Inspection on 01/06/07 for The Ledbury Home

This inspection was carried out on 1st June 2007.

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

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Maple Lodge

Heathlands

Aston Court Nursing Home

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Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Ledbury Home, The Market Street Ledbury Herefordshire HR8 2AQ Lead Inspector Denise Reynolds Key Unannounced Inspection 1st June 2007 12:00 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 Ledbury Home, The DS0000067998.V336814.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. Ledbury Home, The DS0000067998.V336814.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ledbury Home, The Address Market Street Ledbury Herefordshire HR8 2AQ 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) 01531 637 600 01531 637 619 www.shaw.co.uk Shaw Healthcare (Ledbury) Limited Mrs Lorraine Ann Cooling Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36), Physical disability over 65 years of age of places (36) Ledbury Home, The DS0000067998.V336814.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Specific provision regarding service user category PD(E). The potential maximum number of service users 36, in respect of the category physical disability over 65 years of age includes provision for service in respect of two named people. 2nd March 2006 Date of last inspection Brief Description of the Service: The Ledbury Home, which opened in March 2002, is a care home providing nursing care for up to 36 older people. The home is situated within the Ledbury Community Care Centre in the heart of the town. The majority of people who use the service are local and many have lived in the Ledbury area all their lives. The service has a strong identity in the town and is perceived as a local resource. This purpose built centre houses a number of separate services including Social Services, various dental, medical and therapy services, a minor injuries unit, an intermediate care unit (ICU), and an acquired brain injury (ABI) unit. The Ledbury Home is registered to offer services to people aged 65 and over with needs relating to general frailty. The Ledbury Home has two separate areas. On the second floor there are 19 single bedrooms, each with ensuite facilities, plus two communal sitting and dining rooms. On the first floor there is similarly set out accommodation for 17 people, but as the building follows the sloping contours of the land, some rooms look out at ground floor level. The main access to the home is at the first floor level and there is a lift providing access to both floors for people with mobility problems. Ledbury Home, The DS0000067998.V336814.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over two days lasting approximately 8 hours in total. This was a key inspection – this is an inspection where we look at a wide range of areas covered by the National Minimum Standards. To help us plan the inspection we looked at information requested from the Home in November 2006 and the AQAA received in May 2007. We also took into account what people told us in our survey forms in November; we received these from 6 people who were using the service at that time, 7 Home care records, staff records and other records and documents were inspected. There was a tour of the accommodation and discussions with 4 staff, including the manager. Time was spent speaking privately with three people using the service. The inspector met and spoke with the relative of one resident during the inspection and subsequently spoke to 2 relatives on the telephone. Having information from people involved with the service 6 months ago and now was useful because this gave us two sets of views and opinions to take into account. What the service does well: People are given clear information to help them decide if Ledbury Nursing Home is going to the right place for them to move into. Staff find out what peoples’ needs are before offering someone a place to make sure they can give then the correct care. Staff make sure people’s health needs are identified and acted upon promptly and work closely with relevant health and social care professionals to achieve this. The Home is welcoming and friendly and local people who live there are pleased they can remain in the heart of the community. Varied activities are arranged by an activity coordinator so that there are things for people to do. Adult protection is taken seriously and staff have the training they need to understand and recognise the signs of abuse and neglect. The Home is well maintained and provides a clean, comfortable and safe environment for people who live there. There is an attractive garden for people to enjoy in good weather. The organisation uses robust recruitment procedures to ensure that staff they employ are suitable people to work in a care setting. Staff training is given high priority. Health and safety arrangements are well organised by designated staff and health and safety related training is up to date. Ledbury Home, The DS0000067998.V336814.R01.S.doc Version 5.2 Page 6 During our consultations with people in November 2006 and in June 2007 we received a number of positive comments about the service such as ‘100 support’ ‘Staff are good about contacting doctor’ ‘I have no complaints, just praise for her care, which was tender and loving’. ‘There is always full information available to me – the Home is managed in a very professional manner. The care provided is to date of a high standard.’ ‘They care for her very well, staff listen to us.’ ‘Good general attitude and very good food. Very helpful.’ What has improved since the last inspection? What they could do better: Some improvements to the care plans, risk assessments and recording of care are needed to ensure that the standard of care provided is supported by the documentation. People using the service (or their relatives) need to be given their own copy of the complaints procedure so they can refer to it without having to ask. Staffing levels are adequate but given the high levels of care people need, staff may sometimes be too busy to respond quickly to everyone who needs help. Consultation with the fire authority should take place to consider how to make safe arrangements for doors to be held open. A written action plan to address shortfalls would strengthen the established quality assurance measures used at the Home. Please contact the provider for advice of actions taken in response to this Ledbury Home, The DS0000067998.V336814.R01.S.doc Version 5.2 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ledbury Home, The DS0000067998.V336814.