Inspection on 08/11/05 for Ladymead Nursing Home

This inspection was carried out on 8th November 2005.

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

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

Other inspections for this house

Ladymead Nursing Home 13/11/07

Ladymead Nursing Home 03/07/06

Ladymead Nursing Home 13/07/05

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 Mrs A Peace Unannounced Inspection 8th November 2005 08:00 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 Ladymead Nursing Home DS0000024169.V264401.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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.V264401.R01.S.doc Version 5.0 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.V264401.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th July 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 recently been added which has provided additional communal space. 17 single and 5shared 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.V264401.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Mrs Ann Peace Regulatory Inspector carried out this unannounced inspection on Tuesday November 8th 2005. Prior to the inspection all records held on file since the last inspection were reviewed. This inspection was proportional in view of previous inspections at the home being mainly satisfactory. If there are no changes, the report will remain the same as previously stated. During the inspection a tour of the home was carried out and many of the rooms visited. Records relating to the care of residents and the administration of the home were examined. 2 resident’s satisfaction surveys have been received since the last inspection and both stated satisfaction with the home. 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. 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 unsubstantiated. Staff were spoken to during the inspection and all said they enjoyed their work and felt well supported at the home. The conclusion of the Inspector was that a good standard of care continues to be 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, issues identified during the inspection was discussed with Mr Jagannath at the conclusion of the inspection. Ladymead Nursing Home DS0000024169.V264401.R01.S.doc Version 5.0 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Although care records are in place for all residents they are cluttered and untidy with out of date information. Not all have been updated as required and tracking showed some inconsistencies in assessments and evaluations. A suitable activity programme should be provided. The systems for storing some COSHH substances and other products are not safe and should be reviewed. Wedges are still widely used throughout the home despite this being identified as a fire safety hazard at the last inspection. The fire risk assessment for the home did not identify this as a hazard. In view of the proposed government changes to regulation it is important that a robust quality assurance system be implemented at the home and Regulation 26 reports sent to the Commission. Ladymead Nursing Home DS0000024169.V264401.R01.S.doc Version 5.0 Page 7 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.V264401.R01.S.doc Version 5.0 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.V264401.R01.S.doc Version 5.0 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, 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. Ladymead Nursing Home DS0000024169.V264401.R01.S.doc Version 5.0 Page 10 A more comprehensive assessment is carried out once admitted and a care plan and any risk assessments formulated. Ladymead Nursing Home DS0000024169.V264401.R01.S.doc Version 5.0 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. Residents are cared for at Ladymead to a good standard and are respected and treated kindly by the staff. Medication policies and procedures are satisfactory. EVIDENCE: Residents were complimentary about the home and the staff and residents were seen to be treated in a kind and respectful manner by the staff with their privacy being respected. 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. All residents have care plans but social care plans need to be extended to take into account resident’s interests. Ladymead Nursing Home DS0000024169.V264401.R01.S.doc Version 5.0 Page 12 Evidence was available to indicate that residents had access to other health professionals as needed. The medication storage, administration policies and procedures are satisfactory. Unfortunately care records are untidy and cluttered with old information which could confuse staff, especially agency staff. On tracking a number of files the inspector noted some inconsistencies in assessments, reporting and evaluations. This did not appear to affect the care being given by regular staff who know the residents, however records should be re organised into clearer and up to date system. Ladymead Nursing Home DS0000024169.V264401.R01.S.doc Version 5.0 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 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. Social care plans and the activities provided are not satisfactory. 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. A radio, television and books are provided in the communal rooms. Staff do undertake some activities with residents, but on examining the activities book between July and the date of the inspection only the following activities were provided: Ladymead Nursing Home DS0000024169.V264401.R01.S.doc Version 5.0 Page 14 5 fit and active sessions, 4 word game sessions, 2 general non specific sessions, 1 I spy session, 1 singing session, a garden party and 1 session from an outside entertainer, 2 other one to one sessions were held. In all, 17 short activity sessions were held and out of 123 days, this is not satisfactory. The Inspector advised Mr Jagannath to expand social care plans and review the provision and suitability of the activities provided. Care should be taken not to underestimate residents and their abilities. Menus indicated that meals served at the home were well balanced and nutritious. Residents who could offer an opinion were complimentary about the food served. Ladymead Nursing Home DS0000024169.V264401.R01.S.doc Version 5.0 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 the following standard(s): 16,17,18. 