Inspection on 16/11/05 for Ladyville Lodge Nursing Home

This inspection was carried out on 16th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ladyville Lodge Nursing Home 24/09/07

Ladyville Lodge Nursing Home 29/09/06

Ladyville Lodge Nursing Home 23/09/05

Ladyville Lodge Nursing Home 21/03/05

Ladyville Lodge Nursing Home 02/02/05

Ladyville Lodge Nursing Home 27/01/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Ladyville Lodge Nursing Home Fen Lane North Ockendon Upminster Essex RM4 3PR Lead Inspector Harbinder Ghir Unannounced Inspection 16th November 2005 02:15 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 DS0000015597.V268641.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. DS0000015597.V268641.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ladyville Lodge Nursing Home Address Fen Lane North Ockendon Upminster Essex RM4 3PR 01708 855 982 01708 854 899 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) Ashbourne Homes Ltd Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (26) of places DS0000015597.V268641.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 26 BEDS FOR ELDERLY INFIRM 18 BEDS FOR RESIDENTIAL CARE MINIMUM STAFFING NOTICE Date of last inspection 23rd September 2005 Brief Description of the Service: Ladyville Lodge is a 44- place care home for older people. Twenty-eight of the beds are registered for nursing care and 18 for residential. The home has been taken over by Southern Cross Healthcare Limited, which was previously owned and run by Ashbourne Homes Limited. The home consists of a large, two storey house, with a large purpose built annex, set in spacious grounds. All bedrooms are spacious, airy and bright. They all have hand basins, TV points and a call system. There is a passenger lift in place. There are two lounges and a dining room overlooking the garden with disabled access. There are car-parking facilities to the front of the property for staff and visitors. The home is situated in a rural part of Upminister and is not convenient to access by public transport. It is close to the M25, A127 and the A12 and easily accessible by car. DS0000015597.V268641.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Harbinder Ghir, Regulatory Inspector, undertook this unannounced inspection on the 16th November 2005 and was at the premises from 2.15am to 4.25pm. The visit included talking with residents and staff. Some judgements about quality of life within the home were taken from direct conversation with staff and observation. In addition a tour of the premises was undertaken and some records were looked at. 8 Requirements were made at the time of the last inspection, and 3 Requirements have been met. For the remaining 5 Requirements the home has time to meet the timescales set and therefore have been re-stated at this inspection. 3 further Requirements have been identified as part of this inspection process. This was the second statutory inspection for 2005/6, and across the two visits all core standards have been assessed. What the service does well: Ladyville Lodge provides a comfortable and welcoming environment for its residents. It is well decorated, furnished and is clean bright and airy. Residents are protected by clear and comprehensive arrangements for the administration of medication. There are adequate numbers of staff on duty per shift. Residents’ benefit from an experienced manager who recognises their needs. The manager has a clear vision for the home, which she has effectively communicated to residents, relatives and staff. Systems are in place to protect residents’ financial interests. The welfare of staff and service users are promoted by the homes policies and procedures at all times. DS0000015597.V268641.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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. DS0000015597.V268641.R01.S.doc Version 5.0 Page 7 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 DS0000015597.V268641.R01.S.doc Version 5.0 Page 8 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. The homes Statement of Purpose and Service User Guide are good but need to be updated to be in compliance with the Care Homes Regulations Act 2001. Standards 2,3,4,5 were not tested on this visit. However evidence from the last inspection was that; The statement of terms and conditions are comprehensive, informing residents of the services that they are entitled to receive when moving into the home. Trial visits are offered and pre -admission assessments are completed prior to admission to ensure identified needs can be met by the home. EVIDENCE: The Statement of Purpose and Service User Guide were seen, which were presented as two separate documents. The Statement of Purpose needs to be updated to include the age-range and sex of the service users for whom it is intended that accommodation should be provided, the criteria used for admission to the care home, including the care home’s policy and procedure (if DS0000015597.V268641.R01.S.doc Version 5.0 Page 9 any) for emergency admissions, and the size of rooms in the care home. The Service User Guide needs to be updated to include the relevant qualifications of the registered provider, manager and staff working at the home. The complaints procedure within both documents needs to be amended to specify that the Commission for Social Care Inspection can be contacted at any time or stage of anyone making a complaint as required by the regulations. This is Requirement 1. Copies of the document are given to all residents prior to admission and are readily accessible via the manager. Standards 2, 3, 4, 5 were not specifically tested on this visit, as there were no outstanding requirements in relation to the standards. At the time of the last inspection, all of the outcome standards were assessed as met. These standards will be re-tested at a future inspection. DS0000015597.V268641.R01.S.doc Version 5.0 Page 10 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): 9 Residents are protected by clear and comprehensive arrangements for the administration of medication. Standards 7, 8, 10, 11 were not tested on this visit. However evidence from the last inspection was