Inspection on 05/05/09 for Ladycross House Care Home

This inspection was carried out on 5th May 2009.

CQC found this care home to be providing an Adequate service.

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

Ladycross House Care Home 17/10/06

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 16/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Ladycross House Care Home Travers Road Sandiacre Nottingham NG10 5GF Lead Inspector Claire Williams Key Unannounced Inspection 5th May 2009 09:30 DS0000035743.V375292.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Ladycross House Care Home DS0000035743.V375292.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Ladycross House Care Home DS0000035743.V375292.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) 01629 531818 Sara.Topham@Derbyshire.gov.uk 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.V375292.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th August 2007 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 service 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 service also has a separate smoking area. Information about the service is provided in the Statement of Purpose and Service User Guide; both of these documents are made available to people Information received at the time of this visit stated that the fees for the service were £108.90 to £404.06 per week, depending upon funding arrangements. Items not covered by the fees are recorded in the Service user guide. People are informed that they can access a copy of the inspection report. Ladycross House Care Home DS0000035743.V375292.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for the service is One Star. This means the people who use the service experience Adequate quality outcomes The focus of inspections undertaken by the Care Quality Commissions (CQC) is upon outcomes for people and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The inspection visit was unannounced and took place over a period of a day. In order to prepare for this visit we looked at all of the information that we have received since our last visit which was undertaken on 28/08/07. This includes: • The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. • What the service has told us about things that have happened in the service, these are called notifications and are a legal requirement. • The previous key inspection report • Completed surveys from people living at the home, staff, relatives and professionals that visit. During the site visit case tracking was included as part of the methodology. This involved the sampling of a total of three people representing a cross section of the care needs of individuals within the service. Discussions were held with those individuals as able, together with a number of others about the care and services the home provides. These peoples care planning, and associated care records were also examined and their private and communal facilities inspected. Discussions were also held with staff about the arrangements for their deployment, recruitment, induction, training and supervision, and records examined to support the procedures in place. Ladycross House Care Home DS0000035743.V375292.R01.S.doc Version 5.2 Page 6 What the service does well: People told us they had a positive experience when moving into this service and that the staff team were helpful and supportive during this time. People are confident that the service is able to support them and meet their needs. This is because a full assessment of their needs is completed before a decision is made about whether this service is the right place for them. People have access to recreational activities that meet their preferences and this includes trips out and entertainment brought into the service. People told us they were satisfied with the support that they receive. They made the following comments about the staff team: “The staff team are kind, and caring and do their best; their just isn’t enough of them “The staff team are great; they work very hard and always seem to be running around making sure people are ok “The staff team support me in a gentle way and they are very res[ctful when they speak to me”. The visitors we spoke to during our visit made many positive comments about the service, one comment received was: “We always feel welcomed here and the staff members are friendly and informative” People are consulted about the service they receive as they receive annual satisfaction surveys and can attend regular meetings that are facilitated What has improved since the last inspection? What they could do better: Staff members need to have access to updated care plan, healthcare documentation and risk assessments to enable them to support peoples needs. Ladycross House Care Home DS0000035743.V375292.R01.S.doc Version 5.2 Page 7 People who make the decision to self administer medication must have an risk assessment undertaken to ensure they have the capacity and are supported to undertake this task safely. The service needs to ensure that sufficient staff members are on duty in order to meet the dependency need so of the people who live in this service. A record of all complaints received and responded must be made available, so we can access this record ensure all complaints have been address in accordance with the service procedures. All staff must have access formal supervision and regular team meetings. This is to ensure they are supported in their role and aid communication within the service. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Ladycross House Care Home DS0000035743.V375292.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.V375292.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 – not applicable to this service. