Care Home: Ladesfield

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What the care home does well Service user surveys contained comments for example `I am treated with respect and have no complaints`, `it has a nice family friendly atmosphere`, `staff are friendly, meals are good, I feel at home here`, and `I feel safe here`. Staff were observed interacting with the residents in a kind, supportive, patient and respectful manner. A service user survey commented `the staff are very kind and when I get in trouble I ring the bell and they come to help, they are very good`. Residents praised the choice and quality of the meals provided and confirmed that alternatives are always available. Visitors are made welcome to the home. The home welcomes residents` and relatives` views on the services the home provides. Residents are involved in the staff recruitment process and a resident spoken with confirmed this. Staff training is ongoing. What has improved since the last inspection? The manger has successfully completed the application process is now the registered manager of the home. A new infection control audit tool is to be implemented in the near future. Re-decoration is ongoing. New kitchen surfaces have been fitted. Equipment has been purchased for example fridges and washing machine. A new hoist and slings has been purchased together with two profile beds to provide adaptations that assist in supporting individual needs.LadesfieldDS0000037645.V378277.R01.S.docVersion 5.2 What the care home could do better: Maintain appropriate comprehensive food records that comply with the requirements of regulation. Implement a wholly person centred care planning system that would specifically promote meeting the needs of people who have dementia. Provide informative written reviews as part of the care planning system. Promote good infection control practice. All staff to have undertaken training in Infection control. Review of staffing levels in the home to ensure that a meaningful activity programme can be implemented for people using the service, especially to provide stimulation for people who have dementia. Key inspection report CARE HOMES FOR OLDER PEOPLE Ladesfield Vulcan Close Borstal Hill Whitstable Kent CT5 4LZ Lead Inspector Sandra Crosby Key Unannounced Inspection 20th November 09:45 DS0000037645.V378277.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Ladesfield DS0000037645.V378277.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Ladesfield DS0000037645.V378277.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ladesfield Address Vulcan Close Borstal Hill Whitstable Kent CT5 4LZ 01227 261090 01227 266201 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) Kent County Council Mrs Emma Julie McAfee Care Home 35 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Ladesfield DS0000037645.V378277.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) Dementia (DE) - maximum number 10. 2. The maximum number of service users to be accommodated is 35. Date of last inspection 18th February 2009 Brief Description of the Service: The premises, which were purpose built in the 1970s, comprise a three storey detached property set in its own grounds in a quiet area in the outskirts of Whitstable Town. The home is a non-smoking environment. There is a secure and secluded garden area to the rear of the property. The ground and the first floor are registered for 25 older people, 3 of which are respite beds. All bedrooms are single accommodation, none are en-suite but all bedrooms have a wash hand basin. Every bedroom has a call point designed to help residents summon help should it be needed. The second floor of the building is registered for accommodating 10 people with dementia. All rooms are single accommodation with a washbasin. This unit is secure and kept locked at all times. People can only access a secure garden area with assistance from staff. Ladesfield also has two assessment beds for those people who require support from the intermediate care team prior to return to live independently in the community. Recently two mental health assessment beds have been made available. Ladesfield DS0000037645.V378277.R01.S.doc Version 5.2 Page 5 Kent County Council are the Registered Providers. The registered manager is in charge of the day-to-day operation supported by the senior team leader and a number of team leaders. The current weekly fee as provided by the Registered Manager is £397.97. Information on the services provided and the CQC reports for prospective residents are detailed in the Statement of Purpose and Service User Guide. Ladesfield DS0000037645.V378277.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This report contains the findings of the homes key inspection and takes account of information obtained from various sources since the last key inspection of the 18th and 20th February 2009, and a visit to the home. The key inspection visit was unannounced and carried out on Friday 20th November 2009 between 09.45 and 15.30. During the inspection the inspector spoke with the registered manager, staff on duty and people who use the service. Various records were seen during the visit, together with an accompanied tour of some areas of the premises. Information contained in the last returned Annual Quality Assurance Assessment (AQAA), completed by the now registered manager was clear and informative. This information has been used together with information gained and observations made at the time of the inspection visit all of which has been used when completing this report. Twelve service user surveys and ten staff surveys were sent to the home for completion and return. Nine service user surveys and five staff surveys were returned completed at the time of writing this report. The aim of the visit was to carry out an inspection against the key standards of the National Minimum Standards for Older Persons in accordance with the Inspecting for Better Lives (IBL) process. Judgements have been made for each outcome area in this report and these have been made using the Key Lines of Regulatory Assessment (KLORA), which is guidance used to ensure that a fair and proportionate judgement is made in each outcome area. More information about KLORAs can be found on the Care Quality Commissions (CQC) website. The findings of this inspection were discussed with the registered manager at the end of the visit, and overall indicate that this home is providing good quality outcomes provision for the residents and in line with CQC ratings agenda this service has achieved a good 2* rating. Ladesfield DS0000037645.V378277.R01.S.doc Version 5.2 Page 7 What