Inspection on 13/07/05 for Ladymead Nursing Home

This inspection was carried out on 13th July 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

Ladymead Nursing Home 13/11/07

Ladymead Nursing Home 03/07/06

Ladymead Nursing Home 08/11/05

Ladymead Nursing Home 19/10/04

Ladymead Nursing Home 29/03/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Ladymead Nursing Home Albourne Road Hurstpierpoint Haywards Heath, West Sussex BN6 9ES Lead Inspector Ann Peace Announced Wednesday, 13 July 2005 V230071 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Name H60 H11 S24169 Ladymead V230071 130705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Ladymead Nursing Home Address Albourne road, Hurstpierpoint, Haywards Heath, West Sussex, BN6 9ES Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01273 834873 Mr Warren Ball, Mr Phillip Hale. Mr Motilall Jagannath Care Home 27 places Category(ies) of Old age, not falling within any other category registration, with number (OP) 27 places of places Name H60 H11 S24169 Ladymead V230071 130705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th September 2004 Brief Description of the Service: Ladymead is a care home registered to provide nursing care for 27 older people. The home is located in Hurstpierpoint close to village amenities. Ladymead is a three storey detached house with a conservatory and large gardens to the rear and sides of the property. It offers 17 single rooms and 5 shared rooms on the ground and first floors. A passenger lift is available for rooms on the first floor. Mr Ball and Mr Hale own the service. They have been granted planning permission to extend the premises. Name H60 H11 S24169 Ladymead V230071 130705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Mrs Ann Peace Regulatory Inspector carried out this announced inspection on Tuesday July 13th 2005. Prior to the inspection all records held on file since the last inspection were reviewed. Mr Jagannath the Registered manager for the home had submitted a pre inspection questionnaire and other related records in good time for the inspection. During the inspection a tour of the home was carried out and the majority of the rooms visited. Records relating to the care of residents and the administration of the home, including a number of staff records were examined. A case tracking exercise for a number of residents was carried out. Information was taken from their records since pre-admission and tracked to care being given, the continuity of that care and any equipment used. 4 satisfaction surveys were returned to The Commission. All were from relatives. Two were positive about the home, the way it is managed and the way the staff carry out the care. Two others were also complimentary, but did identify some concerns that were followed up by the Inspector. Two relatives were spoken to during the inspection and were complimentary about the home and the staff. Two letters recently sent to the home were shown to the Inspector. Quotes from the letters and survey forms included: “lovely clean home staff, mother has improved since living here”. “Staff and residents friendly”. “Staff make mother feel like an individual”. “Impressed by the work of the staff organising events”. One anonymous complaint had been sent to the Commission and issues identified in the letter were looked into as part of the inspection. The complaint was found to be partially substantiated and action that needed to be taken was discussed with Mr Ball and Mr Jagannath. Staff were spoken to during the inspection and all said they enjoyed their work and felt well supported at the home. Name H60 H11 S24169 Ladymead V230071 130705 Stage 4.doc Version 1.30 Page 6 The conclusion of the Inspector was that in the main a good standard of care is provided at Ladymead from a caring and committed team. No immediate requirements were made so a feedback form was not left at the home following the inspection. Any matters arising from the inspection were discussed with Mr Ball The responsible Individual for the home and Mr Jagannath at the conclusion of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Criminal record bureau checks made for staff should be enhanced and not standard. Training for all staff including ancillary staff in correct infection control procedures and training in adult protection should be in place. Name H60 H11 S24169 Ladymead V230071 130705 Stage 4.doc Version 1.30 Page 7 Risk assessments should be in place for all radiators that are not covered, and baths, even if not in use should be monitored at safe temperatures or adjusted so they cannot be turned on. Residents should have access to call bells while in the lounge. The Environmental Health Department have made requirements following an inspection. The inspector was told that some action has been taken and work is still ongoing. Wedges to keep doors open are widely used throughout the home Mr Jagannath is reminded of the safety implications of this and to ensure risk assessments are in place and regularly updated. Residents should be allowed to rise when they wish within reason and not be woken, washed and dressed very early in the morning unless it is through choice. 