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Inspection on 29/09/06 for Ladyville Lodge Nursing Home

Also see our care home review for Ladyville Lodge Nursing Home for more information

This inspection was carried out on 29th September 2006.

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.

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 manager has only recently taken up her post but she has already made some changes to the layout of the furniture within the home and undertaken a thorough medication audit. The home has a very welcoming atmosphere and is clean and tidy. Residents and relatives commented that staff are very welcoming, approachable and helpful. Nursing staff are responsive to people`s concerns and the manager has an `open door policy`. Staffing levels are appropriate and residents commented that there were not rushed. Residents` dietary needs are more than adequately met, with a varied menu and a chef that caters to peoples` individual choices and needs. An activities co-ordinator is employed and has been working at the home for a number of years, residents spoke fondly of her and it was noted in residents` records that she spends time talking to residents on a 1:1 basis.

What has improved since the last inspection?

Five of the previous requirements and the one recommendation have been met. The Statement of Purpose has been reviewed and updated. Policies and procedure for handling death and dying are in place and accessible. All parts of the home free from hazards a far as reasonably practicable. In that all hazardous liquids are kept in locked cupboards. Individual records are kept securely in accordance with the Data Protection Act 1998. Staff are mindful to promote the dignity of residents at all times.

What the care home could do better:

All medication charts must be completed appropriately and all medication stored as per instruction from the manufacturers. Some parts of the home need to be redecorated and adequately maintained and some of the furniture needs to be replaced, in particular bedside cabinets and dining room chairs. Staff must receive at least six supervision meetings a year and also receive a yearly appraisal of their work and future training needs. 50% of the care staff must complete their NVQ 2. The manager is recently in post, however she must submit an application to the Commission and must register as required by the care Homes Regulations. It is recommended that the manager looks at `end of life` care plans for the residents. That a training audit is undertaken of all the staff that will identify training that has taken place and any future training needs and that a quality assurance survey is undertaken to obtain the views of the residents, relatives and stakeholders.

