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Inspection on 09/05/07 for Ladydale Residential Home

Also see our care home review for Ladydale Residential Home for more information

This inspection was carried out on 9th May 2007.

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

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

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

What the care home could do better:

There was a need to keep all storage areas and walkways tidy and free from clutter. Care must be taken to ensure that homely remedies/ spectacles are not left in communal areas. The Environmental Health Officer has asked for ventilation to be fitted in the laundry and the area off the main kitchen where the refrigerators and freezers are located. In this large home, consideration needs to be given to the timing of the medication rounds to ensure that there is sufficient time between each administration session. There needs to be more regular supervision of staff at all levels

Ladydale Residential Home 9 Fynney Street Leek Staffordshire ST13 5LF Lead Inspector Mrs Linda Clowes Key Unannounced Inspection 9 May 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ladydale Residential Home DS0000004967.V343245.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ladydale Residential Home DS0000004967.V343245.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ladydale Residential Home Address 9 Fynney Street Leek Staffordshire ST13 5LF 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) 01538 386442 01538 385158 ladydale@arc-homes.co.uk Aegis Residential Care Homes Limited Mrs Deborah Johnson 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.V343245.R01.S.doc Version 5.2 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 3rd November 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 newer single-storey wing 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 ensuite facilities. Assisted bathing and shower facilities were situated throughout. 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.V343245.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this unannounced inspection which took place over 9.5 hours. This was a key inspection that was inspected against the National Minimum Standards for Care Homes for Older People and the Care Homes Regulations 2001. Consequently, the intention was to inspect all of the core standards on this visit. Various methods were used to obtain information regarding the services provided by the home. Questionnaires were sent to service users and nine responded. Questionnaires were returned by thirteen relatives/representatives of service users. The home was asked to forward Comment Cards to local GP practices, local Community Nursing Teams and Social Work Teams who were involved with placing or visiting people in the home and two GP practices have responded. The manager had completed a Pre-Inspection Questionnaire to provide statistical information including occupancy levels and staffing. The Statement of Purpose and Service User Guide were displayed in the reception area of the home and a copy of these documents was issued to each new service user. It was understood that there had been no change to these documents since the last inspection as a consequence they were not inspected on this visit. They will be monitored on the next visit. A new Manager and Deputy Manager had been appointed at the end of 2006. Both had worked in the home for some time and had been promoted following the retirement of the last manager. There had been improvements to the environment since the last inspection visit and further upgrading was planned. All respondents to questionnaires and those service users spoken with on the day were satisfied with the care they received in the home, although two made negative comments regarding the food served on the day. From observations it was clear that service users were relaxed and confident in their communication with staff. Routines and lifestyles of individuals were accommodated by the home. On the day of the inspection there were forty-eight permanent residents in the home. The current charges were from £357 to £455 per week. Ladydale Residential Home DS0000004967.V343245.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? A large glass light well has been fitted in the roof of the main lounge which has greatly improved the lighting levels and is a very attractive feature. Redecoration and new seating areas make this a pleasant area for service users to relax. The dining areas have been redecorated and rearranged and tables were attractively laid with matching tablecloths and napkins. The toilet area off the main lounge has been completely refurbished and is a big improvement. A shower facility has been fitted in the en-suite of one of the bedrooms. It is understood that there are plans to upgrade the bathroom and hairdressing salon on the lower ground floor and to upgrade the other bathrooms throughout the home during the course of the next twelve months. There Ladydale Residential Home DS0000004967.V343245.R01.S.doc Version 5.2 Page 7 were also plans to purchase new outdoor furniture and parasols for the patio areas. What they could do better: 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. The summary of this inspection report can be made available in other formats on request. Ladydale Residential Home DS0000004967.V343245.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 Ladydale Residential Home DS0000004967.V343245.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5. The home did not offer intermediate care. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users receive the information they need to make a choice regarding the services provided by the care home. They are encouraged to have shortstay admissions prior to decisions being made regarding permanent admission. Pre-admission assessments are made to determine whether the home can meet their individual needs. Clear and comprehensive contracts outline the terms and conditions of residency. EVIDENCE: The majority of service users at Ladydale were elderly people. Three individuals with learning disabilities lived in semi-independent accommodation in the grounds. This inspection did not monitor the semi-independent accommodation on this occasion as one person was away on holiday, the two others had decided to spend time in the main house and the inspector spoke Ladydale Residential Home DS0000004967.V343245.R01.S.doc Version 5.2 Page 10 with them there. All service users confirmed they had received service user guides and contracts. All relatives/representatives who took part in this inspection confirmed that they had received sufficient information regarding the home. Prospective new service users were assessed to ensure that the home could meet their needs. The new manager confirmed that she undertook home visits where required and written confirmation that the home was able to meet individual needs was noted on service user files. Ladydale Residential Home DS0000004967.V343245.