Inspection on 11/06/08 for Lancam Nursing Home

This inspection was carried out on 11th June 2008.

CSCI found this care home to be providing an Adequate service.

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

Lancam Nursing Home 28/01/09

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Lancam Nursing Home 55-57 Netherlands Road New Barnet Hertfordshire EN5 1BP Lead Inspector Mr Teferi Degeneh and Ms Ffion Simmons Key Unannounced Inspection 09:20 11th June 2008 X10029.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 Lancam Nursing Home DS0000069184.V362535.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 and Care Homes for Adults 18 – 65*. 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. Lancam Nursing Home DS0000069184.V362535.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lancam Nursing Home Address 55-57 Netherlands Road New Barnet Hertfordshire EN5 1BP 020 8440 7904 020 8449 0557 lancam@hotmail.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Lancam Nursing Care Limited ****Post Vacant**** Care Home 12 Category(ies) of Physical disability (12), Physical disability over registration, with number 65 years of age (12) of places Lancam Nursing Home DS0000069184.V362535.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide personal care with nursing, including accommodation, to service users of both sexes whose primary care needs on admission to the home are within the following categories:Service users with a Physical Disability (Catergory PD) Service users with a Physical Disability who are over 65 years of age (Category PD(E)) The maximum number of service users who can be accommodated is 12 2. Date of last inspection 18th January 2008 Brief Description of the Service: Lancam is a privately owned care home registered to provide nursing care to twelve adults with physical disabilities. The registration category for Lancam allows service users with physical disabilities to continue to receive care at the home when they pass the age of 65 years. There are four single bedrooms and four double bedrooms on the ground floor and first floors of the home. A shaft lift connects the two floors. There are three bathrooms, two of which have assisted baths and one en suite that is not used by the service user who is bed bound. There is a lounge and dining room on the ground floor. There is a large attractive garden to the rear of the home. The home is a in a pleasant residential area close to local shops and transport links. Service users vary in age from early fifties to over eighty. The homes registration conditions allow this. The home has operating for many years but was bought by the current owner last year. Mrs Glenda Barker is the acting manager of the home. Fees charged at the home range between £700 and £1350. A copy of this Inspection report can be requested directly from the home or through the CSCI website (web address can be found on page 2 of this report.) Lancam Nursing Home DS0000069184.V362535.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The inspection was undertaken over a period of eight hours, starting at 9:20 am and concluding at approximately 5:45 pm. Ffion Simmons, a regulation inspector, accompanied the lead Inspector during the inspection. Glenda Baker, an acting manager and Dr Sisil Wimalaratne, one of the owners of the home, were present throughout the inspection. The inspection activity undertaken included a tour of the building, the examination of service users’ files including care records, the examination of health and safety records, the viewing of staff rotas and discussions with people who use the service, care staff and the home’s management. We have also checked the annual quality assurance assessment (AQAA), which was completed and returned to us as part of this inspection, before and after the inspection. The surveys, which were completed by people who use the service, their relatives and professionals, were also considered as part of this inspection We have seen good interaction between staff and residents. The people we spoke to have good opinion about the manager. The residents are satisfied with the care they receive from the staff. The food is good and it was evident from discussions, observations and records that the home works hard to meet people’s cultural, dietary and religious needs. What the service does well: What has improved since the last inspection? Care plans have been updated and there is evidence that people who use the service have been involved in the process. The acting manager and the owner have consulted with the service users’ regarding the preferences of the meals. This has improved the quality of the meals at the home. Complaints are now recorded and appropriately investigated. The home’s policy on safeguarding has been updated and the local authority’s policy on safeguarding obtained. The staff have attended training on safeguarding adults. The well being of people who use the service is reassured by the home’s actions to train staff and to update its safeguarding policy. The owner has now ensured that all staff Lancam Nursing Home DS0000069184.V362535.R01.S.doc Version 5.2 Page 6 who work at the home have a satisfactory criminal record bureau certificate. The acting manager has submitted her application to the Commission for Social Care Inspection to be the registered manager of 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. Lancam Nursing Home DS0000069184.V362535.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Lancam Nursing Home DS0000069184.V362535.