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have access to the required information and assessment process in order to be assured their needs can be met by this service. EVIDENCE: In our annual quality assurance questionnaire completed by the service they told us that Care managers carry out a full assessment of need, and then the service make a judgement to ensure they are able to meet that person’s needs. They told us they complete a 24/72 hour review to enable the person and their carer’s to mention any concerns, so that the personal service plan can be adjusted to ensure staff members are aware of any preferred options. They said they offer prospective people an opportunity for a day visit which allows an informed choice. They also told us they give people and their carer’s relevant and up-to-date information of the establishment. Ladycross House Care Home DS0000035743.V375292.R01.S.doc Version 5.2 Page 10 We can confirm that a statement of purpose and service user guide was available to people living in this service and to any prospective people wishing to move into the home. These documents have not been updated recently and therefore do not reflect the current fees and the new contact details for Care Quality Commission. We spoke with a person who was visiting the service for a period of respite. They confirmed that an assessment of their needs had been undertaken, before they moved in, and they had received assurances their needs could be met. We were told by this person that their admission ‘went smoothly’ and that the staff were “very helpful and supportive”. The person told us that their stay was going well, and they were enjoying the rest. We looked at the records for three people; one of these was for a person who had recently moved into the home. Copies of assessments carried out by Social Services care managers were seen on two peoples records. These were detailed and included information concerning each persons health and personal care needs, social interests, relevant history and family involvement. This enables the staff to have a basic overview of easy person. Information in the third file was out of date and the assessment in the working file was in relation to domically care. An updated assessment was found on the electronic system which had not been authorized and printed off to enable the staff team to refer to. The home does not provide formal intermediate care and therefore standard 6 was not assessed. Ladycross House Care Home DS0000035743.V375292.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 8, and 10. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The lack of access to updated care plans and risk assessments has the potential to compromise the delivery of care provided to people. EVIDENCE: In our annual quality assurance questionnaire completed by the service they told us: they have access to people’s records on ‘Framework I’ including assessments and care plans. They complete on-going assessments to ensure they meet peoples changing needs, and undertake regular reviews. They told us they obtain specialist equipment to promote peoples independence, and to safeguard staff. We looked at three files and two of these contained care plans that had been completed electronically. Both of these plans were out of date, based on the Ladycross House Care Home DS0000035743.V375292.R01.S.doc Version 5.2 Page 12 information that we had accessed in the daily well being logs and from speaking with the staff team. The third file we examined did not contain a care plan, but had information referring to the previous domiciliary service the person used to receive. This means the staff team do not have access to written information which directs and informs the delivery of care for these people. It was clear from the discussions with staff members and from the information provided in the handover sessions that all staff members did know the current needs for all three people. Staff members told us that the information provided during the handover was vital in ensuring that the staff team are informed about people’s needs and any changes that have been observed. This was an essential form of communication within this service. During the later part of our visit we did access updated care plans that were being held electronically for all three people whose care we looked at more closely. It became apparent that due to the lack of communication, the assistant managers were unaware these had been completed and therefore the information was not printed off so they could be used as a working document for the staff to access. We found the situation to be the same for the risk assessments in place. One person did not have any completed risk assessments; therefore staff did not have access to information about the healthcare needs this person may have or if they needed to be monitored. We left an immediate requirement in relation to this requesting for these assessments to be completed within a 48 hour timescale. The risk assessments in the other 2 working files were out of date. For example a falls risk assessment for one person was dated 2006. We found that copies of the updated risk assessments were being held electronically for these two people. We were told that these documents had not been transferred to the working file, for the staff to access as the assistant managers did not know they had been completed. The lack of communication in this area has the potential to compromise the care people receive due to staff not having access to updated information to underpin their practice. There was no evidence that the files or the care plans were reviewed on a monthly basis, therefore these shortfalls had not been identified. It was reported to us that the service has had issues with staff shortages (please see staffing section), and this has impacted on the auditing and completion of the records as the managers have had to work with the care staff to ensure peoples needs are met on a daily basis. We were also told that the staff shortages are affecting the support people require to have a bath. People told us that on occasions they have not been able to have a bath on their preferred day due to shortages and one person Ladycross House Care Home DS0000035743.V375292.R01.S.doc Version 5.2 Page 13 had to wait a week until this support was provided. We examined the bath recording