CARE HOMES FOR OLDER PEOPLE Ladyville Lodge Nursing Home Fen Lane North Ockendon Upminster Essex RM4 3PR Lead Inspector Julie Legg Key Unannounced Inspection 29th September 2006 10:00 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 Ladyville Lodge Nursing Home DS0000015597.V314393.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. Ladyville Lodge Nursing Home DS0000015597.V314393.R01.S.doc Version 5.2 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 ladyville.lodge@ashbourne-homes.co.uk 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 Limited Alison Jane Graham Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Ladyville Lodge Nursing Home DS0000015597.V314393.R01.S.doc Version 5.2 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 16th November 2005 Brief Description of the Service: Ladyville Lodge is a 44- place care home for older people. Twenty-six 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 Upminster and is not convenient to access by public transport. It is close to the M25, A127 and the A12 and easily accessible by car. Ladyville Lodge Nursing Home DS0000015597.V314393.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a day and lasted eight hours. The inspector spoke to a number of residents about their experience if living at the home and to three relatives whilst visiting the home. Discussions took place with the service manager the manager, the nurse on duty, care staff, the housekeeper, the administrator and the chef. Staff were spoken to about care practices and their employment at the home. They were also observed directly and indirectly providing care to residents. A tour of the home took place and a number of staff and residents’ records were examined. What the service does well: What has improved since the last inspection? Five of the previous requirements and the one recommendation have been met. The Statement of Purpose has been reviewed and updated. Policies and procedure for handling death and dying are in place and accessible. All parts of the home free from hazards a far as reasonably practicable. In that all hazardous liquids are kept in locked cupboards. Individual records are kept securely in accordance with the Data Protection Act 1998. Staff are mindful to promote the dignity of residents at all times. Ladyville Lodge Nursing Home DS0000015597.V314393.R01.S.doc Version 5.2 Page 6 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. Ladyville Lodge Nursing Home DS0000015597.V314393.R01.S.doc Version 5.2 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 Ladyville Lodge Nursing Home DS0000015597.V314393.R01.S.doc Version 5.2 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, 3, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Prospective residents and their relatives have detailed information on the home to enable them to make an informed choice about moving into the home. A detailed pre-admission assessment is undertaken of all prospective residents, this will ensure that their identified needs can be appropriately met by the home. Prospective residents and their relatives are able to visit the home prior to their admission and obtain a copy of the statement of purpose and the service user guide. EVIDENCE: The Statement of Purpose and the Service User Guide have been revised and further developed. It now clearly sets out the objectives and philosophy of the service, the age range of the residents for whom it is intended that accommodation should be provided and the criteria used for admission to the home. This was a previous requirement that has now been met. Ladyville Lodge Nursing Home DS0000015597.V314393.R01.S.doc Version 5.2 Page 9 The files of two new residents were looked at. Prior to the residents being admitted to the home, the manager had undertaken an in-depth pre-admission assessment; she had also obtained a copy of the local authority’s assessment and further information from health professionals. Residents and relatives are able to visit the home prior to a resident moving in. the inspector spoke to three relatives, who all stated their relatives were unable to visit the home prior to their admission due to their frailty. However all of the relatives had visited this and other homes before making their choice. One relative stated that “I visited Ladyville first and none of the others came up to their standard.” Another relative stated, “I was made to feel really welcome when I visited the home”. The home does not provide intermediate care. Ladyville Lodge Nursing Home DS0000015597.V314393.R01.S.doc Version 5.2 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): 7,8,9, 10 and 11 Quality in this outcome area is good. This judgement has been made using available including a visit to the service. The health and personal care needs of each resident are set out in individual care plans. These plans are very informative and are being evaluated on a regular basis to ensure that residents’ needs continue to be met. There are clear medication policies and procedures for staff to follow, however medication records are not always being completed correctly, which could put residents at risk. Residents are treated with respect and the arrangements for their personal care ensures that their privacy is upheld. Residents’ wishes in relation to death and dying are clearly identified on their care plans. Ladyville Lodge Nursing Home DS0000015597.V314393.R01.S.doc Version 5.2 Page 11 EVIDENCE: Each resident has their own care plan, six of these care plans were examined. The care plans are detailed and comprehensive, identifying residents’ personal, social, cultural, religious and health needs and how these needs should be met. There is also a life story, which gives details of the resident’s family, hobbies, previous occupation and any other significent events. There was evidence that body maps are routinely completed following an accident or incident. The recordings of fluid and food intake and pressure wound charts are completed satisfactory. All residents are weighed at least monthly and if weight loss is noticed then residents are weighed weekly and advice sought from their GP. A new care planning system has been introduced into the home. The staff are to be congratulated on their hard work in completing such comprehensive care plans. Residents care plans that were examined showed that that the majority are being evaluated on a monthly basis and that these