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 3, and 6 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. New service users are reassured that their admission to the home is based on the outcome of their assessment and the ability of the home to meet thir needs. EVIDENCE: We looked at five residents’ files and spoke to the manager. The manager said she visits prospective service users and completes their assessment before admission. The files we have seen contained evidence of preadmission assessments. The assessments are detailed in describing the health, social, emotional and psychological needs of the people who use the service. A number of residents spoken to said they are happy with their placements. Lancam Nursing Home DS0000069184.V362535.R01.S.doc Version 5.2 Page 9 Many of the residents have lived at the home for many years. The Annual Quality Assurance Assessment (AQAA), which we have asked for and completed and sent to us by the manager, states that the home welcomes applications from diverse groups in society without prejudging peoples ways of life. Service users who receive funds from local or health authorities are expected to be assessed by their social workers. The manager confirmed in discussions and in the AQAA that the home accepts residents only if it believes that it can meet their diverse needs. The home does not provide intermediate care. Lancam Nursing Home DS0000069184.V362535.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The care plan and risk assessment systems are satisfactory and the health and personal care needs of the people who use the service are met. However, inadequate medication management has put the residents well-being at risk. EVIDENCE: Lancam Nursing Home DS0000069184.V362535.R01.S.doc Version 5.2 Page 11 We tracked the care of five residents during the inspection, and in doing so we checked their personal files. Each resident had a care plan in place on their files. The care plans covered health and personal care needs as well as their social care needs. We noted that attempts have been made to involve residents in reviewing their progress during the month. Daily notes were checked and reflected how residents health and personal care needs are being met. There was limited information in the daily notes however to reflect how the residents social care needs are being met. There was detailed information on file of how staff should support a resident to meet their religious needs, which is very important to them. On the files checked there was information about the residents life story providing background into the life experiences of the residents. The files seen demonstrated that these risk assessments were being reviewed on a regular basis. Equipment for the prevention of pressure ulcers is in use in the home, and each resident we observed was nursed on a pressure relieving mattress, and they commented that they were comfortable on these. Care plans were in place for residents who have been identified of being at risk of developing pressure ulcers and records provided the evidence that residents were being turned regularly to prevent pressure area breakdown. Where residents require complex wound care, the home requests the input of the Tissue Viability Nurse who provides specialist advice on the management of the wounds. Other risk assessments in use in the home include manual handling risk assessment; falls risk assessments and nutritional assessments, which were also updated regularly. Residents have access to the multi-disciplinary team, which includes the General Practitioner, dentist optician, Chiropodist and Physiotherapist. Visits by the multi-disciplinary team are not always recorded in the files of residents, and it is recommended that up-to-date records of visits by the multidisciplinary team are kept. The home has an up-to-date policy in place for the safe management of medication. Medication is administered by a registered nurse. Staff confirmed that they have recently received training in the safe administration of medication. The medication arrives into the home mainly in blister packs and were securely stored at the time of the inspection. Controlled drugs are currently in use in the home, and the balances were checked and were correct and they were stored in line with the legislative requirements. As part of a good practice, the home was advised to include the name of the resident alongside the name of the controlled drug both in the index of the controlled drugs book and on the appropriate page. During the inspection, we saw evidence that controlled drugs had recently been returned to Pharmacy, which is not in line with the current guidelines for the disposal of controlled medication. The acting manager confirmed that they are now aware of the Lancam Nursing Home DS0000069184.V362535.R01.S.doc Version 5.2 Page 12 correct procedures for the disposal of controlled drugs and will be implementing the correct procedures as soon as possible. The temperature of the storeroom and the fridge where medication is kept is monitored on a daily basis to ensure that the medication is stored at the correct temperature. Some medicines in the home were in liquid form. But the dates when the bottles were opened were not written, and they could well be out-of-date and could be risk to the residents’ health. We checked the medication administration records sheets (MARS) and found some gaps in the recording of medication. We audited a sample of loose tablets to check if the quantity of the tablets could be reconciled against the number of signatures. We found that there were irregularities, for example, we counted the number of loose tablets of a drug used for the cardiovascular system against the signatures on the MARS and found that there were one too many tablets in the pack, but the MARS showed that they were all signed as given. There were two gaps in the administration records of a medication used for the gastro-intestinal system. A count of these tablets indicated that the medication had not been administered as prescribed. We checked the MARS and we found that there were no photographs of residents with the charts. We discussed that it would be useful to have a recent photograph of the resident, with permission, on the MARS so that residents can be easily and safely identified. It would also be useful to identify allergies and to note them on the MARS to constantly remind the staff who administer medication. We noted that the home has surplus stock of one medication in particular as the pharmacist is supplying more than is required on a monthly basis. This has resulted in excessive amount of this medication in the home. Lancam Nursing Home DS0000069184.V362535.