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. Name H60 H11 S24169 Ladymead V230071 130705 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Name H60 H11 S24169 Ladymead V230071 130705 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5 The home has a pre assessment and assessment process and relatives and their representatives are able to visit to ensure the home will be able to meet their needs. All of the residents have a contract. EVIDENCE: Mr Jagannath told the Inspector that The Statement of Purpose and Service User Guide for the home is still relevant and no changes have been needed. These documents do give potential residents and their relatives a clear picture of what the home offers. Evidence from the case tracking exercise indicated that residents are assessed before admission to the home. A more comprehensive assessment is carried out once admitted and a care plan and any risk assessments formulated. Name H60 H11 S24169 Ladymead V230071 130705 Stage 4.doc Version 1.30 Page 10 One visitor whose mother had recently been admitted to the home said that they had received all of the relevant information they needed and were invited to visit before making a decision. Name H60 H11 S24169 Ladymead V230071 130705 Stage 4.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,10. Residents are cared for at Ladymead to a good standard and are respected and treated kindly by the staff. EVIDENCE: Care plans and risk assessments contain information staff need to care for the residents. Daily records of care given are kept to ensure all needs are met on a daily basis. Plans are regularly updated and show the changing needs of residents. Monitoring records are maintained and handovers take place between shifts to enable staff to be updated. Visits by Doctors and other professionals are recorded with outcomes where necessary. The staff were noted to speak to residents in a caring and sensitive manner. Name H60 H11 S24169 Ladymead V230071 130705 Stage 4.doc Version 1.30 Page 12 The Inspector was told by a small number of residents that they were woken early and it was not through choice. Mr Jagannath said he was unaware of this and that he would ensure that no residents were woken until a reasonable time unless through choice. Name H60 H11 S24169 Ladymead V230071 130705 Stage 4.doc Version 1.30 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15. The home provides a lifestyle that respects the privacy and dignity of residents. The home operates an open door policy for family and friends if the residents choose. Meals served are varied, nutritious and well balanced. Not all residents have control over their lives. EVIDENCE: A number of residents do choose to stay in their rooms for the majority of the time. Others use the lounge or a smaller conservatory. Staff undertake some activities with residents on a regular basis in the home and entertainers are also bought into the home. Surveys forms indicated that residents were happy with the activities on offer. A copy of the menus was given to the Inspector and these indicated that meals served at the home were well balanced and nutritious. Name H60 H11 S24169 Ladymead V230071 130705 Stage 4.doc Version 1.30 Page 14 Residents who could offer an opinion were complimentary about the food served. Staff were noted to help residents who needed feeding in a sensitive and appropriate manner. Not all staff that work in the kitchen had the appropriate training required. Mr Jagannath was advised to address this immediately. Some residents were woken and got up early in the morning and it was not through choice. Name H60 H11 S24169 Ladymead V230071 130705 Stage 4.doc Version 1.30 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18. The clear complaint procedure enables those using the service or their representatives to have confidence that their complaint will be responded to within 28 days. The home operates the West Sussex Adult Protection Guidelines, however the majority but not all staff are trained to recognise and report adult abuse. EVIDENCE: There is a clear complaint procedure available in the home. Residents and visitors said they would know who to complain to if necessary. The Commission has received one complaint since the last inspection. Concerns stated by the complainant were looked into during the inspection and found to be partially substantiated. Some of the staff have not yet had training in Adult Protection and Mr Jagannath was advised to address this as a matter of urgency. Name H60 H11 S24169 Ladymead V230071 130705 Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25,26. Residents live in a well-maintained, clean and comfortable environment with aids and equipment are available to meet identified needs. Gardens laid to lawn are available for residents to use. EVIDENCE: The home is clean and fresh with no unpleasant odours detected during the visit. All internal areas are well decorated and furnished in a homely fashion. Some exterior work is needed to paintwork. Bedrooms are comfortable and meet the needs of