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 and staff are trained to recognise and report adult abuse. EVIDENCE: There is a clear complaint procedure available in the home. Residents said they would know who to complain to if necessary. The Commission has received one complaint since the lat inspection relating to inadequate staffing levels. Concerns stated by the complainant were looked into during the inspection and found to be unsubstantiated. Since the last inspection training in adult protection procedures has been provided. Ladymead Nursing Home DS0000024169.V264401.R01.S.doc Version 5.0 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 the following 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. Some procedures in the home do not protect the safety of residents. 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. 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. Ladymead Nursing Home DS0000024169.V264401.R01.S.doc Version 5.0 Page 17 Call bells are available throughout the home for residents to summon staff if needed. 1 call bell is also available in the lounge and three in the conservatory. Safety checks on equipment and for health and safety purposes are 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. A recent inspection by Health and Safety Executive has been carried out and as a result radiators are being covered. The inspector was informed that the requirements of the Environmental Health Department have now been addressed. The system for storing some COSHH items and other products that may be harmful are not satisfactory and must be reviewed. The continual use of wedges to prop doors open and no risk assessment does not safeguard residents. Ladymead Nursing Home DS0000024169.V264401.R01.S.doc Version 5.0 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 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 There is sufficient staff to meet the needs of residents and staff have the training related to residents needs and health and safety requirements. 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 and more training has been provided since the last inspection. Staff appraisals are being carried out and formal staff supervision is soon to be in operation. Staff training that has been provided since the last inspection includes: manual handling, health and safety, food hygiene, protection of vulnerable adults, and fire safety. Ladymead Nursing Home DS0000024169.V264401.R01.S.doc Version 5.0 Page 19 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 home is well managed and in the main 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 and residents said they were satisfied with the way the home is run. Records were available to indicate that safety checks on fire safety equipment and other safety checks are carried out. Ladymead Nursing Home DS0000024169.V264401.R01.S.doc Version 5.0 Page 20 The Inspector concluded that residents are protected by the majority of the home’s policies, procedures and financial arrangements. No Regulation 26 reports on the conduct of the home have been received by the Commission since the last inspection. Wedges to keep doors open are widely used throughout the home Mr Jagannath is reminded of the safety and insurance implications of this. Mr Jagannath was advised to contact the fire service for advice. The latest fire risk assessment was carried out in October 2005 but the use of wedges to prop doors open was not identified as a hazard. Risk assessments for the home should include the use and storage of COSHH items. During the inspection disinfectant was found to be in reach of residents and had been decanted into inadequately labelled containers. The Health and Safety Executive states in the booklet ‘Health and Safety in Care Homes’: “Where health and safety information is contained on the label the contents should not be decanted into smaller containers unless fully labelled in line with the original bottle”. This was discussed with Mr Jagannath during the inspection and some bottles were immediately removed for safety. Ladymead Nursing Home DS0000024169.V264401.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 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 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 2 3 3 3 2 2 3 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 2 3 3 3 2 2 Ladymead Nursing Home DS0000024169.V264401.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 3 Standard OP38 OP36 OP38 Regulation 23 18 13 Requirement Make adequate arrangements for containing fires. CSCI to be informed of action taken by Provide supervision for staff working at the home. Unnecessary risks to the health and safety of service users are identified and so far as possible eliminated. CSCI to be informed of action taken by A quality assurance system must be implemented. Monthly Regulation 26 reports must be sent to the Commission. Timescale for action 30/11/05 31/12/05 30/11/05 4 5 OP33 OP32 24 26 31/12/05 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ladymead Nursing Home DS0000024169.V264401.R01.S.doc Version 5.0 Page 23 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.V264401.R01.S.doc Version 5.0 Page 24 - 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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