that: The care planning system is clear and consistent to provide staff with the information they need to meet residents’ needs. Residents’ privacy, dignity and independence is promoted, but ways to promote privacy whilst attending to personal care needs, needs to be revisited by the home. Residents’ wishes in the event of death were established in care plans. However, a policy and procedure for handling dying and death is not in place at the home. EVIDENCE: DS0000015597.V268641.R01.S.doc Version 5.0 Page 11 Medication is managed well by the home. Residents at the home are encouraged to exercise control over their administration of medication where residents are able to self-administer. Risk assessments are completed by the home and residents are provided with a personal lockable drawer in their rooms and are protected by the home’s policies and procedures for the selfadministration of medication. Standards 7, 8, 10, 11 were not specifically tested on this visit. The home has time to reach the timescale of 23/12/05 for the outstanding requirements in relation to standards 10 and 11 set at the last inspection and will be tested at the next inspection. At the time of the last inspection, all of the outcomes for standards 7 and 8 were assessed as met. These standards will be re-tested at a future inspection. DS0000015597.V268641.R01.S.doc Version 5.0 Page 12 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): 15 The meals in the home are nutritious offering variety and catering for special diets, which is reflected through the homes daily menu. Standards 12, 13, 14, 15 were not tested on this visit. However evidence from the last inspection was that: Social activities are organised daily within the home and community contact is promoted. Residents’ needs are promoted and they are encouraged to exercise rights and choices. EVIDENCE: A requirement was made at the last inspection report that cultural dietary needs must be catered for as agreed on admission in consultation with the resident admitted. Meal choices and alternatives must be communicated to them appropriate to their communication needs and their language. This requirement has been met at this inspection before the timescale of action date. The home has devised a menu in pictorial formats for those residents who are unable to speak English. Two more members of staff have been DS0000015597.V268641.R01.S.doc Version 5.0 Page 13 employed by the home who are Punjabi speaking and can communicate with residents whose first language is Punjabi. Standards 12, 13, 14, were not specifically tested on this visit, as there were no outstanding requirements in relation to the standards. At the time of the last inspection, all of the outcome standards were assessed as met. These standards will be re-tested at a future inspection. DS0000015597.V268641.R01.S.doc Version 5.0 Page 14 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 The home has a clear complaints procedure and residents and relatives are aware of how to complain and feel that their views are listened to and acted upon. Standard 18 was not tested on this visit. However evidence from the last inspection was that: Policies, procedures and staff training were provided that protected residents from abuse. EVIDENCE: A requirement was made at the last inspection report that the complaints procedure must be up dated to include the address and details of The Commission for Social Care Inspection. This requirement has been met at this inspection before the timescale of action date. Standard 18 was not specifically tested on this visit, as there were no outstanding requirements in relation to the standard. At the time of the last inspection, all of the outcome standards were assessed as met. These standards will be re-tested at a future inspection. DS0000015597.V268641.R01.S.doc Version 5.0 Page 15 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): 21, 22, 26 Standards 19, 20, 23, 24, 25, 26 were not tested on this visit. However evidence from the last inspection was that; The standard of the environment within the home was very good, providing residents with an attractive and homely to live. Residents were put at risk due to health and safety not being adhered to. EVIDENCE: A requirement was made at the last inspection report that all bathrooms and toilets rooms must include an emergency call system and that suitable provision is made for storage for the purpose of the care home and all bathrooms and toilets are kept free of any stored equipment. These requirements have been met at this inspection before the timescale of action date. DS0000015597.V268641.R01.S.doc Version 5.0 Page 16 Bathrooms within the home put residents at significant risk. During a tour of the premises communal toiletries were left out in the main bathroom on the ground floor, which included a shaving razor, which would put residents who are confused or have been diagnosed with dementia at risk. Rubbish was not adequately disposed of as an empty can of a soft drink was left lying on the floor and could be a potential tripping hazard. This presents great health and safety risks to residents living at the home. The manager must ensure health and safety risks are minimised by ensuring bathrooms and toilets are kept free of all hazardous products and are free from communal toiletries and cleaning liquids. This is Requirement is repeated from the last inspection as Requirement 4. Standards 19, 20, 23, 24, 25, 26 were not specifically tested on this visit. The home has time to reach the timescale of 23/12/05 for the outstanding requirement in relation to standards 26 set at the last inspection and will be tested at the next inspection. At the time of the last inspection, all of the outcomes for standards 19, 20, 23, 24, and 25 were assessed as met. These standards will be re-tested at a future inspection. DS0000015597.V268641.R01.S.doc Version 5.0 Page 17 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 There is a good match of qualified staff offering consistency within the home. Standards 28, 29, and 30 were not tested on this visit. However evidence from the last inspection was that; There is a good match of qualified staff offering consistency within the home. Recruitment processes are robust and offer protection to people living at the home. EVIDENCE: The staff duty rota was seen; this showed that staff were working appropriate hours and the home was adequately staffed. 