Care Home: Ludbourne Hall

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What the care home does well The people using the service were confidant that their care needs had been assessed and that their needs could be met, right from the start of their stay in the home. The services provided did not include intermediate care. People using the service had their health, personal and social care needs fully met and this was set out in an individualised plan of care. People were involved in decisions about their lives, and played an active role in planning the care and support they receive. For example on the day of the site visit one person went out of the home accompanied by a member of staff to do personal shopping and purchase something for the homes fish tank. The person said that this gave her a sense of purpose and in contributing to the homes pets felt she was valued as a person, "her opinion counted". She saw this a vital part of her care at the home. People` s lifestyle in the home met their expectations and satisfied their needs. People who used the services were able to make choices about their life style, and were supported to develop their life skills. Social, educational, cultural and recreational activities met individual`s expectations. The manager and staff said that they offered as much choice and opportunity for people to participate in any event that they wished to try. People were empowered through resident meetings and making decisions about things in the home. For example the homes manager had purchased a new notice board, as it had been requested, so that people could be informed of what was happening every day. People enjoyed an appealing, varied diet in pleasant open surroundings, at a time that suited them, with support from staff. People who used the service were able to express their concerns, and complaints and suggestions from those using the service, relatives or other visitors to the home were treated seriously. People lived in a house, which offered a range of facilities and was comfortable, clean and safe. All parts of the home were personalised, clean tidy and comfortable. The people using the service, were supported by Staff, who where trained, skilled and competent. Staff had been subject to rigorous recruitment checks. People said the "staff and the manager are helpful and accommodating" and "the home has really friendly staff". People lived in a well managed home, with the management, administration and staff team, working together to provide a stimulating, safe environment that respected and protected peoples` rights. People said that they felt the home was well managed in a flexible style that allowed people to "carry on as normal". Surveys from relatives and professionals said that the home was run as a family home, with a "family home" atmosphere that people "really benefited from". What has improved since the last inspection? Since the last inspection the manager said that recommendations made from the last inspection report had been completed or were in the process of being completed; this included; Continuing with a programme of protecting the homes` night storage radiators and the governing of the hot water supply to washbasins and baths in residents` en-suites, using a risk-assessment process. Extending the prevention of falls risk-assessment for one resident, to take into account the two small steps that are situated just outside of their bedroom Extending the record of meals and food supplied to residents to contain more detail, e.g.; the vegetables supplied with lunch, the vegetarian option and any other alternatives provided. Documents, such as the home`s infection control guidance had been updated to include the guidance issued by the Department of Health in June 2006. Additionally a `Heat wave` policy and plan had been drawn up for the home taking into account residents collective and individual needs using the NHS guidance also issued by the Department of Health. The home`s fire risk-assessment had been updated as planned to include the recommendations by the Fire Safety Officer. Other areas of improvement have been in the extension and refurbishment of the homes dining area and in progressing with further plans to add a lounge conservatory to the communal space in the home. What the care home could do better: Recommendations made at the site visit were; To extend care plans and care plan reviews to include all aspects of peoples changing care needs. This included more detail of care for those people with memory loss. To introduce a `complaints book/record` that shows any complaints or concerns that people have raised, how they were addressed and the outcome of the complaint. To continue as planned with the refurbishment and redecoration of the home. CARE HOMES FOR OLDER PEOPLE Ludbourne Hall South Street Sherborne Dorset DT9 3LT Lead Inspector Andrea East Key Unannounced Inspection 10th December 2007 10:30 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 Ludbourne Hall DS0000026838.V356438.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. Ludbourne Hall DS0000026838.V356438.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ludbourne Hall Address South Street Sherborne Dorset DT9 3LT 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) 01935 816382 01935 815901 ludbournehall@aol.com Scosa Ltd Mrs Denise Lesley Read Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Ludbourne Hall DS0000026838.V356438.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home providing personal care only- Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category- Code OP The maximum number of service users who can be accommodated is 19. 