Inspection on 03/11/05 for Ladydale Residential Home

This inspection was carried out on 3rd November 2005.

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

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

Other inspections for this house

Ladydale Residential Home 12/11/09

Ladydale Residential Home 09/07/09

Ladydale Residential Home 21/05/09

Ladydale Residential Home 09/05/07

Ladydale Residential Home 14/07/05

Ladydale Residential Home 06/10/04

Ladydale Residential Home 14/06/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Maple Lodge

Polesworth Group 32 Station Road

Heathlands

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Ladydale Residential Home 9 Fynney Street Leek Staffordshire ST13 5LF Lead Inspector Mrs Linda Clowes Unannounced Inspection 3rd November 2005 1:00 X10029.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 Ladydale Residential Home DS0000004967.V263777.R01.S.doc Version 5.0 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 and Care Homes for Adults 18 – 65*. 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. Ladydale Residential Home DS0000004967.V263777.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ladydale Residential Home Address 9 Fynney Street Leek Staffordshire ST13 5LF 01538 386442 01538 385158 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) Aegis Residential Care Homes Limited Mrs Jacqueline Walters Care Home 54 Category(ies) of Learning disability (3), Mental disorder, registration, with number excluding learning disability or dementia (2), of places Mental Disorder, excluding learning disability or dementia - over 65 years of age (6), Old age, not falling within any other category (54), Physical disability (4), Physical disability over 65 years of age (20) Ladydale Residential Home DS0000004967.V263777.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 3 LD minimum age 35 years on admission. 4 PD minimum age 55 years on admission. 2 MD minimum age 55 years on admission. Date of last inspection 14th July 2005 Brief Description of the Service: Ladydale Residential Home was situated in a quiet, mature residential area in the historic market town of Leek. It was a well-established care home for the elderly that provided accommodation for up to fifty-four service users. The main house had four floors. The majority of service user bedrooms were situated on the ground and first floors. A shaft lift and stair chair lift provided service users with easy access to various levels in the home. The new singlestorey wing that opened in November 2002 accommodated ten service users and had its own communal lounge/dining area. Ladydale also had two small annexes, The Coach House with three semi-independent units and The Lodge with two semi-independent units. Service users were able to access all areas of the home as they chose. Ladydale was attractively decorated and furnished throughout to a high standard. Fifty of the bedrooms were single, two were double and 45 had en-suite facilities. There were also four assisted bathrooms and two shower facilities. The home had ample communal lounge and dining space. There were off-road parking facilities and attractive mature gardens surrounding the property with a very pleasant patio area with seating. Fencing had been erected to separate the patio from the car park to promote safety and privacy for service users. There was a comprehensive activities programme for service users to access as and when they wished. Ladydale Residential Home DS0000004967.V263777.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A full inspection covering all National Minimum Standards (NMS) had been carried out at the last inspection. The purpose of this unannounced inspection was to monitor whether the home had implemented the requirements and recommendations of the last report, to target the bathing and toilet facilities and to obtain the views of service users regarding their lives at the home. As a consequence some NMS will not have been inspected on this occasion. Ladydale Residential Home was a large home registered to provide care for 54 people. There was only one vacancy on the day of the inspection. It had achieved a welcoming, calm, “homely” ambience. The home was well managed and had a stable staff group. The quality of care was good and service users expressed satisfaction with the service they received. What the service does well: What has improved since the last inspection? What they could do better: The registered manager should ensure that there is a written service user plan in place for each service user in the home. Care should be taken to ensure that the medication administration record is dated in all instances. Ladydale Residential Home DS0000004967.V263777.R01.S.doc Version 5.0 Page 6 The communal bathrooms were in need of repair, refurbishment and redecoration to bring them up to the high standard of the rest of the care home. Managers should monitor communal areas to ensure that block soap and towels are not introduced in order to prevent infection, toxic conditions and spread of infection in the home. COSHH materials should be securely stored and fire doors should be kept locked shut with no keys left in the locks at all times. 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. Ladydale Residential Home DS0000004967.V263777.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Ladydale Residential Home DS0000004967.V263777.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4 and 5 The home had written information that it made readily available to service users and prospective service users in order that they may make a choice about whether the care home met their needs. It was the home’s policy that prospective service users were subject to a pre-admission assessment to establish whether their needs could be met. Short Stay admissions/trial visits were available to enable service users to “test the water” before making decisions regarding admissions to the home. Ladydale Residential Home DS0000004967.V263777.R01.S.doc Version 5.0 Page 9 EVIDENCE: The Statement of Purpose and Service user Guide was not inspected on this occasion, however the last inspection found comprehensive information about the home and its terms and conditions of residency was readily available to all service users. The manager or her deputy carried out an assessment to ensure that the home could meet individual needs for each service user. A recently admitted service user and their relative confirmed that they had received documentation regarding the home and confirmed that they had found this very helpful. The home did not offer intermediate care facilities. Ladydale Residential Home DS0000004967.V263777.