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Inspection on 03/07/06 for Ladymead Nursing Home

Also see our care home review for Ladymead Nursing Home for more information

This inspection was carried out on 3rd July 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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

What the care home does well

The home provides a clean, comfortable and homely environment with a positive atmosphere. Staff morale is good and staff were noted to be happy going about their work. They were caring, friendly but respectful to residents. Under Mr Jagannath`s leadership and support the staff provide a good standard of care and staff strive very hard to meet the needs of the residents in a caring, professional and friendly manner. Staff have the training they need to meet needs of residents and the requirements of the legislation. Residents were complimentary about the staff and the way they care for them. Residents said that the staff were always there to help them.

What has improved since the last inspection?

The organisation of staff training has improved so now it clearer to see which staff need specific training. Records related to training, recruitment and the general management of the home have improved. The kitchen has been refurbished to a good standard and some internal decoration has been undertaken. The staff have stopped using wedges to hold doors open which was a fire safety risk. Some room doors but not all have now been fitted with DOR guards that will close automatically in the event of a fire. Activities are now arranged on a daily basis. Staff appraisal and supervision sessions have just started at the home. Mr Jagannath told the Inspector that the requirements of the Health and Safety Executive and the Environmental Health Department made since CSCI last inspection have been completed.

What the care home could do better:

The patio to the rear of the property remains unsafe due to the uneven surface and residents are not able to wander out on their own. However the Inspector is aware that there is a proposal for extending the home in the near future and so the patio will be made safe following this. The new professional development records should be tailored to staff roles and expectations rather than a general one for all, also the initial induction sheet for new staff must include a record that the protection of vulnerable adults is discussed. One room where the resident`s privacy could be compromised by the large windows onto the patio would benefit from roller blinds; these would also give residents the ability to have some shade from the sun. There are curtains, but the resident said the addition of blinds would be useful. A small number of radiators still need covering before the heating is turned on for the winter and one window needs restricting to ensure risks to residents are minimised A number of resident`s room doors do not shut completely and would not stop the spread of fire. There is no general risk assessment for the home. A full and robust quality assurance system is not yet in place.