sheet for this particular time and this confirmed that people were supported with bed baths and only two people were supported to have a bath or shower during that week. Discussions we held with people and the care records that we looked at told us that these three people had access to their GPs and other health professionals were contacted and visited when required. All people spoken to told us they receive support which is provided in a safe, respectful and dignified manner, and our observations throughout our visit supported this. The senior staff members administer the medication. They confirmed they had received training in this area, and the records supported this. The medication was stored securely and separate storage and recording was in place for controlled drugs. We identified that one person self medicated and another person partially self medicated. Although they had secure storage for their medication in their bedrooms, a risk assessment had not been completed to ensure they were able to undertake these tasks safely and to ensure they had sufficient support. An audit system was not in place to monitor the standards for the administration of the medication. The records demonstrated that people did receive their medication as prescribed. However we did identify six gaps in the records where the medication had been administered but the staff member had not signed to confirm this. Ladycross House Care Home DS0000035743.V375292.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12-15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have access to recreational activities that meet their preferences EVIDENCE: In our annual quality assurance questionnaire completed by the service they told us they provide a relaxed and comfortable environment, and welcome family, friends and carers of people who live in the service. They told us they offer people a choice of activities, entertainment, and in the menus. On our arrival a group of people were getting ready to go out on a trip around the Derbyshire Dales, and to have lunch. The trip had been organised by the two newly appointed activity coordinators. We were told by the management team and the staff that the trip nearly had to be cancelled due to ongoing issues with staff shortages (please see staffing section). On their return people told us how much they had enjoyed this trip and they made the following comments: Ladycross House Care Home DS0000035743.V375292.R01.S.doc Version 5.2 Page 15 “We had a great time travelling around Derbyshire and the countryside, it was lovely to get out and the meal was lovely”. “I have really enjoyed the trip it was good and the meal was very tasty”. People told us they have a variety of activities provided, but this all depended upon the staffing levels. Two new activity co-coordinators had been recruited but their contracts had not officially started. Information was displayed of the activities that were planned, as was the minutes from the ‘residents meetings’ where forthcoming events were discussed and people are consulted about their preferences. People and their visitors told us they were always welcomed into the service, and the staff members were ‘friendly’. Visitors told us the staff members were informative and ‘always passed messages on about their relative’. People told us the food was ‘good’, and they had ‘lots of choices’. There was a menu board in each dining area and staff members were observed asking people what they would like to eat, from a choice of two main meal options. Alternatives were provided for those who wanted it. We observed that people had snacks and drinks provided throughout the day. We undertook a brief tour of the kitchen and the cook told us she was aware of people’s dietary requirements. Some information about people’s likes and dislikes was detailed in peoples care file for reference. Ladycross House Care Home DS0000035743.V375292.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Systems in place ensure people have confidence to raise their concerns, and are safeguarded from harm. EVIDENCE: In our annual quality assurance questionnaire completed by the service they told us they have regular ‘residents’ meetings in large and small groups to offer people the opportunity to voice their opinions. They said they offer an independent advocacy service, and access befriending service (Age Concern), They said they provide information relating to their complaints procedure, to people and provide new staff with training related to protection of vulnerable adults. A copy of the complaints procedure was displayed in several areas of the building so people can access this. People and their relatives spoken with told us they would not hesitate to raise any concerns with the staff or management team. They said they are confident that all issues would be dealt with quickly; and told us “we have had no cause to complaint”. People told us they felt safe living in this service and they had ‘confidence in the staff team to look after them and deal with any issues’ Ladycross House Care Home DS0000035743.V375292.R01.S.doc Version 5.2 Page 17 We were told the service had received one complaint since our last visit, but the management team were unable to find the record of this. They confirmed that it had been responded to and feedback had been provided to the complainant. Staff members spoken to told us they knew how to respond to both complaints and any safeguarding issues they may witness. They confirmed they had received training in these areas and the records confirmed this. Ladycross House Care Home DS0000035743.V375292.