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ledbury Home, The DS0000067998.V336814.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive clear information to help them decide if Ledbury Nursing Home is going to suit them and meet their needs. Whenever possible staff meet people thinking of moving to the Home to find out what their needs are and to make sure these can be properly catered for in the Home. EVIDENCE: People thinking of using the service (or their relatives) are given a copy of the service user guide. This is clearly set out, written in plain English and available in other formats (eg large print, Braille, symbols, audio) when needed. During the inspection a family came to look around and staff gave this visit high priority. The service user guide is also displayed in the Home together with a copy of the last CSCI inspection report. The service user guide needs to be reviewed and updated to take into account changes in the management arrangements. The guide currently tells people Ledbury Home, The DS0000067998.V336814.R01.S.doc Version 5.2 Page 10 they can ask for a copy of the complaints procedure; this should be made available as a matter of course because some people may feel uncomfortable about asking for a copy. Everyone moving to the Home has an assessment of their care needs done by experienced staff from the Home in addition to any assessment already done by a funding authority. The assessment format covers all the expected topics and the assessments looked at during the inspection contained a lot of informative information. Some sections of the paperwork the service uses had not been fully filled in, because some of the issues relate to both assessment and care planning we have explained this in the health and social care section to avoid duplication. Ledbury Home, The DS0000067998.V336814.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People at Ledbury Care Home are well cared for by thoughtful and committed staff. Concerns regarding people’s health are identified and acted upon promptly and staff work closely with relevant health and social care professionals to make sure people get the medical or social care support they need. Some improvements to the care plans and recording of care are needed to avoid omissions and confusing duplication and ensure that the standard of care is supported by the documentation. EVIDENCE: The majority of people who returned survey forms to us in November 2006 were happy that their personal and care needs were being met. This view was supported by information from relatives and health and social care professionals. Comments received included – ‘100 support’ Ledbury Home, The DS0000067998.V336814.R01.S.doc Version 5.2 Page 12 ‘ Not always possible to cover her needs properly. But medical care very good. ‘Staff are good about contacting doctor’ ‘I have no complaints, just praise for her care, which was tender and loving’. ‘There is always full information available to me – the Home is managed in a very professional manner. The care provided is to date of a high standard.’ People spoken to during the inspection were also satisfied with their care and felt that any shortcomings were due to staff being very busy and not always able to respond quickly or in an individualised way; overall people considered that the quality of care that staff provide is good. Each person has a care plan that covers all the expected topics, including areas that are specific to individual people. There was evidence that people are generally consulted and involved in decisions about how staff should care for them and that the plans for peoples’ care are reviewed although this was not entirely consistent in all the care plans seen. Where aspects of peoples’ care places them at specific risk, for example if they are at risk of developing pressure sores or are immobile, written risk assessments are done to make sure staff know how to provide the correct care. Overall the care plans and risk assessments contain a lot of relevant information and there is evidence of very good observation, recording, reporting and review of care needs. It is essential that this is not undermined by contradictory information and omissions leading to breakdowns in the provision of the correct care. Some examples noted were • Information under ‘communication’ for one person says ‘no problems’ but elsewhere in the file a risk assessment sheet says ‘does not hear very well she needs to be spoken to clearly and loudly’. A risk asst about difficulties with a person’s behaviour says ‘ has her own likes and dislikes and staff to respect them’. This would be of more benefit if it explained the likes and dislikes and how staff should respond to these. 2 moving and handling assessments were seen for one person; these had different dates. Staff were able to explain that the second assessment was to enable the person to take part in something specific as a one off event. This was good practice but at a later date staff could be unsure which they should adhere to. Some examples were found where the records did not detail the care actually being given, this included omissions in the recording of pressure area care. • • • Ledbury Home, The DS0000067998.V336814.R01.S.doc Version 5.2 Page 13 The Home recognises the importance of providing individual care and the records show that things like preferences for the gender of staff to provide personal care have been discussed with people. Some records contained isolated references that seemed contrary to the principles of valuing people as individuals and some staff may need to be reminded that this should be reflected in what they write as well as in how they speak to people. The care records show there is good liaison with health and social care professionals to make sure that peoples’ health needs are responded to promptly. Medication arrangements are well managed and monitored. The Home has plentiful supplies of the equipment it needs to make sure people are comfortable and cared for safely; this includes hoists for safe moving and handling and specialist bathing facilities. Ledbury Home, The DS0000067998.V336814.R01.S.doc Version 5.2 Page 14 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. 