13th October 2006 Date of last inspection Brief Description of the Service: Ludbourne Hall is a registered care home offering both long and short-term places to a maximum of 16 people over the age of 65. The home is owned by Debra and Phillip Scott, under the title of SCOSA Ltd; the registered individual (RI) is Debra Scott and the registered manager is Mrs Denise Read. Ludbourne Hall is situated a short level walk from the centre of Sherborne and is within easy access of the towns facilities including the railway station, gardens and Abbey. Extensions have been added to create the present accommodation comprising 16 bedrooms, a ground floor lounge and separate dining room. Residents’ accommodation is on the ground and first floor. There are assisted bathing and toilet facilities on both floors. The home has a stair lift fitted on the main staircase. The home has an enclosed sheltered patio at the rear of the building and a small parking area is situated at the side of the house. Fees are charged weekly; at present fees range between £375 and £520 per person. The homes service users guide and a copy of the last inspection report could be found in the homes, office and was available on request. Ludbourne Hall DS0000026838.V356438.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection site visit was carried out over a day. A range of documents including staff and individuals’ files, policies and procedures were examined. People were spoken to in the homes lounge and in private rooms and members of staff were also spoken with. The homes manager was present throughout the inspection. Feedback about the home was also received by post in survey questionnaires, in the homes Annual Quality Assurance Audit, and by the homes own quality assurance system. What the service does well: The people using the service were confidant that their care needs had been assessed and that their needs could be met, right from the start of their stay in the home. The services provided did not include intermediate care. People using the service had their health, personal and social care needs fully met and this was set out in an individualised plan of care. People were involved in decisions about their lives, and played an active role in planning the care and support they receive. For example on the day of the site visit one person went out of the home accompanied by a member of staff to do personal shopping and purchase something for the homes fish tank. The person said that this gave her a sense of purpose and in contributing to the homes pets felt she was valued as a person, “her opinion counted”. She saw this a vital part of her care at the home. People’ s lifestyle in the home met their expectations and satisfied their needs. People who used the services were able to make choices about their life style, and were supported to develop their life skills. Social, educational, cultural and recreational activities met individual’s expectations. The manager and staff said that they offered as much choice and opportunity for people to participate in any event that they wished to try. People were empowered through resident meetings and making decisions about things in the home. For example the homes manager had purchased a new notice board, as it had been requested, so that people could be informed of what was happening every day. People enjoyed an appealing, varied diet in pleasant open surroundings, at a time that suited them, with support from staff. Ludbourne Hall DS0000026838.V356438.R01.S.doc Version 5.2 Page 6 People who used the service were able to express their concerns, and complaints and suggestions from those using the service, relatives or other visitors to the home were treated seriously. People lived in a house, which offered a range of facilities and was comfortable, clean and safe. All parts of the home were personalised, clean tidy and comfortable. The people using the service, were supported by Staff, who where trained, skilled and competent. Staff had been subject to rigorous recruitment checks. People said the “staff and the manager are helpful and accommodating” and “the home has really friendly staff”. People lived in a well managed home, with the management, administration and staff team, working together to provide a stimulating, safe environment that respected and protected peoples’ rights. People said that they felt the home was well managed in a flexible style that allowed people to “carry on as normal”. Surveys from relatives and professionals said that the home was run as a family home, with a “family home” atmosphere that people “really benefited from”. What has improved since the last inspection? Since the last inspection the manager said that recommendations made from the last inspection report had been completed or were in the process of being completed; this included; Continuing with a programme of protecting the homes’ night storage radiators and the governing of the hot water supply to washbasins and baths in residents’ en-suites, using a risk-assessment process. Extending the prevention of falls risk-assessment for one resident, to take into account the two small steps that are situated just outside of their bedroom Extending the record of meals and food supplied to residents to contain more detail, e.g.; the vegetables supplied with lunch, the vegetarian option and any other alternatives provided. Documents, such as the home’s infection control guidance had been updated to include the guidance issued by the Department of Health in June 2006. Additionally a ‘Heat wave’ policy and plan had been drawn up for the home taking into account residents collective and individual needs using the NHS guidance also issued by the Department of Health. Ludbourne Hall DS0000026838.V356438.R01.S.doc Version 5.2 Page 7 The home’s fire risk-assessment had been updated as planned to include the recommendations by the Fire Safety Officer. Other areas of improvement have been in the extension and refurbishment of the homes dining area and in progressing with further plans to add a lounge conservatory to the communal space in the home. 