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home maintained detailed and clear information on the needs of each service user that was a good reference tool for care staff. Service users were treated with respect and their right to privacy was upheld. EVIDENCE: The personal care plans for four service users were monitored on this inspection. Each was generated from a comprehensive assessment and included input from service users and/or representatives. The plans were reviewed monthly. It was noted that there had been some lapses in monitoring the weight of individuals and a recommendation has been made as part of this report regarding this issue. (Recommendation 1) Ladydale Residential Home DS0000004967.V343245.R01.S.doc Version 5.2 Page 12 It was noted that appropriate GP consultation had been initiated. Two responses to questionnaires had been received from GP’s who visited the home both expressing satisfaction with the overall care provided to service users within the home, with one adding that the home was an “excellent care provider”. Community Nurses, Opticians and physiotherapists were seen in the home on the day with all expressing satisfaction with the timely way the home addressed individual health care needs. Without exception service users considered they were treated with respect and dignity throughout their daily lives in the home. The inspector accompanied a senior carer for part of the medication round and found satisfactory recording, administration and understanding of issues relating to the medication being administered. An inspection was also made of the Controlled Drugs storage and records system in the home and this was also found to be satisfactory. Staff who were responsible for administering medication had received medication training. In this large home where the majority of people take some form of medication, it was noted that the medication round was still under way quite late into the morning. This issue was discussed with the manager on the day and a recommendation was made that a review be made of the timing of the morning medication round in order that there is sufficient time allowed between administration of medication sessions. (Recommendation 2) Ladydale Residential Home DS0000004967.V343245.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,12,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The daily routines in the home were relaxed, flexible and varied to meet service users preferred lifestyles within a risk assessment framework. Service users maintained contact with family/friends and the local community. The majority of service users expressed satisfaction with the food served. EVIDENCE: There was an Activities Programme in place, copies of which were displayed in the home. It is understood that the home is hoping to employ a further Activities Co-ordinator in the near future. The popular Movement to Music session took place on the afternoon of the inspection with service users and visitors joining in with obvious enjoyment. Various activities take place in the home which service users can choose to take part in or not. The activities include, painting class, in-house entertainers, crafts and needlecraft, church services, musical appreciation, reminiscing, board games, DVD shows, theatre, lunches out. One relative and resident were unhappy that a staff member did not escort the resident into Ladydale Residential Home DS0000004967.V343245.R01.S.doc Version 5.2 Page 14 town for shopping trips but were unaware that there may be a charge for this as it had an impact on staffing in the home. The service user guide does indicate that there may be a charge for escort services. One relative stated that “more activities or outside visits” should take place. They also stated “I would like my mother to have a bit more to look forward to. Maybe a trip or outing now and then”. The inspector spoke with the service user and with her permission discussed issues raised with her and the manager. The service user stated she was satisfied with the outcome. The following comments were made by relatives: “On the whole I am perfectly satisfied that my mother is receiving good care. Any issues, when reported have been resolved satisfactorily”. “The home treats people as individual human beings and with respect. It liaises well with relatives. It ensures that residents have plenty of interesting activities…….It organises lots of outings. The home is Gold Star. My relative is fortunate to spend her days in such an excellent home and we her relatives are happy to know she is so well cared for”. “The general care and consideration given is exceptionally good. In all circumstances accommodation and all the services provided are beyond criticism”. “Generally this is a very good care home and I am satisfied that my mother is comfortable”. “I think the charges are a bit high for people who look after themselves”. “Firm up on signing in and out procedures. It is good to be informal… but also important for security”. “Mum is happy, safe and well cared for – what more could we ask for!”