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are 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 It was evident that the health, personal and social care needs of service users were promoted by the home. Service users and relatives expressed satisfaction with the care provided. EVIDENCE: The home had personal care plans (PCP) for service users that were relevant to their needs. The PCP’s for younger adults were more detailed containing plans for continuing education, social integration, aims and objectives. Ladydale Residential Home DS0000004967.V263777.R01.S.doc Version 5.0 Page 11 The inspector asked to see the service user plan for the most recently admitted service user (admitted 24.10.05). Unfortunately the document had not been completed and a requirement was made for the home to ensure that the service users plan was completed within 24 hours to ensure that staff within the home were aware of the action which needed to be taken to ensure that all aspect of the health, personal and social care needs of the service user were addressed. Service users and relatives spoken with on the day confirmed that they were treated with respect and dignity by management and staff of the home. The home had appropriate policies and procedures for the receipt, recording, storage, handling and administration and disposal of medication. The record of administration was checked on the day and it was noted that the date was not recorded on one medication administration record. A requirement was made for the home to address this issue. The home promoted a “home for life” philosophy and endeavoured to maintain service users in the home as long as their needs could be met. A recommendation was made for obscure glass/Perspex to be fitted to the window of the bathroom on the lower ground floor to ensure that service users privacy and dignity were respected at all times in relation to the provision of personal care. It should be acknowledged that a curtain was being used but this reduced natural daylight into the area. Ladydale Residential Home DS0000004967.V263777.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the 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 Discussions with service users and observations made on the day confirmed that the daily routines in the home were relaxed and flexible. Contact with family and friends was encouraged and community work links were maintained for younger adults. All service users spoken with expressed satisfaction with the food served. Ladydale Residential Home DS0000004967.V263777.R01.S.doc Version 5.0 Page 13 EVIDENCE: The normal routine of Ladydale was for service users to be served breakfast in their rooms and to take their own time to get up and dressed, with assistance from staff as required. Some service users chose to take breakfast in the dining room and this was accommodated. The majority took lunch and tea in the communal dining areas but again those wishing to take meals in their own rooms were accommodated. At the last inspection a recommendation was made that the key worker and service users in The Coach House should liaise with the cook of the home in relation to menu planning, particularly bearing in mind health care needs. It was recommended that this should continue. Service users in The Coach House continued to work towards the aims and objectives in their care plans and attended various centres/work places. The inspector spoke to each service user in this unit and they expressed satisfaction with their lives in the home. There were obvious positive professional and friendly relationships between all parties. A weekly programme of activities was seen on each table in the dining rooms and two service users were observed painting with watercolours. Others were seen knitting, others watched television. Two ladies spoken with stated that they had been on an outing the previous week organised and paid for by the home. A Bonfire Party was arranged for the following night and several service users stated that they were looking forward to this and that members of their family would also be attending. The home continued to offer an eight-week rotational menu. Service users expressed satisfaction with the food served. Ladydale Residential Home DS0000004967.V263777.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) 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 The home had a formal complaints procedure that was made available to service users and other stakeholders. Policies and procedures were in place to protect vulnerable service users. Staff received training in relation to the protection of vulnerable adults from abuse as part of their induction and ongoing training. EVIDENCE: The home had a comprehensive complaints procedure. An inspection of the complaints book found that there had been no formal complaints since the last inspection. The CSCI had not received any complaints regarding Ladydale since the last inspection. It was indicated at the last inspection that the home was not involved in the financial management of service users monies preferring relatives and friends or solicitors to maintain responsibility. For some service users, their financial affairs were monitored through care management arrangements. All staff were informed of adult protection procedures and the Public Interest Disclosure Act 1998 (Whistleblowing) as part of their induction training. Service users spoken with indicated that they felt comfortable and safe in the home. Ladydale Residential Home DS0000004967.V263777.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21 and 26 The location and layout of the home was suitable for the needs of its service users. The home was well maintained, attractively decorated, clean and hygienic throughout. There were sufficient communal lavatories and washing facilities with a high proportion of rooms having their own en-suite facilities. There were aids to daily living fitted throughout the home to promote the independence of service users. Ladydale Residential Home DS0000004967.V263777.R01.S.doc Version 5.0 Page 16 EVIDENCE: Ladydale Residential Home was a large home that had achieved a “homely” ambience. It was loosely divided into separate living units although service users had access to all communal parts of the home. The home was well maintained and decorated to a high standard. There was a routine maintenance and redecoration programme. A maintenance person was employed for 25 hours each week. This inspection focussed on the communal toilet and bathroom facilities in the home. It was considered that the top floor bathroom and the lower ground floor bathroom would benefit from renovation and redecoration to make them