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The social and leisure activities provided at the home have enabled the people who use service to be engaged. The meals are good and the people’s cultural and dietary needs are met. EVIDENCE: Lancam Nursing Home DS0000069184.V362535.R01.S.doc Version 5.2 Page 14 Lunchtime was observed to be a relaxed and a pleasant experience, with residents eating their meals in places of their choice, including in their bedrooms. We observed the chef coming out to check that residents were satisfied with their meals. The pureed meals were nicely presented and plentiful. Staff were supportive, providing individuals the time they needed to finish their meal. Residents commented that they enjoyed their meals and especially liked the barbeques that they occasionally have in the garden. One resident commented in a survey form: The food is excellent. It was evident from discussions with the people who use the service and the staff and from an assessment of the menus that the home provides meals that meet the residents needs. In the AQAA she completed and sent to the Commission for Social Care Inspection, the manager said the home has introduced more cultural foods; expanded chain of food suppliers, and is planning to offer more fresh food choices in the evenings. The manager explained that the home always takes peoples health, cultural and dietary needs into account when providing meals. From discussions with the manager, residents and the staff, it was evident that various activities are provided both within the home and outside the home. Some residents attend social clubs regularly while others are supported to go out to cinemas, public houses and shops. The AQAA states that the home has obtained brochures from local leisure and educational organisations with a view to support the people who use the service to access them. From residents files, the activities book and discussions with the manager it was clear that service users have participated in activities and games including playing dominos, bingos, watching television programmes, and walking in the garden. It was confirmed at the last inspection that the residents are registered to vote on the electoral roll. From observations we noticed that the residents could access communal areas without any restrictions. We also noticed from discussions with the acting manager that a resident has been supported to move out to live independently in the community in a place of their own. It was clear from conversations with the residents that there no time restrictions for going to and getting up from bed. Lancam Nursing Home DS0000069184.V362535.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at the home are confident that they are protected by the availability in the home of trained staff and satisfactory complaints and adult safeguarding policies. EVIDENCE: One complaint has been recorded since the last inspection. Records showed that this complaint has been investigated and an action plan put in place to address the issue. A number of people spoken to confirmed that they can talk to the manager or the owner of the home if they have concerns. A copy of the homes complaints policy has been displayed in the home and has also been included in service users guide. Most of the people who completed the survey forms confirmed that they know how to complain. The manager has updated the homes safeguarding policy and obtained the local authoritys policy on safeguarding adults as required at the last inspection. From discussions with the manager and the staff, and the assessment of staff files it was evident that a number of staff have attended safeguarding adults training. The staff spoken to were confident in describing the actions they should take to safeguard Lancam Nursing Home DS0000069184.V362535.R01.S.doc Version 5.2 Page 16 people who use the service. The staff were observed to have appropriate interactions with the residents. Lancam Nursing Home DS0000069184.V362535.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, and 26 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The facilities, cleanliness and maintenance arrangements make the home a safe and comfortable place to live in for the residents. However, the safety of the home can be further improved by fitting window restrictors for bedrooms on the first floor. Lancam Nursing Home DS0000069184.V362535.R01.S.doc Version 5.2 Page 18 EVIDENCE: The home is accessible and provides a homely environment. Residents have access to lounge and dining areas where they can eat their meals and relax. There is an accessible and spacious well-maintained garden available for residents to enjoy, and a resident commented that they really enjoyed the barbecue they had out there a few days before to the inspection. All parts of the home were clean, bright and free from bad smells on the day of the inspection. We viewed some bedrooms, one of which was a double room. We observed that staff had made sure that a screen was in place to promote the privacy and dignity of the residents who have a shared bedroom. The rooms were clean and tidy and residents who spent their days in bed were nursed on the appropriate pressure relieving mattresses, and appeared comfortable on these. However; the windows of one of the bedrooms on the first floor did not have restrictors and this put the health and safety of the residents at risk. There is a separate laundry room in the home, equipped with the necessary equipment. Guidelines were on display for the prevention and control of infection. The Manager explained that the laundry may be re-sited or updated depending on the planning permissions for the house next door. Signs of old water damage was observed to the ceiling of the laundry room. The care staff are currently doing laundry tasks on top of their other care responsibilities. This issue was discussed and the owner of the home was asked to increase the staffing level on shift to ensure that there are adequate number of staff to undertake all the tasks including laundry. This is mentioned below under Staffing. Lancam Nursing Home DS0000069184.V362535.