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a safe, well-maintained and comfortable environment, which meets their needs. EVIDENCE: In our annual quality assurance questionnaire completed by the service they told us they provide a comfortable environment, and continue to encourage people to personalise their rooms. They said they provide good quality furniture and fittings, and offer good quality and comfortable garden furniture which is easily accessed. They have a sensory garden and walk ways for people to enjoy, and they have a good maintenance programme, in place. Ladycross House Care Home DS0000035743.V375292.R01.S.doc Version 5.2 Page 19 People we spoke to told us they liked the layout of they building and the small units on each wing which they told us “makes it very homely as not too many people are in one area”. People and their relatives told us that the building was always ‘very clean and never smells’. Although there was no domestic support during the time of our visit, all of the communal areas were found to be clean. People whose care we looked at more closely agreed for us to visit their bedrooms, and all rooms had been personalised to their individual preferences. They told us they could have a key to their bedrooms if they choose to, but all three had refused this provision. People told us they were able to move feely around the building and could access all areas, as it is all on one level. Clear signage is available to assist people to familiarise themselves with the location of bedrooms, bathrooms and toilet areas. People told us they liked to assist staff members to look after the garden areas, and each year the service enters a garden competition facilitated by the corporate provider. Pictures were displayed of last year’s entry, when the service came third. People told us they are provided with the aids and equipment to assist them to mobilise within the building, and people who required pressure relieving equipment had this in place. Ladycross House Care Home DS0000035743.V375292.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27 to 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported by a competent and trained staff team. However shortfalls in the staffing levels often result in there not being sufficient staff on duty to meet people’s needs. EVIDENCE: In our annual quality assurance questionnaire completed by the service they told us they provide staffing to meet minimum standards, who are suitably checked, trained and supervised. They said they provide training to meet the needs of the staff and the changing needs of the people they support. They said they try to allow flexibility where possible in order to support staff where needed. We were told by staff and people living in this service that their has been periods of staff shortages, and the staff rotas confirmed this. The staff team told us there have been occasions whereby they have been the only care staff on duty, along with the assistant manager supporting 31 people with varying support needs. Attempts are made to cover sickness absence and the current vacant positions with existing staff, but we were told this system often becomes exhausted. Ladycross House Care Home DS0000035743.V375292.R01.S.doc Version 5.2 Page 21 During our visit we observed that their were staff shortages for the afternoon shift due to sickness. This resulted in a relief staff member who had not worked in the service for a year working alongside a relief manager. Discussions with staff, people, their relatives and the records seen demonstrated how these staff shortfalls impact on outcomes for people, and this includes: people not being able to have a bath on the day they prefer, and sometimes having to wait another week before they are supported in this task. People being supported by staff who are unfamiliar with their needs. People waiting for assistance as staff are supporting people elsewhere in the building. Comments people made include: “The staff do their best, but there just isn’t enough of them” “Sometimes I have to wait, which I don’t mind, but it worries me when I need to use the toilet as I don’t want to have an accident”. We were told there are 5 people with high needs, 21 with medium needs and 4 with low needs. The service told us there should be a total of 529 care hours provided per week. However only 426 care hours were actually worked the week ending 03/05/09. We were told that supervision and team meetings were often cancelled or postponed due to staffing problems and at times activities had to be cancelled. The management team also felt this was the reason peoples care files were not up to date as they are needed to undertake regular care duties. The recruitment information for newly employed staff is now held centrally, and access is now obtained electronically. We viewed the file for two of the most recently employed staff members. All of the required information was available and the required checks had been undertaken to ensure these individuals were suitable for their role. The staff training records are also stored electronically. We were able to look at two staff members training which demonstrated regular training opportunities. However we could not view other records due to the management staff not having access. A training matrix was not in place to give an overview of the training undertaken by the entire staff group. Ladycross House Care Home DS0000035743.V375292.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, and 38. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service is not always managed in people’s best interests due to the shortfalls in the way the service is delivered. EVIDENCE: In our annual quality assurance questionnaire completed by the service they told us the managers have undertaken training in order to fulfil their roles. They recognised they need to ensure they have sufficient relief staff to cover permanent staff sickness and annual leave and to ensure there is a continuation of good care practice. Ladycross House Care Home DS0000035743.V375292.R01.S.doc Version 5.2 Page 23 The registered manager for this service is currently undertaking a social work training course and therefore she is not working at this service on a permanent basis. Her position is being covered by an assistant manager. People we spoke to told us they thought the service was managed to a satisfactory level, but felt the staff shortages have had an impact on the way they are supported. During our visit we identified that essential