place to the Home. Documentary evidence of these visits must be kept at the home for use by Acting Manager and for inspection purposes. (This issue is outstanding from the inspection report dated 23 April 2004) 31 October 2005 Immediate Reqmt. 12 August 2005 12 August 2005 26. 27. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP7 OP7 OP7 OP7 Good Practice Recommendations Each Service Users files should contain the preferred name of the Service User. The name of the Keyworker responsible for the Service User should be recorded in the front of each Service Users file. The date of entry of each Service User to the Home should be recorded in the front of each Service Users file. The name of the admitting Care Manager should be C52 C02 S35743 Ladycross House V235957 300605 Stage 4.doc Version 1.40 Page 25 Ladycross House Care Home 5. OP7 6. OP7 7. OP7 8. 9. 10. 11. OP7 OP7 OP14 OP24 12. OP27 included in the information at the front of each Service Users file. The Acting Manager should undertake formal reviews of care of each Service User at six monthly intervals. The reviews should include the Services User, their relatives and significant staff from the Home. The keyworker for each Service User should update each Service Users records on a monthly basis. This record should then be shown to the Service User, where this is possible, and a record made of any comments made by the Service User. The Acting Manager should review each Service Users file on at least a monthly basis. She could indicate that this has been done by signing the record with a red or green pen. The Acting Manager should maintain a ‘Confidential’ section in each file, as necessary. Service User files should be better laid out, with section dividers that are used appropriately. The Acting Manager should provide information in the Service Users Guide about Advocacy Services available in the surrounding district. All single bedrooms should be provided with comfortable seating for two people. However, this could be discussed with each Service User, or their Representative, and comfortable seating for one person could be provided if they agreed, and if this was recorded within the Service User’s Care Plan. The Registered Providers should provide day care and night care staffing at least in line with that required by the Residential Forum. This figure should not include the Managers working time. (The issue is outstanding from the inspection report dated 23 April 2004) Ladycross House Care Home C52 C02 S35743 Ladycross House V235957 300605 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection South Point 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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