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, and 30 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Even though people who use the service are confident that they are supported by trained and experienced staff, they are not sure if the staffing level during the daytime is sufficient to meet their needs. EVIDENCE: An assessment of the staff rota and a discussion with the acting manager and the owner of the home showed that there are four care staff and a qualified nurse or the acting manager working at the home during the days and three care staff and a nurse in the evenings. There are two care staff on shift after 8 pm. The home has also a domestic assistant who helps with cleaning during the days. Currently there are ten people who live at the home. From observations and discussions with the manager it was understood that a member of staff who was undertaking the laundry tasks had left and that the care staff were covering this job. The owner was asked to look into the staffing Lancam Nursing Home DS0000069184.V362535.R01.S.doc Version 5.2 Page 20 level to ensure that there is an additional member of staff on shift to help with the laundry tasks.This would give the staff sufficient time to provide care to the people who use the servce. The files of five staff who have been recetly recruited were assessed. Three of these staff did not have contracts or terms and conditions of employment in their files. The acting manager and the owner of the home said that they would issue terms and conditions of employment to the staff only after they are satisfied with their work. Important documents such as training certificates, job descriptions, criminal record bureau (CRB) certificates and written references were in the staff files. The home has also a recruitment policy which requires new staff to apply for jobs, attend interviews, supply satisfactory references and CRB ceritficates before starting work at the home. A number of people who were spoken to and who completed survey forms gave satisfactory feedback aboout the staff. Two care staff who were interviewed had a long current and past work experience supporting older people in a care home. From the staff files and discussions with the manager and staff, it was clear that a good number (75 ) of the staff have achieved a national vocational qualification (NVQ) in care. The staff have also attended training programmes such as manual handling, fire safety, first aid, infection control, safeguarding adults and basic food hygiene. The staff records and discussion with the manager confirmed that the staff have regular supervision and have a training programme. In discussion with the staff, we could see that they were aware of the residents needs and were observed to be respectful and compassionate in their approach to the residents. One of the registered nurses that was on induction at the home commented that they have experience of working in a care home with Nursing prior to being employed at this home. Lancam Nursing Home DS0000069184.V362535.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, and 38 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Despite the presence of a committed, knowledgeable, and open acting manager, the quality of the service is yet to improve to ensure that the risks to the people are minimised or eliminated. Lancam Nursing Home DS0000069184.V362535.R01.S.doc Version 5.2 Page 22 EVIDENCE: The acting manager has worked as a senior carer at the home for a number of years. She is a registered nurse and has also successfully completed a management qualification at a postgraduate level. From discussions it was clear that the acting manager had previously managed services and projects. The staff and the residents spoken to had good opinion about the acting manager. They said they find it easy to talk to her. One person said: Glenda is excellent. We found the acting manager knowledgeable, experienced, and open to ideas. She is a hardworking person with a commitment to improve the quality of service for people who use it. She has recently applied to the Commission for Social Care Inspection to be regestered as the manager of the home. The acting manager said she regularly checks medicines, medication records and processes and practices of infection control. She said a senior member of staff has been given a responsibility to undertake a quality review of the service. She said people who use the service give their views informally to staff and formally at the residents meetings, which usually take place monthly. An assessment of the minutes of a residents meeting indicated that the residents discussed issues that concerned them. The home has also prepared a questionnaire for the people who use the service and this has been distributed and collected from some residents. The content and format of the questionnaires appeared to need improvement, which the manager agreed to do. Also the manager is aware that the purpose of the quality review is to seek the views of all the stakeholders and to collate the outcome and to put an action plan to improve the serve. The acting manager explained that the home does not manage the residents money. She said that the residents’ relatives look after their finance. However, she said, the relatives of one person gives some money to the owner of the home for personal and toiletery expenses. The acting manager confirmed that records of receipt of money and expenses for this person are kept by the home. As mentioned above under Environment, the