evaluations are reflecting changes to the care required and detailing progress of an individual resident. Residents’ files have written evidence that they are seen by other health professionals including opticians, dentists, chiropodists, tissue viability nurse, GP and hospital out-patient appointments. One resident told the inspector that she had recently been seen by the optician and now had new glasses. Risk assessments were examined. The risk assessments are detailed and cover area such as use of a hoist, nutritional needs, continence, falls, pressure area and moving & handling. All of the risk assessments had been evaluated on a monthly basis and some more frequently, when a change in risk has been identified. Medication policies and procedures were examined and found to be up to date. Medication Administration Records (MAR) that were examined showed that there was a gap in the signatory column on one MAR sheet, a signature or refusal of medication must be recorded every time and when administering medication that states ’one or two tablets to be taken’ the number given also needs to be recorded. This is Requirement 1. The inspector spoke to a number of residents and relatives who all said that all staff were respectful and thoughtful when attending to personal care. One relative stated that ‘she is always dressed appropriately and they treat her with kindness’. Another relative stated, “ The staff are very caring”. Residents comments were “the staff are lovely”, “they are very nice people, they look after me”, “I love X I wish I could buy her”. Staff talked about and were Ladyville Lodge Nursing Home DS0000015597.V314393.R01.S.doc Version 5.2 Page 12 observed to treat residents in a respectful and sensitive manner. They understood the need to promote dignity through practices such as in a way they addresses residents and when entering bedrooms, bathrooms and toilets. This was a previous requirement that has now been met. Residents’ wishes in relation to their death (cremation or burial) are recorded in their care plans, however it would be appropriate for every resident to have an ‘end of life’ care plan, which would give information on involvement of relatives in their final hours and what they wanted to happen. This is Recommendation 1. Staff and other residents have the opportunity to attend residents’ funerals, and on the day of the inspection, staff were attending the funeral of a resident. Ladyville Lodge Nursing Home DS0000015597.V314393.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, and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has an activities co-ordinator who ensures that a varied programme of activities is available, which suit individual needs, preferences and capacities. Visiting times are flexible and people are made to feel welcome when visiting the home. This ensures that residents are able to maintain contact with their families and friends as they wish. Residents are assisted to exercise choice and control over their lives. The meals in the home are well presented and nutritionally balanced. They offer both choice and variety to residents. EVIDENCE: Residents were asked their views and care plans were examined. The home has an activity co-ordinator who visits the home five hours a day, five days a week. Activities timetables were displayed around the home and include a wide range of activities and entertainment for the residents to participate in, video shows, quizzes, sing-along, chair aerobics, knitting and bingo. The activities Ladyville Lodge Nursing Home DS0000015597.V314393.R01.S.doc Version 5.2 Page 14 co-ordinator also spends time talking to residents in small groups and on a one to one basis. Some of the residents had recently had an enjoyable day at Southend on Sea. The signing in book shows a steady stream of visitors to the home on most days. Visitors are invited to join in activities such as ‘dog shows’ and when entertainers visit. The care plans contain information about preferred activities including spiritual and cultural activities. Regular church services are held in the home. Residents are encouraged to go out with relatives where possible. On the day of the inspection one resident had been to a garden centre with her daughter, another resident said that she went out with her son. Members of staff were observed sitting and talking with the residents and a quiz had also taken place during the morning. One resident whose first language is not English, receives a volunteer as well as her family, who can speak to her in her own language. There is also a hairdresser who visits regularly. Visiting times are flexible and visitors confirmed that they could visit at any time. All of the relatives spoken to stated, “I am made to feel very welcome and I’m always offered tea or coffee”. Residents have the choice of where to see their visitors, this can take place in the lounge, or their own bedroom. Residents’ care plans indicate their preferred name, their choice as to where they take their meals and their wishes regarding death. One resident stated “I go to bed when I want and get up when I want”. Another resident stated “I like to have my evening meal in my bedroom and the chef always brings me a lightly boiled egg, which I thoroughly enjoy”. Residents are encouraged to bring in their own personal possessions with them when coming to live at the home and this was evident when the inspector visited the residents’ bedrooms. Items such as radios, televisions, photographs, pictures and ornaments enabled the rooms to feel more homely. Meals are mostly served in the dining room, though some residents prefer to have their meals in their bedrooms. There is two choices of the main meal, however the chef stated, “I would always cook something different if either of the choices were not to a resident’s liking”. On the day of the inspection the meals looked appetising and nutritionally balanced. The choice for lunch was haddock and chips or cheese and potato pie, however he cooked five other meals which were; poached fish in a white sauce and duchess potato, cornbeef and mashed potato, sausages and chips, fried egg and mashed potato and omelette and chips. Some of the residents are on specialist diets, such as, pureed, diabetic and gluten free. The chef makes homemade cakes at least three days a week, and for residents that are on diabetic and gluten free diets their cakes are made separately. The home has recently had a ‘cockney day’, where the residents had pie, mash and liquor for lunch and seafood and salmon sandwiches for tea. Both residents and relatives were very complimentary of the food. The chef meets with all new residents and their families to talk about their likes and dislikes. He also keeps a daily book of residents’ choices and this assists in planning future menus ensuring he caters Ladyville Lodge Nursing Home DS0000015597.V314393.R01.S.doc Version 5.2 Page 15 for the residents varying dietary needs and their preferences. Many of the residents require assistance with eating their meals and staff were seen to carry out this task appropriately, talking to residents and not rushing them. Ladyville Lodge Nursing Home DS0000015597.V314393.