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 this service. Ledbury Care Home is a friendly service where visitors are made welcome. The food provided is nutritious and staff have a good awareness of peoples’ dietary needs. Some people think more of the food could be ‘home cooked’. A range of group activities are provided and the needs and abilities of individual people are also catered for. EVIDENCE: The Home has an activity coordinator who takes the lead in organising a range of activities. Information about forthcoming events is included in a monthly newsletter and displayed around the building. During May the social calendar included a varied range of activities and on the day of the inspection a group of people were taking part in an art class. This is a weekly event and many of the paintings people have done are displayed around the Home. The activity organiser also visits people in their rooms if they are unable or prefer not to join in with the communal activities – Ledbury Home, The DS0000067998.V336814.R01.S.doc Version 5.2 Page 15 ‘ ………. doesn’t leave her room, but the activities coordinator visits her in her room which she enjoys’ The May newsletter contained an excellent mix off topics aimed at keeping people in touch with the world around them. The service user guide explains that visitors are welcome at any time, and asks people to be aware of security of the building when arriving and leaving the building. The Home has a room that can be booked for larger numbers of visitors and for family parties. This is a good way of helping people to keep in touch with family and friends. The Home is actively supported by Ledbury Mother’s Union who visit and spend time with people living there. Staff had recently gone to considerable lengths to enable a service user to vote in the local elections. Throughout the two visits staff were heard speaking to people in a friendly and caring way. People said that staff are polite to them and respect their privacy eg they knock on peoples’ doors and wait to be asked in before entering. Some of the care records contain good information about the ways in which people may enjoy spending their time; in other cases this information was less developed. Similarly, information about family links, birthdays etc was more detailed in some records than in others. Having this information (if people wish to provide it) is one way for staff to help people keep in touch with relatives and to spend time doing things they enjoy and can still do with support. People spoken to during the inspection said they liked the food although some comments were made about a need for more fresh fruit and freshly prepared foods. Comments made included – ‘Sometimes they are ok and sometimes they are not very good’ ‘Meals very good 100 ’ ‘Not much fruit’ A few people commented that staff are very busy at meal times due to the number of people who need assistance with eating. The staff plan to encourage more resident participation in activities in the coming years and hope to continue to expand contact with local groups. Ledbury Home, The DS0000067998.V336814.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. 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 this service. There is a suitable complaints procedure available; people using the service (or their relatives) need to be given their own copy so they can refer to it without having to ask. Adult protection is taken seriously and staff have the training they need to understand and recognise the signs of abuse and neglect. EVIDENCE: The Home rarely receives complaints and those dealt with in the past were addressed satisfactorily. No complaints have been received by CSCI about the service. None of the health and social care professionals who returned survey forms had received complaints. Copies of the complaints procedure are not routinely given to people. People may be anxious about asking for a copy and should be given one as part of the service user guide. However, the people we had contact with did know how to make a complaint if they needed to. Policies and procedures regarding the protection of vulnerable adults are in place and staff have access to these. Care staff cover the protection of vulnerable adults in their induction and NVQ training. The Herefordshire adult protection coordinator has done training at the unit, the last time being in April 2006. The manager understands the local multi agency adult protection arrangements and where necessary has made referrals. Ledbury Home, The DS0000067998.V336814.R01.S.doc Version 5.2 Page 17 Ledbury Home, The DS0000067998.V336814.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The organisation has good arrangements for the upkeep of the Home to keep the building, equipment and furnishings in a good state of repair. The Home provides a clean, comfortable and safe environment for people who live there. There is an attractive garden for people to enjoy in good weather. EVIDENCE: The organisation continues to invest in the premises and during the last year new bathroom equipment and 2 new dishwashers have been installed. A CCTV system has been introduced to assist with security at the entrance. The bedrooms are all single and have an en-suite toilet and shower. People are able to bring personal possessions with them to make their rooms comfortable, homely and familiar. There are no double rooms but should a couple wish to share, the Home allocates each person a bedroom and then with appropriate furniture converts one of the bedrooms to a sitting room. Ledbury Home, The DS0000067998.V336814.R01.S.doc Version 5.2 Page 19 There is a well-equipped assisted bathroom on each floor and good sized toilets to provide space for staff to assist people who are unable to manage on their own or need to use a walking frame or wheel chair. There is a lounge and dining room on both floors although many people choose to stay in their rooms or are too unwell to do so. There are good hygiene and infection control arrangements and the home was clean, tidy and free from offensive odours. Most people who sent us surveys in November thought the Home was always clean and fresh, one person wrote – ‘100 to cleaners’ Another person thought this was something that had improved ‘My room was not always getting dusted. But with a little encouragement from me the cleaners are getting better!’ Fire records and some maintenance records were inspected and these indicated that good attention is paid to safety, repair and maintenance. The Facilities Manager and maintenance man deal with these arrangements for the whole complex and are conscientious in making sure all required work is done. Ledbury Home, The DS0000067998.V336814.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The organisation uses robust recruitment procedures to ensure that staff they employ are suitable people to work in a care setting. Staff training is given high priority, particularly in respect of health and safety related topics. Staffing levels are adequate but given the high levels of care people need, staff may sometimes be too busy to respond quickly to everyone who needs help. EVIDENCE: During both days of the inspection nurse and care staffing levels were as described in the service user guide. Domestic and laundry staff were also on duty. Some people we have had contact with have said they think that on some occasions, particularly at weekends, there may not be enough on duty to cope with everything that needs to be done. They felt that there are times, including at meal times when staff are under pressure to respond to people within reasonable lengths of time although they do their best to do so. During the inspection staff were caring for several people who were unwell and were indeed very busy. Comments we received included – ‘Sufficient numbers are not always in evidence at the weekends’ ‘Sometimes its looks thin on the ground at weekends’ ‘How timely this is depends on pressure of work on the staff’ ‘Often the inevitable delay’ Ledbury Home, The DS0000067998.V336814.R01.S.doc Version 5.2 Page 21 There were lots of positive comments made about the staff team including, ‘All staff here are 100 and more’ ‘The staff mostly put themselves at your disposal and are very helpful.’ People spoken to said that they found the staff very kind and patient. Staff training is viewed as very important and regular training is arranged by the organisation. There are systems in place to monitor staff attendance and to highlight when updates are due. Staff NVQ training is due to be reestablished because the proportion of care staff with this qualification is now very low. The nursing staff take lead roles in specific areas of expertise, these include tissue viability, diabetes and health and safety. There are plans to extend the number of areas covered in this way during the next 12 months. The organisation has well established recruitment procedures, including equality and diversity monitoring and the records of two new staff showed that these are being followed. The records did not include details to show the dates and disclosure numbers of staff CRB checks Ledbury Home, The DS0000067998.V336814.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Ledbury Care Home is well managed by a competent and experienced manager. Health and safety arrangements are well organised by designated staff and health and safety related training is up to date. Shaw healthcare, the service provider, has quality assurance systems in place to help them monitor and improve the service. EVIDENCE: The manager has been in post for approximately 2 years and has done the Registered Managers Award in addition to her nursing qualification. She has an open management style and has a positive approach to working with the Commission. Ledbury Home, The DS0000067998.V336814.R01.S.doc Version 5.2 Page 23 Shaw healthcare quality assurance processes are used at the Home. These show consistently high levels of satisfaction with most aspects of the service. Currently the results of the surveys are collated to show statistical information but an action plan is not developed to show how any shortfalls are going to be addressed. A system of supervision and staff meetings for all grades of staff has been started but is not yet fully established. The Home avoids involvement with peoples’ personal finances and encourages relatives to assist with this whenever possible. Procedures are in place to ensure that any financial transactions for service users are documented. A safe is available for any money or valuables given to the Home for safe keeping. Health and safety in the Home is well managed through the use of regular maintenance checks, the implementation of relevant policies and the provision of training to staff. During the inspection it was noted that wedges were being used to hold some fire doors open. This may compromise the safety of people in the building in the event of a fire. The importance of finding a different solution for people who want their doors open was drawn to the attention of the Registered Manager. Ledbury Home, The DS0000067998.V336814.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 Ledbury Home, The DS0000067998.V336814.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action 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 OP7 Good Practice Recommendations The care plans and risk assessments need to be reviewed to make sure they do not contain contradictory information or significant omissions that could lead to breakdowns in the provision of the correct care. Arrangements need to be made to ensure that all care plans and risk assessments are reviewed regularly. The complaints procedure needs to be given to people using the service (or their relatives) as a matter of course because some may feel uncomfortable about asking for a copy. Staffing arrangements need to be reviewed to ensure they are adequate for the range of care needs being catered for. A written action plan to address shortfalls would strengthen the established quality assurance measures. Consultation with the fire authority should take place to DS0000067998.V336814.R01.S.doc Version 5.2 Page 26 2 3 OP7 OP16 4 5 6 OP27 OP33 OP38 Ledbury Home, The consider how to make safe arrangements for doors to be held open. Ledbury Home, The DS0000067998.V336814.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Ledbury Home, The DS0000067998.V336814.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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