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. The summary of this inspection report can be made available in other formats on request. Ludbourne Hall DS0000026838.V356438.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 Ludbourne Hall DS0000026838.V356438.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): 3 (6 is not applicable) Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The people using the service were confidant that their care needs had been assessed and that their needs could be met, right from the start of their stay in the home. The services provided did not include intermediate care. EVIDENCE: The manager said that People were welcomed into the home after a preadmission assessment, had been discussed and completed with the person (or their advocate) planning to move into the home. Two files compiled for each person living at the home were examined. Both files held information about the needs of the person planning to stay at the home. These assessments had been completed before people had moved into the home. The assessments consisted of a basic information sheet, an Ludbourne Hall DS0000026838.V356438.R01.S.doc Version 5.2 Page 10 admission form and pre assessment details of how people wished to be cared for. Other forms completed on entering the home were weight charts, manual handling plans and a record of personal property and possessions. The manager said that to ensure peoples needs were assessed and discussed, before people moved into the home, she would be happy to visit people at hospital, at home, or welcome them into the home on a temporary visit. People said that they knew about the home and the care they needed before committing themselves to coming into the home on a permanent basis. The manager said that the home does not provide intermediate care Ludbourne Hall DS0000026838.V356438.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): 7,8,9,10 & 11 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People using the service had their health, personal and social care needs fully met and this was set out in an individualised plan of care. People were involved in decisions about their lives, and played an active role in planning the care and support they receive. EVIDENCE: Two files compiled for each person living at the home were examined. Both files held a range of information, including assessments and care plans for those people living at the home. The files included ongoing assessments, reviews of care, care plans and care information. Care plans were not as detailed or specific to individuals needs, as they could be. For example the review of care needs was signed and dated but did not Ludbourne Hall DS0000026838.V356438.R01.S.doc Version 5.2 Page 12 include any detail on what care needs had changed, what had improved or what the person had enjoyed doing over the month. These records are important as it gives care staff ongoing information on how to care for people in the way they wished to be cared for. Files also held assessment tools such as weight charts and a record of health professionals visits, such as the optician, the district nurse and the doctor. One survey from a health professional said that the home provided “support to the community nurse to carry out instructions, for example if the nurse required a resident to drink more care staff would monitor this”. Another survey from a health professional said they “have a clear understanding of residents needs” Surveys completed by the people living at the home and by their relatives and advocates said that, people were involved in their care and felt well cared for. Staff, were observed following good medication administration practices such as staying with the person receiving medication until the medication had been taken. This ensured that medication has been taken as prescribed and that individuals have an opportunity to discuss any issues with staff. People’s medications were reviewed regularly with the local pharmacist on an individual basis and this was recorded. Medication administration good practices including good storage, administration and recording of medications had been carried out. Staff supported one person, to administer their own medication safely. The storage area of the medication remains in the kitchen and the manager has previously acknowledged that this is not ideal. The manager continued to explore alternative arrangements for the storage of medication. Ludbourne Hall DS0000026838.V356438.