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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents and their relatives can be confident that their complaints will be listened to, and acted upon. Residents are protected from abuse by the policies, procedures and practices within the home. EVIDENCE: The complaints book was examined during the inspection and the home has received three complaints since the last inspection (November 2005). Two of these complaints have been resolved to the satisfaction of the complainant and the third complaint is ongoing, however the inspector was satisfied that this complaint was being dealt with appropriately. The complaints procedure is on the notice board. Four residents were asked, “if you were unhappy about anything in the home, who would you talk to?” Three residents said they would talk to Y (a senior carer) and the other resident said she would talk to her daughter. All of the relatives that were spoken to said that they would talk to the manager if they had any concerns and felt confident that they would be listened to and their complaints acted upon. There is a written policy and procedure for dealing with allegations of abuse and whistle blowing. Appropriate training has taken place for staff and this subject is also dealt with as part of care staff’s induction as well as their NVQ2 programme. Staff that were spoken to confirmed they had attended training Ladyville Lodge Nursing Home DS0000015597.V314393.R01.S.doc Version 5.2 Page 17 and were aware of the actions to be taken if there were any concerns about the welfare or safety of residents. Ladyville Lodge Nursing Home DS0000015597.V314393.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,24,25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home is welcoming, clean and hygienic. However a redecoration and refurbishment programme needs to be undertaken to enable the residents to live in a well-maintained and comfortable environment. There are sufficient and toilets and bathrooms for the number of residents but the flooring in one of the bathrooms needs to be replaced as this could compromise the safety of the residents. Some bedrooms need to be redecorated and furniture replaced to meet the needs of the residents. EVIDENCE: The home needs to undertake a redecoration programme as well as a weekly maintenance programme, to ensure that the residents live in a comfortable Ladyville Lodge Nursing Home DS0000015597.V314393.R01.S.doc Version 5.2 Page 19 home. The home employs a maintenance person but there needs to be an effective system in place for staff to report items that require repair or attention. The inspector undertook a tour of the home during the inspection. The living area of the home consists of two lounges and a dining room, which are homely appropriately furnished, however the dining room chairs are now looking worn and need to be replaced. Most of the bedrooms are adequately furnished and have been personalised by the residents with photographs, pictures, televisions and radios. Some of the bedroom furniture is showing signs of wear; chipped bedside cabinets, which need to be replaced. There are sufficient toilets and bathrooms, which were clean and tidy but one of the bathroom’s flooring needs to be replaced. Though all of the bed linen and towels were clean there was a limited supply. The home must be appropriately furnished to meet the needs of the residents. This is Requirement 2. The hallways and some of the bedrooms need to be redecorated as the paintwork and walls are scuffed in places. The courtyard needs to be tidied up with the removal of any tubs or any other garden material that could present as a safety issue to the residents. The home must be maintained to ensure the safety and comfort of the residents. This is Requirement 3. The kitchen was found to be extremely clean and all food was appropriately stored. Refrigerator and freezer temperatures are regularly taken and recorded. The home is cleaned on a daily basis and throughout the inspection all areas were found to be clean and there are adequate systems in place to ensure that the home is free from any offensive odours. Ladyville Lodge Nursing Home DS0000015597.V314393.R01.S.doc Version 5.2 Page 20 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 and30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s staffing levels are satisfactory and there is sufficient staff on duty. However, the manager needs to ensure the staff receive the training they require to meet the needs of the residents. The home has a clear recruitment policy and procedure and appropriate checks are undertaken, which ensures the protection of residents. EVIDENCE: The home has a stable workforce and is currently fully staffed. On the day of the inspection staffing levels were seen to be appropriate to meet the needs of the residents. The staff rotas were examined and the rota correlated with the number of staff on duty. Staffing levels are 8 carers and I nurse during the day and 3 waking carers and 1 nurse during the night. Since the last inspection, staff files showed that staff have undergone training in dementia awareness, moving and handling, food and hygiene. The new manager is actively working to ensure that by the end of this year 50 of the care staff will have their NVQ 2. This was a previous requirement that has not been met within the timescale. This is Requirement 4. Ladyville Lodge Nursing Home DS0000015597.V314393.R01.S.doc Version 5.2 Page 21 It would be beneficial for the residents if the manager carried out a training audit for all staff to ensure that they are appropriately qualified and trained to meet the residents’ needs. This is Recommendation 2. Staff files that were examined showed that all relevant recruitment procedures are being followed. All files have a completed application form, two written references and all had Criminal Record Bureau (CRB) checks. Ladyville Lodge Nursing Home DS0000015597.V314393.R01.S.doc Version 5.2 Page 22 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): 31,33,35,36,37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. 