CARE HOMES FOR OLDER PEOPLE Ladymead Nursing Home Albourne Road Hurstpierpoint Haywards Heath West Sussex BN6 9ES Lead Inspector Mrs A Peace Key Unannounced Inspection 3rd July 2006 09:30 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 Ladymead Nursing Home DS0000024169.V301444.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. Ladymead Nursing Home DS0000024169.V301444.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ladymead Nursing Home Address Albourne Road Hurstpierpoint Haywards Heath West Sussex BN6 9ES 01273 834873 01273 834745 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) Mr Warren Ball Mr Philip Hale Mr Motilall Jagannath Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Ladymead Nursing Home DS0000024169.V301444.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th November 2005 Brief Description of the Service: Ladymead is a care home registered to provide nursing care for 27 older people. The home is situated in the village of Hurstpierpoint close to village amenities. Mr W Ball and Mr P Hale own the service. Ladymead is a three storey large detached house, a conservatory has been added which has provided additional communal space. 17 single and 5-shared bedrooms are available for residents on the ground and first floor. A passenger lift is available to access those rooms on the first floor. Large gardens, which overlook the South Downs, are to the rear and side of the home. There are plans to extend the premises in the near future. Ladymead Nursing Home DS0000024169.V301444.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Mrs Ann Peace carried out this unannounced fieldwork inspection on 3rd July 2006. This is the first inspection for the year 2006-2007. It is called a key inspection and will determine the frequency of visits/inspections hereafter. Before this fieldwork visit records held on file and information received from the home since the last inspection were reviewed. CSCI received satisfaction survey forms from residents and their relatives. They were all generally complimentary. Mr Jagannath the Registered Manager for the home was present for the inspection. A general tour of the home was undertaken and the majority of rooms visited, there was a nice homely atmosphere and staff were friendly and helpful during the visit. Residents looked comfortable and happy. A case tracking exercise from records of admission to care given was carried out for a number of residents. Staff records and relevant records relating to the administration and management of the home were examined. The records seen were maintained in a satisfactory manner. The majority of the residents were spoken to and six residents at length. All of the residents spoken with were happy with the care they receive, comments included “ staff are very kind and look after us extremely well,” “I can get up when I want”, “staff make time to come and talk to me,” very happy to be at the home and appreciate all the care the staff give to me they are very kind and caring”. Staff said they enjoyed working at the home; they were trained for the jobs they have to do and had support from senior staff. The inspector sampled the midday meal and spoke to residents said they enjoyed it. The Inspector concluded that a good standard of care is given at Ladymead by a caring and professional staff team. No immediate requirements were made so a feedback form was not left at the home following the fieldwork. Any issues identified, which needed action, were discussed with Mr Jagannath at the conclusion of the visit. Ladymead Nursing Home DS0000024169.V301444.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The organisation of staff training has improved so now it clearer to see which staff need specific training. Records related to training, recruitment and the general management of the home have improved. The kitchen has been refurbished to a good standard and some internal decoration has been undertaken. The staff have stopped using wedges to hold doors open which was a fire safety risk. Some room doors but not all have now been fitted with DOR guards that will close automatically in the event of a fire. Activities are now arranged on a daily basis. Staff appraisal and supervision sessions have just started at the home. Mr Jagannath told the Inspector that the requirements of the Health and Safety Executive and the Environmental Health Department made since CSCI last inspection have been completed. Ladymead Nursing Home DS0000024169.V301444.R01.S.doc Version 5.2 Page 7 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. Ladymead Nursing Home DS0000024169.V301444.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 Ladymead Nursing Home DS0000024169.V301444.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service have good information about the home in order to make an informed decision about whether the service is right for them. All residents have a personalised needs assessment to ensure their needs can be identified and met, and contracts are given. Prospective residents and their relatives can visit the home. Intermediate care is not offered at Ladymead. EVIDENCE: Case tracking confirmed good practice, the manager visits all prospective residents to ensure home will meet identified needs. Two service users did say they had been given enough information to enable them to make a decision whether to move into the home. Other residents were too frail to tell inspector. Written documentation was adequate and included a copy of the care management assessments where appropriate. The free nursing care assessments were also in the files. Ladymead Nursing Home DS0000024169.V301444.R01.S.doc Version 5.2 Page 10 Basic information was available to staff to ensure they could meet the needs of the residents admitted. All residents have a written contract and terms and conditions of residence. The current fees were included; this means that residents and their advocates have the information they need about the service they will receive and how much it will cost them. Five resident’s records were case tracked from pre assessments, assessments, care plans, risk assessments, visits by other professionals, medication, provision of equipment and room facilities. All rooms were visited and all had the appropriate equipment related to their risk assessments and needs. Where possible these residents were spoken to. Ladymead Nursing Home DS0000024169.V301444.