. “I feel that everything is done very well for the comfort of the residents”. “They could be more pro-active in advising me of my mother’s day to day well being” One relative indicated that they were unhappy that a service users room had not been refurbished. However, on checking this year’s refurbishment programme it was seen that the room was due for upgrading this year. The routine in the care home was for service users to be served breakfast in their rooms and to take their own time to get up and dressed, with assistance Ladydale Residential Home DS0000004967.V343245.R01.S.doc Version 5.2 Page 15 from staff where required. Service users who wished to take breakfast in the dining room were free to do so. The majority took lunch and tea in the communal dining areas, either in the main house or in the lounge/dining area in the new wing. The home provided meals in service users own rooms should they so choose. Service users in the supported living areas of the home were encouraged to prepare their own breakfast (and some other meals/snacks) or visited the main dining room. On a number of days each week several attended other establishments to carry out work or training activities where meals were provided. A key worker was designated to the learning disability unit and service users in this unit were very happy with their lives in the home and the staff member who was responsible for the majority of their care. One of these service users was on holiday on the day of this inspection and two had decided to spend the day in the main house where two service users had birthdays. Birthday teas, including home cooked birthday cakes, had been prepared to celebrate these occasions. The home continued to offer an eight-week rotational menu. There had been a change in cook and deputy cook. Menus showed that a varied and nutritional diet was provided in the main. The majority of service users expressed satisfaction with the quality of food served. One person who responded to the questionnaire stated “The meals are of good quality and varied..” On the day of this inspection two service users complained that there was too much pastry in the diet. An inspection of the week’s menu found this to be the case. This was discussed with the manager on the day who agreed that changes would be made. A recommendation has been made in relation to this issue (Recommendation 3) Community links were maintained for all service users within a risk assessment framework. Taking into account their abilities and vulnerabilities. Arrangements had been made for postal voting so that service users could take part in recent local elections. The home publishes a regular Newsletter. Service users are encouraged to contribute. Ladydale Residential Home DS0000004967.V343245.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home were aware of issues of abuse, however the home’s Protection of Vulnerable Adults Policy needed to be updated to reflect current agreed procedures with other agencies. The complaints procedure was displayed in the home. EVIDENCE: An inspection of the home’s Protection of Vulnerable Adults Policy found that it needed to be reviewed and updated to reflect current agreements with Local Authorities and the Police. A recommendation has been made in relation to this matter (Recommendation 4) The complaints procedure was displayed in the home. An inspection of the Complaints Record identified that two complaints had been received and had been appropriately addressed to the satisfaction of service users/representatives within the 28 days timescale. The Commission had not received any formal complaints about the home since the last inspection. Staff received training at induction regarding how they must respond to suspicion or evidence of abuse and are issued with information including Ladydale Residential Home DS0000004967.V343245.R01.S.doc Version 5.2 Page 17 whistle blowing. This issue is also addressed through NVQ training and other in-house training. It is important that upon receipt of the current procedures agreed with Local Authorities and the Police, staff receive appropriate training. It was identified that service users maintained responsibility for their own finances or had family members or solicitors who acted on their behalf. The home, therefore, held no responsibility for the finances of any of its service users. Ladydale Residential Home DS0000004967.V343245.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The 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 aids to daily living fitted throughout the home for the benefit of service users. EVIDENCE: The proprietors were committed to an on-going programme of maintenance and refurbishment to improve the environment for the benefit of the people who used the service. The Operations Director and Estates Director were in the home on the day of the inspection. They confirmed that there were plans to upgrade the lower Ladydale Residential Home DS0000004967.V343245.R01.S.doc Version 5.2 Page 19 ground floor bathroom and hairdressing salon and to refurbish communal bathrooms throughout the home in the next twelve months. There were also plans to upgrade the reception area to make it more user-friendly and provide a more confidential meeting area for staff and visitors. In view of the fact that the present reception area does not overview visitors entering and leaving the premises, discussions took place with the manager and directors regarding security in the home. They were asked to consider this issue whilst upgrading the reception area. A recommendation has been made regarding this matter. (Recommendation 5) It was recommended that a review is made of the storage of paper goods in the COSHH storage corridor in view of the damp walls in this area. (Recommendation 6) Since the last inspection, improvements and redecoration had been carried out in many areas of the home. The grounds and external view of the home had improved. Gardens were neat and tidy with plans to purchase outdoor furniture and parasols ready for the summer. The toilet area off the main lounge had been upgraded. A large light well had been fitted in the roof of the main lounge. Redecoration and refurbishment of communal areas had been carried out making them very attractive areas for service users to spend time. Aids to daily living were fitted throughout the home to maximise service users independence. One wall in the dining area had been fitted with spotlights to display various artwork made by service users. One service user confirmed “I hold painting classes twice per week. My own paintings have just been displayed in the lounge, with good effect, even special lighting”. One service user in one of the supported living units complained that they had been promised that a shower would be installed as they were unable to use the bath. The manager and directors confirmed that this would be carried out in the next month. Individual bedrooms were personalised by residents with many containing possessions brought from home and were very attractive personal spaces. There were areas in the home that needed redecoration and refurbishment but these had been identified and were part of this year’s “Refurbishment Programme”. Ladydale Residential Home DS0000004967.V343245.R01.S.doc Version 5.2 Page 20 The home employed a Handy Person for five days each week. Ladydale Residential Home DS0000004967.V343245.