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 is effectively communicating to residents, relatives and staff. Residents’ financial interests are safeguarded by the policy and procedures of the home. Staff receive supervision but there needs to be an adequate system in place to ensure that regular supervision and yearly appraisals take place. Resident’s rights and best interests are safeguarded by the home’s policies, procedures and record keeping. Residents and staff’s health, safety and welfare are promoted and protected. Ladyville Lodge Nursing Home DS0000015597.V314393.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager has only been in post for four weeks. She is an experienced manager who has previously worked with older people in a residential setting. In the short time the manager has been in post, she has already improved some areas of the home; rearranging furniture to give a more homely feel, a comprehensive medication audit has been undertaken, she has met with heads of care and staff on both units and also the residents. A full staff meeting is arranged for the 5th October and a relatives’ meeting is to be arranged in the near future. The manager must submit an application to the Commission and must be registered as required by the Care Home Regulations within the next six months (31st March 2007). This is Requirement 5. The quality assurance system includes seeking the views of residents and relatives, by the home holding separate monthly meetings for each group. The minutes of the relatives meeting were displayed in the main reception area and include ways in which issues raised will be actioned by the management team. The Commission receives reports regarding monthly visits in accordance with Regulation 26 visits. These reports are comprehensive, giving a good picture of how the organisation assesses itself. It would be beneficial to the manager for her to instigate a quality assurance survey taking into account the residents, relatives and stakeholders views and from this develop an annual development plan that reflects the aims and outcomes for the residents. This is Recommendation 3. The home has an appropriate policy and procedures regarding the safeguarding of residents’ finances. The inspector checked three residents’ accounts, all of the monies checked against their balance sheets and all items of monies spent were reconciled with receipts for goods that were obtained. The administrator has responsibility for residents’ finances, the manager audits these accounts monthly and then reconciliation takes place every quarter by the organisation’s area administrator. From discussions with staff and the manager some supervision has taken place but there was no evidence that this is happening on a regular basis (at least six times a year) or that yearly appraisals have taken place. This was a previous requirement that has not been met within the timescale. This is Requirement 6. Ladyville Lodge Nursing Home DS0000015597.V314393.R01.S.doc Version 5.2 Page 24 Record keeping by the home was kept up to date and was in good order, daily report sheets were completed by the care staff and the activity co-ordinator, which give an informative picture of the resident’s day. All residents’ files that were examined showed that they contained the relevant information. A previous requirement concerning the security of care plans has been rectified and these are now kept in a secure and lockable cabinet. This previous requirement is now met. The home has carried out all relevant health and safety checks. Fire drills and alarm testing are regularly undertaken. Water, freezer and refrigerator temperatures are also regularly recorded. All staff have undertaken moving & handling training, which is updated on a regular basis. Residents’ files showed that all risk assessments are being reviewed on a regular basis or when a change in need is identified. Ladyville Lodge Nursing Home DS0000015597.V314393.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 X 18 3 2 2 2 X 3 2 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 3 3 Ladyville Lodge Nursing Home DS0000015597.V314393.R01.S.doc Version 5.2 Page 26 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 OP9 Regulation 13(2) Requirement The registered person must ensure the safekeeping of medication and that the correct recording of medication is undertaken. The registered person must ensure that the home is in a good state of repair externally and internally and that it is reasonably decorated. The registered persons must ensure that all furniture, floor coverings and bedding are fit for the purpose. The registered person to ensure a minimum ratio of 50 NVQ trained staff is achieved by 2005. Previous timescale of 16/02/05 not met. 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 DS0000015597.V314393.R01.S.doc Timescale for action 31/12/06 2. OP19 OP21 23(2)(b)( d) 31/01/07 3. OP24 OP20 16(2)© 31/01/07 4. OP30 28 31/03/07 5. OP31 8,9,10 31/03/07 6. OP36 18 (2) 31/01/07 Ladyville Lodge Nursing Home Version 5.2 Page 27 care home are appropriately supervised. In that: staff are supervised at least 6 times a year and receive a yearly appraisal. Previous timescale of 16/02/05 not met. 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. 3. Refer to Standard OP11 OP30 OP33 Good Practice Recommendations For each resident to have an ‘end of life care plan’ For the manager to carry out a training audit on each member of staff For the manager to carry out a quality assurance survey including residents, relatives and stakeholders. Ladyville Lodge Nursing Home DS0000015597.V314393.R01.S.doc Version 5.2 Page 28 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. Extracts may not be used or reproduced without the express permission of CSCI Ladyville Lodge Nursing Home DS0000015597.V314393.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. 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