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13.14 & 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People’ s lifestyle in the home met their expectations and satisfied their needs. People who used the services were able to make choices about their life style, and were supported to develop their life skills. Social, educational, cultural and recreational activities met individual’s expectations. People enjoyed an appealing, varied diet in pleasant open surroundings, at a time that suited them, with considerate support from staff EVIDENCE: People said that they had a choice in how they spent their time and if they wished to join in activities in the home. Assessment and care plan information included basic information about how people wished to spend their time. Ludbourne Hall DS0000026838.V356438.R01.S.doc Version 5.2 Page 14 Including “life plans” that had been completed with the person living at the home and staff. So that staff had some idea of what peoples personal history had been, for example past interests and employment. This was designed to make staff more aware of the persons specific interests and a way of considering what activities or stimulation could be provided to that person.l Staff, were aware of peoples past hobbies and interests and how they may wish to spend their time either in the home or with their family. The manager said that the development of an activities programme that built on peoples’ strengths had been developed and comments from surveys reflected this, such as; “this home does everything possible to enable one of my service users to continue living as he wishes whilst ensuring every risk is minimised”. The development of activities in the home was also discussed in the homes ‘resident meetings’ and this was recorded. Surveys from relatives and carers said that they were welcomed into the home. Staff, were observed in the homes kitchen preparing individualised meals for each person. Staff, were clearly aware of peoples choices and preferences. For example using smaller plates for those people with a small appetite and cooking a separate meal for someone who did not want what was on the planned menu. People said that the meals in the home were “very nice ” and that they could choose to eat in the homes dining room or in their own rooms. Ludbourne Hall DS0000026838.V356438.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 & 18 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People who used the service were able to express their concerns, and complaints and suggestions from those using the service, relatives or other visitors to the home were treated seriously. People were protected from abuse, and had their rights protected EVIDENCE: The homes service users guide and statement of purpose included details of how people could raise concerns and complaints. The information provided included the Commissions details so that people were informed about how they could make complaints. Staff said that they had received training on adult protection / safeguarding issues and were aware of who to contact if they had any concerns. Some Staff files held records of some of the training staff had received in this area. People said that they felt able to raise concerns with the staff or the manager. one survey from a relative said “they take the time to listen” they are flexible in their approach to problems”. Ludbourne Hall DS0000026838.V356438.R01.S.doc Version 5.2 Page 16 The manager said that they had no ‘formal complaints’ so there was no entries in the complaints record/book. The manager agreed to record complaints and how they were resolved, in a complaints booked which was to be purchased and introduced. The manager said that despite the lack of recording she monitored complaints and tried to address any concerns not matter how big or small quickly. Ludbourne Hall DS0000026838.V356438.R01.S.doc Version 5.2 Page 17 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 & 26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People lived in a well -maintained house, which offered a range of facilities and was comfortable, clean and safe. EVIDENCE: The premises, was toured with the homes manager and time was also spent in the kitchen with staff and in peoples private rooms. The home presented as clean, tidy and private rooms had been personalised to each person’s tastes and preferences. The manager and staff group had implemented a range of health and safety audit checks to ensure the safety of the building. This included a risk assessment for every room, equipment testing and records for fire safety checks. Ludbourne Hall DS0000026838.V356438.R01.S.doc Version 5.2 Page 18 Other safety measure for the premises included the ongoing guarding of radiators, restricting and monitoring water temperatures and restricting window openings. These measures help to ensure that the home was a safe environment for people to live in. Since the last inspection the manager said that they had acted upon recommendations made at the previous inspection; For example they had extended risk assessments to include; A programme of protecting the homes’ night storage radiators and the governing of the hot water supply to washbasins and baths in peoples’ ensuites, updating the home’s infection control guidance to include the guidance issued by the Department of Health in June 2006. Additionally the home’s fire risk-assessment had been updated as planned to include the recommendations by the Fire Safety Officer. The kitchen was clean and tidy and records had been kept of cleaning schedules and temperature monitoring of equipment and foods. Demonstrating good food health and hygiene practices. There are some parts of the home that have become tired and worn and for example some corridor areas. The manager was aware of the need to address this and had made plans to include this in the future development of the home. Since the last inspection the homes dining room and lounge had benefited from refurbishment and redecoration. The manager had plans to use part of the dining area for people having an interest in computer technology. Ludbourne Hall DS0000026838.V356438.R01.S.doc Version 5.2 Page 19 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 & 