the residents. Residents and their relatives have been encouraged to personalise their rooms to make them more homely. Name H60 H11 S24169 Ladymead V230071 130705 Stage 4.doc Version 1.30 Page 17 Call bells are available in the majority of areas for residents to summon staff if needed. Call bells were not available in the lounge; Mr Ball told the Inspector that this would be addressed. Safety checks on equipment and for health and safety purposes were recorded at regular intervals and the majority of risk assessments are carried out. There is a pleasant garden overlooking the downs accessed through a conservatory which could be used by residents if they wished. The patio to the rear of the home is uneven, however a notice was displayed identifying it as a trip hazard and the Inspector was informed that residents do not go out unattended. Following a recent inspection by The Environmental Health Department requirements were made and these are in the process of being addressed. One bath when tested had a hot water temperature above those recommended by Health and Safety Executive. The Inspector was aware that this bath is not in use however Mr Jagannath was advised to make this safe. Name H60 H11 S24169 Ladymead V230071 130705 Stage 4.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30. There is sufficient staff to meet the needs of residents and the majority of staff have the training related to residents needs and health and safety requirements. A number of staff still did not have the correct Criminal Record Bureau disclosures in their files. EVIDENCE: Duty rotas are available and these indicated that staff are employed with the appropriate skill mix to meet the needs of residents over the 24-hour period. Residents said that staff are attentive and do come as promptly as possible when called. Care staff are also encouraged to achieve a National Vocational Qualification while working at the home. A number of staff did not have the correct up to date training in food handling hygiene, infection control and adult protection. Name H60 H11 S24169 Ladymead V230071 130705 Stage 4.doc Version 1.30 Page 19 One member of staff was seen not following safe infection control procedures and Mr Jagannath was informed of this during the inspection. A number of staff did not have the correct CRB disclosures in their files Mr Jagannath was told that this and the training needs needed to be addressed. Name H60 H11 S24169 Ladymead V230071 130705 Stage 4.doc Version 1.30 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36,37,38. The home is well managed and is run in the best interests of the residents. The majority of the environmental, health and safety risks to the residents are protected by the practices of the home. EVIDENCE: Mr Jagannath is at present undertaking The Registered Managers Award. Senior Nurses assist Mr Jagannath in the running of the home. Mr Ball sends Regulation 26 reports to the Commission about the conduct of the home. Name H60 H11 S24169 Ladymead V230071 130705 Stage 4.doc Version 1.30 Page 21 Staff appraisals are being carried out and formal staff supervision is soon to be in operation. Wedges to keep doors open are widely used throughout the home Mr Jagannath is reminded of the safety implications of this. The Inspector concluded that generally the home is being run by a good management and staff team in the best interest of the residents. Name H60 H11 S24169 Ladymead V230071 130705 Stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION 2 2 3 3 3 2 2 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 3 3 x x 2 2 2 Name H60 H11 S24169 Ladymead V230071 130705 Stage 4.doc Version 1.30 Page 23 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 18 Regulation 13 (6) Timescale for action The registered person shall make 31/8/05 arrangements by training staff to prevent service users being harmed or suffering abuse or being placed at risk of harm and abuse. Ensure that persons employed to 31/8/05 work at the care home have training appropriate to the work they are to perform. Ensure the premises meet with 31/8/05 the requirements of The Environmental Health Department. CSCI to be informed when compliance will be complete by Unnecessary risks to the health 31/8/05 and welfare of service users are identified and so far as possible elimintated. Re Baths Temperatures and radiators. CSCI to be informed of action taken by. Requirement 2. 30 18(1 c ) 3. 19 16 4. 25 13( c ) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Name H60 H11 S24169 Ladymead V230071 130705 Stage 4.doc Version 1.30 Page 24 No. 1. 2. Refer to Standard 38 22 Good Practice Recommendations The provision of a safe method, advised by the fire service for residents to keep their doors open so they are not at risk from fire. Residents should have access to call bells in all parts of the home. Name H60 H11 S24169 Ladymead V230071 130705 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection 2nd Floor, Ridgeworth House Liverpool Gardens Worthing, West Sussex BN11 1RY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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