documents such as care plans and risk assessments have not been available for the staff to access, due to these being held electronically. This can compromise the delivery of peoples care as the staff team need access to updated information to assist them to support people’s needs. There are no audit systems in place to monitor the information provided to staff; therefore these shortfalls had not been previously identified. The staff members we spoke to told us that the management team “do their best” and they said they felt supported by them in their role. The records demonstrated that the staff team have not received formal supervision or team meetings for some time, and we were told this was due to the staff shortages. The staff team confirmed that the management team did support them during periods of short staffing and undertake care related tasks; however this has resulted in the management team not fulfilling their roles in respect of ensuring all care planning documents are in place and accessible. We looked at the systems and arrangements for the management and handling of peoples money. These were found to be satisfactory, and people told us they were happy with the systems in place. People have access to regular meetings and the minutes from these are displayed within the building. The focus of these meetings had been about forthcoming activities and not general matters about the way the service is managed. The new activity co-ordinators intend to broaden the discussion areas, so that more general areas can be discussed. People had an opportunity to completed quality assurance surveys last year and the report of the findings is displayed in the service; this demonstrated people’s satisfaction with the service provided. A delegate of the corporate provider visits the service on a monthly basis. The reports from these visits demonstrated they are aware of the issues and impact from the staff shortages. In response to this they have arranged for staff from the community to work in this service, and cover vacant shifts. However this support is variable and dependent upon the availability of these staff based on the demand of their community work. The information we received from this service demonstrated that systems are in place to ensure the health and safety of the building is monitored. This ensures people live in safe environment and the staff team are supported by safe working systems. Assess against AQAA. Ladycross House Care Home DS0000035743.V375292.R01.S.doc Version 5.2 Page 24 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 X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 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 X X X X X X 3 STAFFING Standard No Score 27 2 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 X X 3 Ladycross House Care Home DS0000035743.V375292.R01.S.doc Version 5.2 Page 25 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. Standard OP7 Regulation 15(1) Requirement Staff must have access to care plans that are up to date and kept under regular review. This is to ensure that people have their needs identified, and to ensure staff have clear direction on how to meet people’s needs. Risk assessments must be completed on the person identified during our visit. This is to ensure peoples healthcare needs are identified and met. Immediate requirement issued. Staff must have access to updated risk assessments to enable them to monitor people’s healthcare needs. Medication risk assessments must be completed on people who wish to self medicate to demonstrate that these people have the capacity to store and administer their medication safely DS0000035743.V375292.R01.S.doc Timescale for action 01/08/09 2. OP8 12(1)a b13(4)c14 (1)a 07/05/09 3. OP8 12(1)a b13(4)c14 (1)a 13.2 01/08/09 4. OP9 01/08/09 Ladycross House Care Home Version 5.2 Page 26 5. OP16 22 (8) A record of the complaints received must be made available in the service. 01/08/09 6. 7. OP27 OP36 18 (1) (a) 18 (2) These to ensure all complaints are responded to in accordance with the procedure in place. You must be able to demonstrate 01/08/09 that sufficient staff are on duty to meet people’s needs. All staff must have access to 01/08/09 formal supervision. This is to ensure they receive appropriate support. 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. Refer to Standard OP1 OP7 OP7 Good Practice Recommendations The statement of purpose and service user guide should be updated to reflect the current fees for living in this service and the name change of the regulator. Care plans should be reviewed every month and altered to accurately reflect the needs of the person. Staff should have access to care plans that are up to date This is to ensure that people have their needs identified, and to ensure staff have clear direction on how to meet peoples needs. A regular audit should be undertaken to monitor the medication practices and identify any shortfalls. The staffing levels should continue to be monitored in accordance with the dependency needs of the people living in the home, to ensure the staffing levels continue to meet people’s needs. A training matrix should be in place to give an overview of the training needs of the staff group. DS0000035743.V375292.R01.S.doc Version 5.2 Page 27 4. 5. OP9 OP27 6. OP30 Ladycross House Care Home 7. 8. 9. 10. OP32 OP33 OP36 OP38 The management team should have access to all of the staff training records in order to monitor staff training requirements and plan refresher training. Systems should be implemented to monitor all of the standards of the service provided to people and to identify any shortfalls. Each staff member should receive formal supervision at least six times a year, so that they are supported to fulfil their roles and responsibilities. A system should be implemented to monitor the frequency of falls for each person living in this service. Ladycross House Care Home DS0000035743.V375292.R01.S.doc Version 5.2 Page 28 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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