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users needs were met by the numbers and skills mix of staff. Robust recruitment procedures and Induction Training protected service users. EVIDENCE: From information provided it was identified that the dependency needs of service users was 35 with low and 13 with medium needs. The rotas showed that there were sufficient staff to meet the needs of service users. No agency staff had been used in the last eight weeks. The records showed that the home employed 40 care staff and that 15 had attained NVQ level 2 or above. This equates to approximately 37 . The registered manager was aware of the need to ensure that 50 of the care workers are trained to NVQ level 2 in Care at any one time. It was noted, however, that since November 2005, 35 staff members had left the home. NVQ training was an on-going part of training in the home. The home now had an in-house trained trainer for moving and handling, 3 trained trainers for health and safety, 2 fire marshals. Two staff were shortly going on training in relation to the Mental Capacity Act. Food Hygiene training was needed for some staff but this was in hand. Ladydale Residential Home DS0000004967.V343245.R01.S.doc Version 5.2 Page 22 The new registered manager had worked in the home for some years and had previously been the Deputy Manager. She had attained her Registered Managers Award and National Vocational Qualification (NVQ) level 4. An inspection of a small random sample of personnel files found that the home carried out robust recruitment procedures that included the taking up of references and CRB (police checks) for all new recruits. The majority of service users who responded to questionnaires were satisfied with the staff in the home indicating that they received the care and support they needed. One stated that staff nearly always listened and acted on what they said but sometimes forgot. One stated “I am content enough. I get on well with people”. Ladydale Residential Home DS0000004967.V343245.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,36,37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was managed by a qualified and competent manager. There were clear lines of accountability in the home. The best interests of service users were promoted by staff at all levels. EVIDENCE: The home had addressed issues from the last report ensuring that all care staff received annual updates for moving and handling. Several areas of the home were cluttered with articles left around by staff that presented trip hazards. A nasal spray was found in the window in the dining Ladydale Residential Home DS0000004967.V343245.R01.S.doc Version 5.2 Page 24 room. Two pairs of spectacles were seen in the bathroom window. These issues were discussed with the manager on the day. It was noted that there had been a lapse in supervision of care staff and this needs to be addressed in order to ensure that all aspects of practice, the philosophy of the home and career development needs are monitored to promote good practice at all levels in the home. (Requirement 2). It was noticed that Fire Risk Assessments needed to be undertaken in respect of each service user in the home to identify emergency evacuation needs. (Recommendation 7) An inspection was made of the following records which were found to be satisfactory: Fire Records Maintenance Records (including gas and electricity) Accident Records Legionella Hot water testing Portable Equipment Testing An inspection of the home’s Insurance document found current and appropriate insurance cover was in place. Ladydale Residential Home DS0000004967.V343245.R01.S.doc Version 5.2 Page 25 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 4 4 4 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 4 18 3 2 4 3 3 3 3 4 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 4 3 X 2 3 3 Ladydale Residential Home DS0000004967.V343245.R01.S.doc Version 5.2 Page 26 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 OP19 Regulation 13(4)(a) Requirement All parts of the home to which service users have access should be free from clutter and trip hazards for the health and safety of service users. All care staff working at the care home must be appropriately supervised to ensure they continue to provide good quality care for the benefit of people who use the service Timescale for action 09/05/07 2 OP36 18(2)(a) 31/05/07 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 OP8 Good Practice Recommendations It was recommended that the home’s policy of weighing service users on admission and thereafter monthly, be adhered to, to promote the health and well-being of people who use the service. It was recommended that consideration be given to the timing of the medication rounds to ensure that sufficient time was allowed between each administration session to DS0000004967.V343245.R01.S.doc Version 5.2 Page 27 2 OP9 Ladydale Residential Home 3 OP15 4 OP18 5 OP19 5 6 OP19 OP38 meet the individual needs of people who use the service. It was recommended that a review of the menu is undertaken to ensure that too much pastry is not served in any one day or week for the benefit and well-being of people who use the service. It was recommended that the home obtains a copy of the Local Authority Protection of Vulnerable Adults from Abuse Guidance document and provides appropriate training for staff regarding the current procedures for the protection from abuse of people who use the service. It was recommended that consideration be given to security of the building in view of the number of entrances and exits in the home in order to promote the health and safety of service users. It was recommended that a review of arrangements for the storage of paper goods in the COSHH corridor be undertaken due to damp walls in this area. It was recommended that Fire Risk Assessments be undertaken in respect of each service user in the home to identify emergency evacuation needs and any staffing implications this might have for the health and safety of people who use the service. Ladydale Residential Home DS0000004967.V343245.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V343245.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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