the service does well: Service user surveys contained comments for example I am treated with respect and have no complaints, it has a nice family friendly atmosphere, staff are friendly, meals are good, I feel at home here, and I feel safe here. Staff were observed interacting with the residents in a kind, supportive, patient and respectful manner. A service user survey commented the staff are very kind and when I get in trouble I ring the bell and they come to help, they are very good. Residents praised the choice and quality of the meals provided and confirmed that alternatives are always available. Visitors are made welcome to the home. The home welcomes residents and relatives views on the services the home provides. Residents are involved in the staff recruitment process and a resident spoken with confirmed this. Staff training is ongoing. What has improved since the last inspection? The manger has successfully completed the application process is now the registered manager of the home. A new infection control audit tool is to be implemented in the near future. Re-decoration is ongoing. New kitchen surfaces have been fitted. Equipment has been purchased for example fridges and washing machine. A new hoist and slings has been purchased together with two profile beds to provide adaptations that assist in supporting individual needs. Ladesfield DS0000037645.V378277.R01.S.doc Version 5.2 Page 8 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Ladesfield DS0000037645.V378277.R01.S.doc Version 5.2 Page 9 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 Ladesfield DS0000037645.V378277.R01.S.doc Version 5.3 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 6 were inspected. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are provided with the information they need to make an informed choice about moving into the home. Pre-admission assessments ensure that the home can meet the persons needs. The home has 2 assessment beds for those people requiring support from the intermediate care team. Ladesfield DS0000037645.V378277.R01.S.doc Version 5.3 Page 11 EVIDENCE: At the last inspection visit it was confirmed that the Statement of Purpose and Service User guide provided residents with detailed information of the services the home provides. Four completed service user surveys stated the person did received enough information to help them decide if the home was the right place for them before they moved in. Five surveys stated no, they did not receive enough information one of which stated they were brought in as an emergency. A copy of the last two inspection reports were seen on display at reception. No resident is admitted to the home without a comprehensive assessment having been carried out by care management and a senior suitably qualified member of the home. These are carried out to ensure that the home can meet the assessed needs of the prospective resident. The findings of the assessments are used to formulate a care plan. Completed assessment documentation was seen as part of the care planning system. The home has a number of assessment beds for people requiring support from the intermediate care team (2) or the mental health team (2). Ladesfield DS0000037645.V378277.R01.S.doc Version 5.3 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 were inspected. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People do not fully benefit from care planning that shows that person centred care is promoted. People can be confident that their health care needs are met. People are mainly protected by the homes administration and recording of medication. People can feel confident that they will be treated with respect and their right to privacy is upheld. Ladesfield DS0000037645.V378277.R01.S.doc Version 5.3 Page 13 EVIDENCE: The new computerised care planning system that was to concentrate on a person centred approach has not been implemented to date. A sample of care plans was examined. This evidenced that generally health, social and cultural care needs are mainly recorded. Care plans are supported and informed by a range of risk assessments relating to adequate nutrition, risk of skin breakdown, moving and handling and self-medication. Wherever possible the resident or their advocate had signed the care plan evidencing their input and agreement. Overall the care plans contained all components as required by regulation; however some records were not signed and dated. A care plan seen for a person who was admitted in August 2009 had documentation that had not as yet been completed for example nutritional assessment. Reviews seen in one care plan comprised of the date and initials only, with no written information to support the review. The registered manager agreed to address these issues. Residents health care needs in respect of diabetes management, wound care and blood tests are met by a team of district nurses. Visits from the GP, district nurses and other visiting health professionals are recorded in a separate folder for easy access during handovers but would need to become part of a wholly person centred care planning system. The registered manager reported excellent communication with health professionals. The nine completed service user surveys all stated that people always get the medical care that they need. The medication room was visited and a review of medication charts, including the controlled drugs book and the medication returns book evidenced good recording. There has been medication errors reported to the Commission, and the registered manager has taken appropriate action to address this issue. The registered manager confirmed that regular medication audits are being undertaken to check compliance. Residents are encouraged to self-medicate as appropriate. Residents are treated with dignity and respect and observation of staff practice during the visit confirmed this. Six service user surveys stated that staff always listen to them and act on what the person says, one survey stated usually and one survey stated sometimes. Ladesfield DS0000037645.V378277.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 were inspected. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are provided with some organised activities, which could be further improved. People benefit from being encouraged to maintain contact with families and friends. People enjoy a good, balanced and wholesome diet with special diets being catered for, although records required to be maintained do not support this. Ladesfield DS0000037645.V378277.R01.S.doc Version 5.3 Page 15 EVIDENCE: There is no dedicated person to provide a range of activities at the home. The registered manager said a monthly music for health session is provided, and that staff when there is time initiate activity sessions for example quizzes and bingo. A programme of activities was seen on the Somerset Suite noticieboard and included for the day of the visit a word search, and hand massage and polish activities. Service user surveys of which five stated that the home always arranges activities that people can take part in, two surveys stated usually and two surveys stated sometimes. The home does not have any transport to take people out and about, and the position of the home being on a steep hill prohibits staff taking people in a wheelchair for a walk. It was discussed with the registered manager that the staffing level at the home should be reviewed to incorporate hours specifically for the provision of activities and stimulation for those persons who have dementia. A range of activities have been planned for the coming festive season. In the Somerset Suite (dementia unit), the noticeboard is not used to its full potential and issues discussed with the registered manager included it stating the wrong date, the menu for the day was in very small writing, and a blank space was seen where the staff today pictures should have been. The registered manager said that action is being taken to improve the noticeboard, and that picture menus are being prepared. The registered manager agreed to address the issues raised. The Service User Guide gives information in respect of religious services available. The home provides opportunities for residents to practice their religion. A communion service is held once a week and a catholic priest visits the home. Family and friends are welcomed at any time and people are able to have visitors when they want. It was noted that small seating areas have been arranged around the home so that people can sit in privacy. Overall comments about the meals were positive. Residents are provided with a choice of varied, wholesome meals, which include fresh fruit. The registered manager said that menus are regularly reviewed in accordance with residents wishes. Seven service user surveys stated that people always liked the meals at the home, one survey stated usually and one survey stated sometimes. The record of the food provided was seen, and showed that the records had not been kept up to date, and did not provide written evidence that a varied and nutritious diet with alternatives available was provided as required by regulation. The registered manager agreed to address this issue. Ladesfield DS0000037645.V378277.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 were inspected. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People feel confident to air their views and their complaints are listened to and acted upon. People are mainly protected from harm and staff are trained to safeguard vulnerable adults. Ladesfield DS0000037645.V378277.R01.S.doc Version 5.3 Page 17 EVIDENCE: The home has policies and procedures in place in relation to the action to be taken if and when a complaint is made. The registered manager confirmed that there had been no formal complaints made since the last inspection visit to the home. All nine completed service user surveys confirmed that people knew there was someone they could speak to informally if they were unhappy, and indicated that people knew how to make a formal complaint. The staff training matrix indicates that staff undertake training in Safeguarding of Vulnerable People, Mental Capacity Act and Deprivation of Liberty training and training in relation to Valuing Diversity. The registered manager makes effective use of the Safeguarding of Vulnerable Adults procedures in raising issues of concern that affect the well-being of the residents. There has been one adult protection alert raised since the last inspection visit. Appropriate action has been taken by management, and the final outcome of the investigation is still awaited. Ladesfield DS0000037645.V378277.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 were inspected. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from living in a pleasant, homely environment that is continually improved and maintained. People have access to safe gardens that are being improved. People are encouraged to maximise their independence by having access to the range of specialist equipment supplied by the home. People live in a clean and hygienic environment. Ladesfield DS0000037645.V378277.R01.S.doc Version 5.3 Page 19 EVIDENCE: The Somerset Suite based on the top floor, which provides respite care for people with a diagnosis of dementia, is comfortable, pleasant, spacious and light. This is a secure unit, and residents have access to a safe and secure garden. Work is ongoing to improve the garden areas of the home. Improvements continue to be made to the rest of the home. Re-decoration is ongoing, new kitchen surfaces have been fitted and equipment has been purchased for example fridges and a washing machine. The majority of the bedrooms on the ground and first floor are small. Whilst this does not pose a problem for ambulant residents, for those who are wheelchair bound and need a hoist and two members of staff to transfer, it may do. The registered manager said there is a good team of domestic staff consisting of five people who are responsible for cleaning and laundry. Bedrooms and communal areas were clean, tidy and mainly free from unpleasant odours. Eight service user surveys stated the home is always fresh and clean, and one survey stated usually. On the accompanied tour of some areas of the home it was observed that a clinical waste bin had no lid, and was not foot operated, and a rubbish bin was seen that had no lid. The registered manager took immediate action in relation to these issues. A new infection control audit tool is being introduced to promote good infection control practice. The staff training matrix indicated that not all staff have received training in infection control and a requirement has been made. Ladesfield DS0000037645.V378277.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 were inspected. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from being cared for by staff who are mainly well trained and supervised. People are protected by the homes recruitment procedures. Ladesfield DS0000037645.V378277.R01.S.doc Version 5.3 Page 21 EVIDENCE: The registered manager reported that recruitment of new staff is progressing, and that currently agency staff are being used as appropriate to maintain staffing levels that meet the dependency needs of the people at the home. In the smaller Somerset Suite, the staffing levels are dependent upon the number of people and their dependency. Currently there are two carers allocated to work on the Somerset Suite and four carers for the main areas of the home on the day shifts. There are three waking staff with a Team Leader sleeping in on the premises at night. In addition there are designated kitchen, cleaning, maintenance and administration staff. Completed staff surveys provided comments for example under what the home could do better more staff to meet clients high dependency needs and more staff so you are not rushing all the time. Following discussion with the registered manager a recommendation is made for the staffing levels at the home to be reviewed especially in relation to incorporating hours specifically for the provision of activities and stimulation for those persons who have dementia. The registered manager reported that over 80 of staff have or are in the process of obtaining an NVQ in Care. All staff have undertaken the common induction training in line with Skills for Care as an update for current skills. It was reported at the last inspection visit that three staff files were examined and these demonstrated sound recruitment procedures. Good documentation was noted including POVA first and CRB checks, interview notes, two written references, evidence of induction and other training. Staff files were not viewed at this inspection visit, however the registered manager confirmed that a thorough recruitment procedure is completed when new staff are appointed. One resident spoken with confirmed that she took part in the interview process for new staff. A training matrix is now in place and staff training is ongoing. Staff are provided with all mandatory training such as fire safety awareness, moving and handling, food hygiene, and first aid. Specialist training is provided for example Dementia Care, Challenging Behaviour, Equality and Diversity and Palliative care. Team leaders undertake a sixteen week medication training course. This training is also available to care staff. Completed staff surveys stated in relation to what the home does well training for staff and good training prospects. As part of the appraisal process, personal action and development plans have been devised. The registered manager confirmed that regular supervision is undertaken with written records maintained for all staff. Ladesfield DS0000037645.V378277.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38 were inspected. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management of the home provides leadership, guidance and direction to staff to ensure that people receive consistent quality care. Sound financial procedures protect people. Peoples health, safety and welfare are promoted. Ladesfield DS0000037645.V378277.R01.S.doc Version 5.3 Page 23 EVIDENCE: The manager has been in post for just over a year and has successfully completed the application process and is now registered with the Commission as the registered manager of the home. A senior team leader has been appointed to support the registered manager and assist the management team of the home. The registered manager is approachable and operates an open door policy. She is well aware of those areas where improvements can and should be made. It was previously reported that the registered manager has been trained in budget and business planning and demonstrated a commitment to provide strong management leadership. There are clear lines of accountability within the organisation and the home. The Operations Manager meets with the registered manager monthly for supervision and monitoring. The home welcomes residents and relatives views on the services the home provides. A feedback form has been introduced to that effect. Residents are involved in the staff recruitment process. Residents meetings take place and questionnaires are sent out and an annual quality audit undertaken. The registered manager ensures that she or a member of the senior team sees all residents every day and encourages feedback. Exit questionnaires have been introduced for all short-term residents. It was reported at the last inspection visit about the introduction of safe systems for the management of residents monies and belongings whilst staying in the home. For this purpose, residents have been provided with a lockable facility in their room. Where the home is involved with looking after residents monies, a robust safeguarding system is in place. Records were not viewed at this visit. Accident records are well maintained and evaluated. Incidents of a challenging nature are recorded on ABC charts. The registered manager informs the CQC and other authorities of any reportable event. The AQAA confirmed that all equipment and services have been serviced or tested as recommended by the manufacturer or other regulatory body. Dates of last review or certificate were supplied. Ladesfield DS0000037645.V378277.R01.S.doc Version 5.3 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 3 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 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Ladesfield DS0000037645.V378277.R01.S.doc Version 5.3 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. 1. Standard OP15 Regulation 17(2) Sch 4 13 Requirement Records of the food provided for service users in sufficient detail to enable any person inspecting the records to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and of any special diets prepared for individual service users Timescale for action 30/11/09 2. OP26 13(3) Maintain appropriate records of the food provided in the home The registered person shall make 31/03/10 suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home. All staff to undertake Infection Control training. Ladesfield DS0000037645.V378277.R01.S.doc Version 5.3 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations Implement a person centred care planning system to support how the service meets the individual needs of people and as part of this system provide informative regular reviews of the individual care plans. Review the staffing levels at the home to incorporate hours specifically for the provision of activities and stimulation for those persons who have dementia. 2. OP18 Ladesfield DS0000037645.V378277.R01.S.doc Version 5.3 Page 27 Care Quality Commission South East Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.southeast@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Ladesfield DS0000037645.V378277.R01.S.doc Version 5.3 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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