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11. The quality in this outcome area is very good. This judgement has been made using available evidence including a visit to this service. Residents have up to date assessments, care plans and risk assessments, which identify individual needs and instruct staff how to meet their needs. Privacy and dignity are respected in the home. The inspector concluded that residents and their families would be treated with care, sensitivity and respect at times of death. The medication administration procedures in the home are safe. EVIDENCE: The residents all had up to date individualised care plans, full assessments, basic social history, risk assessments related to their problems and night care plans. Visit and feedback from other health professionals were recorded. Medication records were seen and were in order, medication for these 5 residents were checked and the controlled drugs for one resident were checked and were in order. A record of the dates for medicine reviews by the GP were recorded. Ladymead Nursing Home DS0000024169.V301444.R01.S.doc Version 5.2 Page 12 The Statement of Purpose for the home says medicines must be handed in when residents are admitted to the home, this was discussed with Mr Jagannath and the Inspector told him he should recognise choice if residents have the capacity to self administer their own medication. Adequate arrangements are in place for the disposal of medicines. Residents were spoken to and all were complimentary about the staff and the care they give. One lady said, “they could not be looked after any better”, a man said, “the staff were kind and caring”. Another lady said, “she was very well cared for and that staff were very approachable and kind”. Generally residents said they did not know what was in their care plans but did not want to know. Residents spoken to felt their privacy was respected and that staff were sensitive when they did need help, they also said staff did answer bells promptly the majority of the time. Many residents were too frail to give an opinion but they looked clean and well cared for. It was a very hot day and portable fans were on in resident’s rooms. One resident who has diverse needs said she was respected and staff did ensure that they carried out her wishes which the inspector confirmed were in the care plan. Through looking at complimentary letters from relatives of residents who have died, by observing the state of poorly residents being nursed in bed and by speaking to staff and residents the inspector concluded that residents and their families would be treated with care, sensitivity and respect at times of death. Ladymead Nursing Home DS0000024169.V301444.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A limited range of activities are available within the home but these did not reflect or track to the basic lifestyle assessments that were recorded and need to be further expanded. Residents do not have access to safe outdoor facilities. Meals are served in a pleasant setting with staff helping frail residents appropriately; residents said they were generally happy with the meals served. EVIDENCE: Due to an administrative error by CSCI survey forms were not available before inspection but some have since been received and have been included in the report. In the hallway of the home previous CSCI survey forms were available for anyone to take and complete. Photographs of the staff are on the wall although these do need updating as new staff have been employed. There was an activities program on the notice board which said activity sessions are arranged every afternoon, singing, music movement, lotto, quiz and news sessions. Ladymead Nursing Home DS0000024169.V301444.R01.S.doc Version 5.2 Page 14 Although this is an improvement, life histories and social care plans could not be tracked to individual social care needs and must be developed to evidence that residents are being offered activities that they like. One resident who does have particular religious needs did tell the inspector that the staff was meeting these. Residents are able to stay in their rooms during the day if they wish, other use the main lounge which has a television and music system, there is a pleasant conservatory available which was being used by two residents on the morning of the inspection. The rear and side of the home have beautiful views over The South Downs which some residents can see from their windows and the conservatory. There is a rear patio with garden furniture available but this is very uneven and residents would not be able to wander out on their own. This had been identified at a risk at previous inspections, a risk assessment was carried out and safety signs put out but due to proposed planned building work no further action has been taken. A number of residents did say that they would have liked to have gone outside but that staff had difficulty wheeling chairs over the uneven patio. One resident has her own little patio garden outside her room which had lots of flowering plants in pots which she tends with the help of her daughter. Since the last inspection the kitchen has been refurbished to a good standard. The part time chef said there was plenty of food and an inspection of the stores confirmed this. The food on the day of the inspection was Spaghetti bolognaise, minced beef or omelette, followed by strawberries and cream, melon or a milky pudding. The chef had a general overview of what residents likes and dislikes but was not aware of individual nutritional needs. The was discussed with Mr Jagannath, and he was advised to find a way of communicating to the chefs to outcome of resident’s nutritional assessments to ensure they all are aware of residents nutritional needs. The home has a comfortable dining room with homely furnishings which was nicely set for lunch. The menu was on the board to inform residents. A number of residents take their meals in their room through choice. Residents looked as if they did enjoy the meal and when spoken with the majority said that generally they were happy with the food. One comment card was negative about the food served and this will be followed up with the manager. The majority of residents wear full bibs at mealtimes and this has been ongoing habit for a long time in the home, this should be reviewed, perhaps through a survey or at the next residents meeting to ensure that dignity is Ladymead Nursing Home DS0000024169.V301444.R01.S.doc Version 5.2 Page 15 promoted by only using full bibs where absolutely necessary and this is what the residents want. Various clergy visit the home to visit residents who wish to fulfil their spiritual needs. Ladymead Nursing Home DS0000024169.V301444.