4 to 5 members of staff were on duty for residential care and 2 to 3 carers were on duty for nursing care during the day. At night 3 carers and 1 nurse were on duty, who were all waking staff. During the inspection it was observed that adequate numbers of staff were on duty. Two members of staff spoken were high in morale and referred to putting the needs of the residents first. This was also observed as staff were seen to respect residents and were accessible and approachable. One resident spoken to stated that the staff were very approachable. The home does not have a ratio of 50 and above of NVQ trained staff. This is Requirement 5. Standards 28, 29, and 30 were not specifically tested on this visit, as there were no outstanding requirements in relation to the standards. At the time of DS0000015597.V268641.R01.S.doc Version 5.0 Page 18 the last inspection, all of the outcome standards were assessed as met. These standards will be re-tested at a future inspection. DS0000015597.V268641.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, 35, 36 Residents’ benefit from an experienced manager who recognises their needs and manages the home well. The manager has a clear vision for the home, which she has effectively communicated to residents, relatives and staff. Systems are in place to protect residents’ financial interests. Staff supervision needs to be made a high priority for the home, to ensure staff are kept up to date with developments within the home and their training and developments needs are regularly updated. Standards 33, 37 and 38 30 were not tested on this visit. However evidence from the last inspection was that; The systems for Service User consultation are good with evidence that Service User views are sought and acted on. The security of records needs to be urgently reviewed by the home. DS0000015597.V268641.R01.S.doc Version 5.0 Page 20 The welfare of staff and service users are promoted by the homes policies and procedures at all times. EVIDENCE: The manager has many years experience of working with this service user group and is in the process of completing the Registered Managers Award. The manager of the home has worked at the home for nearly 2 years and has not yet registered with the Commission for Social Care Inspection. The manager must submit an application to the Commission and must register as required by the Care Home Regulations. This is Requirement 6. Staff spoken to at the home stated the home was well run and they were well supported by the manager. Residents were encouraged to manage their own financial affairs or to have assistance from their families and representatives, although the home would hold small quantities of cash for residents if requested. A simplified system of holding and recording residents’ cash by the home was in place. All written transactions and receipts were maintained and kept up to date by the registered person. Staff supervision is not taking place regularly. Staff records seen identified members of staff had not been supervised regularly. The manager informed that she was aware of the lack supervision staff were receiving. It was highlighted that all members of staff must be supervised at least 6 times a year to ensure they are kept updated of any changes within the home and their training development needs are identified. This is Requirement 9. Standards 33, 37 and 39 were not specifically tested on this visit. The home has time to reach the timescale of 23/12/05 for the outstanding requirement in relation to standard 37 set at the last inspection and will be tested at the next inspection. At the time of the last inspection, all of the outcomes for standards 33 and 39 were assessed as met. These standards will be re-tested at a future inspection. DS0000015597.V268641.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 2 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X 3 3 X X X x STAFFING Standard No Score 27 2 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 X X 3 2 X X DS0000015597.V268641.R01.S.doc Version 5.0 Page 22 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 OP1 Regulation 4, 5 Requirement Timescale for action 16/02/05 2 OP10 12(a) The registered person is required to review and update the Statement of Purpose and Service User Guide in compliance with The Care Homes Regulations. The registered person shall make 23/12/05 suitable arrangement to ensure that the care home is conducted in a manner which respects the privacy and dignity of service users at all times. Policies and procedure for handling dying and death are in place and accessible at all times. Re-stated 23/12/05 3 OP11 12 (2) (3) 4 OP26 13 (4) (a) The registered person shall 23/11/05 ensure all parts of the home to service users have access to are so far as reasonably practicable free from hazards to their safety. In that all hazardous liquids are kept in locked cupboards around the home and bathrooms and toilets are kept free of all hazardous products and are free from communal toiletries and DS0000015597.V268641.R01.S.doc Version 5.0 Page 23 cleaning liquids. 5 OP27 28 The registered person to ensure a minimum ratio of 50 NVQ trained staff is achieved by 2005. The manager must submit an application to the Commission and must register as required by the Care Homes Regulations. The registered person shall ensure that persons working at care home are appropriately supervised. In that: staff are supervised at least 6 times a year. Individual records are kept securely in accordance with the Data Protection Act 1998. 16/02/05 6 OP31 8,9,10 16/02/05 7 OP36 18 (2) 16/02/05 8 OP37 17 (1)(3) 23/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP15 Good Practice Recommendations All opened foods are stored in airtight containers. DS0000015597.V268641.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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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