more cosy and “homely”. Repairs needed carrying out to the side of the bath in the top floor bathroom as this had broken off and there were sharp edges around the bath area. A requirement was made for the home to address this issue within one week. A recommendation was made earlier in this report regarding the window in the lower ground floor bathroom. There were a total of four assisted baths and seven separate toilets situated throughout the home. Attractive communal areas were situated throughout the home. The grounds were well maintained and there were pleasant patio areas. Of the 50 single rooms 45 had en-suite facilities and both double bedrooms also had en-suite facilities. The manager indicated that there were plans to provide en-suite showers in those rooms where this was possible. Although paper towels and liquid soap were provided it was noted that towels and block soap were in use in several communal areas. The manager was asked to remove these to prevent infection, toxic conditions and the spread of infection in the care home. A requirement was made for this to be addressed on the day. Ladydale Residential Home DS0000004967.V263777.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the 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 The home carried out robust recruitment procedures that included the taking up of references and police checks. There were sufficient staff with the skills mix to meet the needs of service users. The Group’s Training Officer carried out all mandatory training. Thorough induction training was carried out inhouse. EVIDENCE: An inspection of staff files found that training was being carried out for all staff that included moving and handling training, infection control, abuse and ongoing National Vocational Qualification level 2 in Care. The NVQ training was provided by an independent external trainer. A recommendation was made that a training matrix be introduced in order to be able to easily identify that training for the whole staff group had been completed within required timescales. Ladydale Residential Home DS0000004967.V263777.R01.S.doc Version 5.0 Page 18 The home had robust recruitment procedures in place that included the taking up of references and Criminal Record Bureau Enhanced Disclosure checks for all new recruits. A requirement was made for the home to maintain a copy of each employee’s current passports to meet regulations. Ladydale Residential Home DS0000004967.V263777.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36 and 38 The home was managed by an experienced and competent manager. There were clear lines of accountability in the home and good leadership promoted professional relationships throughout. Service users best interests and safety were promoted by staff at all levels. Ladydale Residential Home DS0000004967.V263777.R01.S.doc Version 5.0 Page 20 EVIDENCE: The home benefited from the leadership and management approach of the registered manager. There was a co-operative and confident staff team who worked well together for the benefit of service users. The Deputy Manager was currently studying her NVQ level 4 in Management/Registered Managers Award. The views of service users were sought by the organisation through their annual Quality Audit. Copies were displayed on the notice board in the main hallway. Regular staff supervision was taking place carried out by the registered manager and her deputy. Fire records were inspected on the day and found to be satisfactory. The maintenance of gas boilers/fittings was up to date. Shower head sterilization was carried out regularly. The shaft lift, stair chair lift and hoists throughout the home had been routinely maintained. An inspection of the environment found that COSHH materials were not being securely stored in communal toilets and bathing/showering areas. It was also noted that two fire doors marked “Keep Locked” and which led to the COSHH storage area had keys in the locks. Requirements were made for the home to address these matters immediately. Ladydale Residential Home DS0000004967.V263777.R01.S.doc Version 5.0 Page 21 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 X 2 X 3 3 4 3 5 4 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 4 11 4 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 ENVIRONMENT Standard No Score 19 2 20 X 21 3 22 X 23 X 24 X 25 X 26 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 4 32 4 33 3 34 X 35 3 36 3 37 3 38 2 Ladydale Residential Home DS0000004967.V263777.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? No 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 7 Regulation 15(1) Requirement Timescale for action 04/11/05 2 9 13(2) 3 19 13(4) 4 26 13(3) The registered person shall ensure that a written service user’s plan as to how the service user’s needs in respect of his health and welfare are to be met is in place in respect of all service users resident in the home. The registered person shall 03/11/05 ensure that the Medication Administration Record is dated in all instances. The registered person shall 10/11/05 ensure that the bath panel in the top floor bathroom is repaired/replaced and that there are no sharp edges around the bath. The registered person shall 03/11/05 ensure that towels and block soaps are removed from communal toilet/bathing areas to prevent infection, toxic conditions and the spread of infection in the care home. DS0000004967.V263777.R01.S.doc Version 5.0 Ladydale Residential Home Page 23 5 28 17(2) 6 7 38 38 13(4) 13(4) The registered person shall 07/11/05 ensure that as part of the recruitment procedure for staff in the home that a copy of the prospective employee’s passport is obtained. The registered person shall 03/11/05 ensure that at all times COSHH materials are securely stored. The registered person shall 03/11/05 ensure that fire doors marked “Keep Locked” are kept locked at all times. 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 10 Good Practice Recommendations It was recommended that consideration be given to providing obscure glass/Perspex in the window of the lower ground floor bathroom to ensure service users privacy and dignity are respected at all times. It was recommended that the key worker and residents of The Coach House continue to liaise with the Cook in relation to menu planning taking into account health care needs. It was recommended that a training matrix be introduced in order to easily identify that staff training has been completed and is up to date. 2 15 3 30 Ladydale Residential Home DS0000004967.V263777.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. Ladydale Residential Home DS0000004967.V263777.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!