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users feel safe and listened to, their legal rights are protected and staff are trained to protect vulnerable adults. EVIDENCE: The complaints procedure is displayed in the hallway of the home and is available to all residents, staff and visitors. Residents said they felt safe and listened to and are able to speak to staff and the manager if they were not happy. One anonymous complaint was received by CSCI which said that there was not enough staff working at the home at weekends. CSCI asked the providers to investigate; the result of their investigation was the complaint was not substantiated. Following this, Mr Jagannath discussed the complaint at the residents meeting and explained to residents that if they ring their bell staff would come as soon as possible. No further complaint has been received by CSCI. Residents confirmed that they can vote in elections and did not feel in any way their legal rights were impinged. Staff spoken to had basic knowledge of the action to be taken if abuse was suspected. The records of new staff confirmed that they are instructed in Adult protection procedures. Ladymead Nursing Home DS0000024169.V301444.R01.S.doc Version 5.2 Page 17 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 the following standard(s): 19,20,21,23,24,25,26 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service Residents live in a safe, homely, clean and comfortable internal environment and there are sufficient facilities and equipment to meet their needs. Residents would not be able to access safe outside space independently, and the patio area is not safe for staff or visitors. EVIDENCE: The home was clean and had a warm and welcoming atmosphere. Lots of flowering pots of plants were around the entrance which made the home look inviting and the entrance hall clean and bright. The majority of rooms were visited and all were clean, well furnished and have been personalised by residents with small items of furniture, ornaments and photographs. Communal areas were clean well furnished and homely. Ladymead Nursing Home DS0000024169.V301444.R01.S.doc Version 5.2 Page 18 The rooms of those residents case tracked showed individuals had been able to personalise their rooms and they were clean and well presented and had the equipment indicated from their risk assessments. Residents generally said they thought their rooms were comfortable. The Inspector was on the patio and could clearly see into a large double room which faced onto the patio and gardens, the room has large windows and it was very hot. When the Inspector spoke to the resident they said although there were curtains they would like some blinds for shade and privacy but they had not thought to ask. This was discussed with Mr Jagannath who said it would not be a problem to provide roller blinds. Since the last inspection ten bedrooms doors have been fitted with DOR guards which automatically close in the event of a fire. These were for residents who wished to have their doors open all of the time. On the day of the visit residents in their rooms had been given portable electric fans to try and make them more comfortable. Records to indicate safety checks are carried out on equipment and testing of water temperatures were up to date and COSHH items were stored safely. All residents have access to call bells whether in their rooms or in communal areas. Residents have sufficient lavatories and bathrooms although they are dated. One toilet on the first floor is at an odd angle and residents would have difficulty using it, however there is another close by. The sluices and the laundry were clean and tidy. Aids and equipment are provided and are in satisfactory quality. Since the last inspection both the Health and Safety Executive and the Environmental Health Department have inspected the home and both make requirements for action. Mr Jagannath stated that these requirements have now been met. Ladymead Nursing Home DS0000024169.V301444.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service There are sufficient staff employed to ensure that resident’s needs are met. The home has a sound recruitment policy and appropriate checks are made. Staff training is provided and staff are competent to do their jobs. EVIDENCE: On arrival the door was promptly opened by a member of staff and the Inspector was greeted in a friendly manner. The duty rota recorded that 2 nursing staff were on duty plus 4 care assistants in the morning, 1 nurse and 3 carers in the afternoon and 1 nurse and 3 carers at night. There was a cook, housekeeper, cleaner, kitchen assistant and maintenance man on duty on the day of the inspection. The staff records of the 6 new staff were inspected and the inspector was able to speak to 2 of them. The recruitment records have improved and all those seen complied with legislation. Ladymead Nursing Home DS0000024169.V301444.R01.S.doc Version 5.2 Page 20 The training records have improved and are easier to read. All new staff had received a basic induction and the Mr Jagannath said that the more in depth induction booklet was being reviewed. During random examination of other records one member of staff was out of date with fire safety training Mr Jagannath said this would be attended to. Staff now have training and development records and although these were in order Mr Jagannath was advised to tailor the training and development plan to individual staff and their job descriptions. Staff were due to attend food handing hygiene course the day after this visit. Other mandatory training such as fire safety, manual handling, food hygiene, first aid, COSHH, abuse and health and safety is being carried out on a regular basis and records were available. The inspector discussed with Mr Jagannath the need for the handyman to attend a health and safety course. All of the residents spoken with were full of praise for the Manager and the staff team. Five staff were spoken to including two new members of staff, they all said they were happy at the home and felt well supported. All confirmed training and the new members of staff stated their induction had been appropriate. Mr Jagannath said 47 of staff now have NVQ. Ladymead Nursing Home DS0000024169.V301444.