home was bright, clean and free from bad smells. The acting manager confirmed that she regularly checks the infection control policy of the home is implemented by the staff. There is a list of cleaning materials which could be hazardous to health and safety of the people who live or work at the home. It was clear from discussions with the acting manager and from observations that these substances have been kept in locked cabinets. There is a system for recording incidents and accidents. We noticed that two incidents, which have occurred sice the last inspection, have been recorded and dealt with appropriately. Facilities of the home are well Lancam Nursing Home DS0000069184.V362535.R01.S.doc Version 5.2 Page 23 maintained with the evidence that regular tests and services to the passenger lift, boliers, call bells and emergency lightings. A pest control officer who routinely visited the home on 16/05/08 confirmed that they inspected all accissible bait stations and could not find any pest activity at time of visit. A health and safety officer who visited the home on 28 November 2007 asked the owner of the home to undertake nine activities, including doing risk assessment of the home, making cleaning products accessible to cleaning staff and to displaying health and safety law poster at the home. There was no recorded evidence that all the requirements have been complied with. From discussions with the acting manager and from the assessment of the visitors book we learnt that a fire officer visited the home on 18/03/08. Discussions revealed that the fire officer required the home to provide more fire detectors. Written report of this visit was not available to check if and what other requirements were made by the fire officer. We asked the acting manager during the feedback session at the end of the inspection to take action to comply with the fire officers requirement to reduce and eliminate the risk of fire at the home. Lancam Nursing Home DS0000069184.V362535.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 X 2 X 3 3 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 2 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 2 34 X 35 3 36 X 37 X 38 2 Lancam Nursing Home DS0000069184.V362535.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. 1 Standard OP9 Regulation 13(2) Requirement The registered person must ensure that all medicines administered in the home are recorded and signed for by the staff. When service users miss their medication for any reason, this must also be recorded by specifying the reasons. This will ensure that people receive the correct levels of medication. Timescale for action 19/06/08 2 OP9 13(2) The registered person must investigate the reasons why there were gaps of medicines not being administered and signed for on some occasions by staff. Action must be put in place to ensure that medication is safely stored and administered as prescribed. In this way the risk to the residents would be eliminated. This was an immediate requirement. Records must be kept of the 30/06/08 dates when bottles of medication in liquid form are opened. This will help the home know how long the medicines have been opened and consequently reduce risks to people who use the service. DS0000069184.V362535.R01.S.doc Version 5.2 Page 26 Lancam Nursing Home 3 OP9 13(2) 4 OP22 23(2) 5 OP27 18(1) 6 OP29 18 7 OP33 24 8 OP38 23(1)(2) 9 OP38 23(4) Details of allergies must be recorded on the medication administration sheets. This will prevent mistakes from occurring and ensures the safe administration of medication. Bedroom windows on the first floor must be assessed and fitted with window restrictors. This will reduce or eliminate some accidents and incidents and ensures the health and safety of people who use the service. There must be a designated staff to do the laundry tasks. This would give care staff sufficient time to provide personal and social care to the people who use the service. All staff working at the home must have letters of employment which details terms and conditions of service. The registered person must ensure that the employment of any persons on a temporary basis should not prevent service users from receiving services that meet their needs. Quality assurance systems must be fully implemented. This would give the residents and their representatives an opportunity to have a say on the quality of services and facilities. All matters raised on 28 November 2007 by the health and safety officer must be complied with. A written confirmation of this compliance must be sent to the Commission for Social Care Inspection. The requirements made on March 18 2008 by the local fire officer must be complied with. A written confirmation of this compliance must be sent to the DS0000069184.V362535.R01.S.doc 30/06/08 30/06/08 31/08/08 30/07/08 31/08/08 31/08/08 31/08/08 Lancam Nursing Home Version 5.2 Page 27 Commission for Social Care Inspection. 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 Refer to Standard OP7 OP9 Good Practice Recommendations The registered person should ensure that care plans contain detailed information regarding the needs the needs of the people who use the service and how these are met. The registered person should include the name of the residents alongside the name of the controlled drugs both in the index of the controlled drugs book and on the appropriate page The registered person should keep the records of visits to the home of general practitioners, physiotherapists, opticians and all other visits made by health professional. The registered person should ensure that there are recent photographs of the residents, with permission, on the MARS so that residents can be easily and safely identified. 3 4 OP9 OP9 Lancam Nursing Home DS0000069184.V362535.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. Lancam Nursing Home DS0000069184.V362535.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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