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The people using the service, were supported by Staff, who were trained, skilled and competent. Staff had been subject to rigorous recruitment checks. EVIDENCE: Surveys from relatives and carers said; I am really pleased “with the way my father has settled and the staff and manager have helped that to happen all the staff and the manager are helpful and accommodating” and “the home has really friendly staff”. The manager said that training for staff continued to be planned for the future, building on training that had already been completed. Training included a detailed, induction training pack for staff newly employed in the home. The manager had also completed a range of training so that, knowledge and skills could be passed on to staff. The manger was also working with the deputy manager to provide ongoing supervision and training for staff. Staff said that they had the opportunity to attend training. Ludbourne Hall DS0000026838.V356438.R01.S.doc Version 5.2 Page 20 Staff files held clear details of staff roles and responsibilities in job descriptions and procedure documents. The home had a good recruitment process that included interview checklists and questions, references and police checks, identity checks and photographs of staff. The manager said that there had been no changes in staff since the last inspection. Ludbourne Hall DS0000026838.V356438.R01.S.doc Version 5.2 Page 21 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 & 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People lived in a well managed home, with the management and staff team, working together to provide a stimulating, safe environment that respected and protected peoples’ rights. EVIDENCE: The manager, deputy manager and staff team had a range of experience, skills and training in care and management. A range of policies, procedures and systems were in place to ensure that the home was well managed and well maintained. For example risk assessments for peoples care and documents for the safe maintenance of the building. Ludbourne Hall DS0000026838.V356438.R01.S.doc Version 5.2 Page 22 A basic quality assurance system had been developed to assist in monitoring and improving services. People were asked about the service provided and how it could be improved. The manager had responded to quality surveys completed by the people living there by introducing an information/notice board. The suggestion of a board had been made by someone living at the home and this board was used to inform people what was on the menu for the day, activities planned for that day, who was working at the home and any other news items. People said that they felt the home was well managed in a flexible style that allowed people to “carry on as normal”. Examples given were in people bringing in pets such as a budgie and the homes fish tank and parrot. People were very involved in the care of these pets and saw them as a way to make the home feel more homely. Other examples were in people being supported to do personal shopping accompanied by staff or popping over to the park for a stroll. One person said “it is just like being at home”. Surveys from relatives and professionals said that the home was run as a family home, with a “family home” atmosphere that people “really benefited from”. The manager said that the service tried not to manage peoples’ finances and that finances were dealt with as much as possible through outside advocates, such as family members or solicitors. For those people that had money the home oversaw, there were good recording systems in place including receipts for purchases made on behalf of the person living at the home. Other quality monitoring tools that ensured the health, safety and welfare of the people living and working at the home, included checklists, ‘residents meetings’ staff meetings and an annual development plan. The manager said that the annual development plan was in the process of being updated to include the dining area and plans for the new conservatory. The manger confirmed that recommendations made from the last inspection had been addressed; So that the home’s infection control guidance had been updated to include the guidance issued by the Department of Health in June 2006. In addition a ‘Heat wave’ policy and plan had been drawn up for the home taking into account residents collective and individual needs using the NHS guidance also issued by the Department of Health. The home’s fire risk-assessment had also been updated as planned and include the recommendations by the Fire Safety Officer. Ludbourne Hall DS0000026838.V356438.R01.S.doc Version 5.2 Page 23 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 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 2 17 3 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Ludbourne Hall DS0000026838.V356438.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? 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 2 3 Refer to Standard OP7 OP16 OP19 Good Practice Recommendations Extend care plans and care plan reviews to include all aspects of peoples changing care needs. Introduce a ‘complaints book/record’ that show any complaints or concerns that people have raised, how they were addressed and the outcome of the complaint. As planned continue with the planned refurbishment and redecoration of the home. Ludbourne Hall DS0000026838.V356438.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 Ludbourne Hall DS0000026838.V356438.R01.S.doc Version 5.2 Page 26 - 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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