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37,38. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed by a well-qualified, caring and competent manager and is run in the best interests of residents. Resident’s financial interests are safeguarded and in the majority of cases the health and safety of residents are promoted and protected. The views of residents, their families and friends are not sought formally although through various means some views are recorded. The company have yet to measure by a full survey how successful the home is at meeting its aims and objectives and the statement of purpose of the home. EVIDENCE: Ladymead Nursing Home DS0000024169.V301444.R01.S.doc Version 5.2 Page 22 Mr Jagannath is presently undertaking the Registered Managers Award but is aware that under Standard 31 that although he is a Registered Nurse the qualification should have been achieved by 2005 so understands the reason why this standard will not be met. Mr Jagannath was present for inspection, he and all of the staff were open, friendly and helpful. The Inspector could see that there were clear lines of accountability in the home and that residents and staff benefit from Mr Jagannaths leadership. Mr W Ball one of the Providers carries out regular Regulation 26 visits to the home and sends CSCI a copy of his reports which are detailed and inform CSCI of the conduct of the care home. The notice board in the hallway of the home had a copy of the residents meeting minutes for all to see also minutes of a staff meeting. Mr Jagannath has started some audits within the home and the Inspector saw evidence of this, but the system does need to be expanded to cover all aspects of the home in order to meet the standard. CSCI survey forms were available in the hallway of the home, unfortunately the surveys for this inspection did not reach the home in time for any to be completed before the inspection. Appropriate policies and procedures were available and Insurance cover is available in the home and was displayed on the wall in the hall. Residents are encouraged to manage their own affairs with the help of relatives or advocates if necessary. A staff supervision and appraisal system has started but not all staff have been seen formally. From reviewing records, speaking to residents and staff the Inspector concluded that service users rights and best interests were safeguarded by the home’s record keeping. Staff training records are available to indicate that staff have received training in appropriate health and safety procedures and that further training is been planned throughout the year. The Inspector noted that a sash window on the stairs of the home was open to its full width; although residents do not usually access this area it is still a risk. Mr Jagannath was advised to take action to maintain safety of the residents. The fire safety systems had been tested in accordance with the fire service recommendations and the fire escape was clear. There is no general risk assessment for the home although various ones were available, e.g. radiators, kitchen and patio. Mr Jagannath was advised to complete one. Mr Jagannath told the Inspector that a fire safety risk assessment was due to be carried out in September 2006. Ladymead Nursing Home DS0000024169.V301444.R01.S.doc Version 5.2 Page 23 Mr Jagannath was advised to go around the home following the visit and check that all of the doors shut properly to ensure residents would be safe as possible if a fire were to occur. There was a previous requirement to cover radiators and all but 3 have now been done Mr Jagannath said the rest would be done before the heating was turned on again. Ladymead Nursing Home DS0000024169.V301444.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A 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 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 3 3 2 3 2 Ladymead Nursing Home DS0000024169.V301444.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? yes 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 OP26 Regulation 13 Requirement Pipe work and radiators should be guarded or have guaranteed low temperature surfaces. CSCI to be informed when this will be complete by Make adequate arrangements for containing fires. CSCI to be informed of action taken by Unnecessary risks to the health and safety of service users are identified and so far as possible eliminated. (Window Restrictors) CSCI to be informed of action taken by A quality assurance system must be implemented. CSCI to be informed of action that will be taken by Timescale for action 07/08/06 2 OP38 23 07/08/06 3. OP38 13 07/08/06 4. OP33 24 07/08/06 Ladymead Nursing Home DS0000024169.V301444.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 OP30 Refer to Standard OP15 Good Practice Recommendations The chefs should be regularly updated on the nutritional status of residents to enable them to meet any identified or changing needs. Staff professional development profiles should reflect their roles and any specialised training needs related to their work. Ladymead Nursing Home DS0000024169.V301444.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Worthing LO 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. Extracts may not be used or reproduced without the express permission of CSCI Ladymead Nursing Home DS0000024169.V301444.R01.S.doc Version 5.2 Page 28 - 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!