Inspection on 12/10/06 for Lansbury Court Nursing Home

This inspection was carried out on 12th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Lansbury Court Nursing Home 22/06/08

Lansbury Court Nursing Home 19/06/07

Lansbury Court Nursing Home 09/11/05

Lansbury Court Nursing Home 09/06/05

Lansbury Court Nursing Home 16/12/04

Lansbury Court Nursing Home 24/05/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Lansbury Court Nursing Home Parkhouse Avenue Castletown Sunderland SR5 3DF Lead Inspector Sheila Head Key Unannounced Inspection 12th October 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lansbury Court Nursing Home DS0000018199.V312074.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. Lansbury Court Nursing Home DS0000018199.V312074.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lansbury Court Nursing Home Address Parkhouse Avenue Castletown Sunderland SR5 3DF 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) 0191 549 3950 0191 549 3955 Southern Cross Care Management Limited Mrs. Norene Ann Johnson Care Home 56 Category(ies) of Dementia - over 65 years of age (27), Old age, registration, with number not falling within any other category (56), of places Physical disability (1) Lansbury Court Nursing Home DS0000018199.V312074.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The PD category of registration refers to current service user only The service may from time-to-time admit persons under the age of 65 within the OP category of registration. 9th November 2005 Date of last inspection Brief Description of the Service: Lansbury Court is registered to provide personal and general nursing care for up to thirty-seven older persons and has a separate nineteen-bed unit for personal care to older persons with dementia. The Home is a purpose built single storey building. Single room accommodation is provided, some with en-suite facilities. There is adequate communal living space with good access to all areas of the home. It is built in a quadrangle shape with a central enclosed paved area and is surrounded by grassed areas. There is ample car parking to the rear of the property. There is easy access to local amenities and the Home is situated on a public transport route. Lansbury Court Nursing Home DS0000018199.V312074.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and carried out over one day taking nine hours. The manager was present throughout. Before the inspection the Commission for Social Care Inspection had received up to date information from the manager about services provided by the home. Case tracking was used to review the quality of the service from the service user’s perspective. Therefore, a sample of files were examined. The inspector also toured the building, talked with residents, visitors and staff, then examined documentation and records that included maintenance, staff files, medication administration and training for staff. The inspector also observed breakfast time and shared lunch with the residents. Fees for this service range from £359 - £407 per person per week. What the service does well: What has improved since the last inspection? The dementia unit was being redecorated during the inspection. Primary colours have been chosen for the handrails along each corridor and those that were complete were helpful to residents, as they clearly helped residents find their way around. The chosen colour scheme is creating a lighter environment in the corridor areas of the unit that will enhance the residents’ living space. The garden area has been trellised and now offers residents a secure outside area. New furniture has been bought for the general unit lounge that is suitable for residents and is domestic in nature. Lansbury Court Nursing Home DS0000018199.V312074.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lansbury Court Nursing Home DS0000018199.V312074.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lansbury Court Nursing Home DS0000018199.V312074.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home’s pre admission assessment process does not always identify the needs of potential residents and may mean service users’ needs go unmet. EVIDENCE: Case tracking showed that pre admission assessments were not always completed. The home is waiting for new documentation to be introduced however this has not yet taken place. Assessments were not detailed, some did not contain relatives or resident input and in three cases there was no evidence of where the assessment took place. Lansbury Court Nursing Home DS0000018199.V312074.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Although there is a care planning system in place it is not always completed in full so that the needs of residents are not always met. The home has a robust medicines policy but it was not implemented correctly so residents were at potential risk. Residents are usually treated with respect and the staff safeguard their privacy. Lansbury Court Nursing Home DS0000018199.V312074.R01.S.doc Version 5.2 Page 10 EVIDENCE: The home is still waiting to start using a new system of recording and documenting the care residents are assessed for and how they receive it. Some care plan training has taken place but this has been ad hoc and does not reflect the new documentation. Staff who work in the dementia unit have not been trained in the new assessment process as this has been shelved and they are waiting for a more suitable format. Each resident did have an individual care plan, however there appeared to be little consistency with contents. Most had risk assessments in place however some of these assessments did not lead onto a care plan. For example, one resident’s nutritional intake had been assessed as high risk yet there were no instructions for staff to follow such as type of diet or if they should be weighed. Some had care plans that were not completed. In one plan a wound evaluation that said ‘dress wound’, but did not say how to, and the instruction was written ‘educate staff’. Another care plan stated ‘staff to be aware of this resident’s mental state’, but did not include any detail or instruction as to what their ‘mental state’ may be or, how staff should look after the resident. Another read ‘staff to encourage conversation’ but again there were no written instructions about how to achieve this. Where files lack detail and instruction, the staff will not know how to give appropriate care to some residents so that they may not have their needs fully met. Care files from both units had similar problems. The home uses a monitored dosage system that helps minimise errors. This means that prescriptions are dispensed by the pharmacy into blister packs that show the date and time the drugs are to be given. The Medication Administration Record was completed correctly. Required medication had all been given and had been correctly signed for by staff. However, the system of ‘making available’ medication is bad practice and unsafe. Medication is sometimes left out for residents who cannot take the medicine during the medicine ‘round’. This means that staff do not observe that the medication has been taken by the person it was intended for, and it is unsafe as someone else other than the resident it is prescribed for, could easily take it. The Controlled Drug Register was correct and reflected the amounts of medication locked in the cupboard. The register itself was correct but staff had not entered page numbers when transferring totals to new pages so the record was misleading and difficult to follow. The drugs’ fridge was unlocked and two bottles of eye drops were in use but no opening date had been recorded on the bottle. This is poor practice as this means it is difficult to know the discard date for these medicines which may affect the efficiency of this medication. Some medication stored in the fridge Lansbury Court Nursing Home DS0000018199.V312074.R01.S.doc Version 5.2 Page 11 was no longer prescribed for any resident and should have been returned to the pharmacy so that incorrect usage is prevented. The first aid box that is located in the treatment room contained two ‘airways’, which should not be available for people to use unless properly trained. Potential misuse of this equipment puts staff and residents at risk. Some residents require a thickener to be used in their drinks so that they are able to take liquids safely. Thickeners are prescribed individually however a ‘communal’ tub was being used in the dining room. Three trolleys that are used to transport and keep the medication are supposed to be kept locked at all times except when staff are giving out drugs to residents. When the inspector entered the home the trolleys were ‘parked’ by the entrance to the dining room. All three were open but staff were elsewhere and this bad practice potentially puts residents and visitors at risk. The home operates a good practice policy whereby staff that are giving out medication wear a noticeable red tabard with the message do not disturb giving out medicines written on it which promotes safety and enables staff to concentrate when giving medicines. This practice was not practised when the inspector arrived but later in the morning when the manager arrived staff were wearing tabards correctly. In the dementia unit staff were kind and polite to the residents. They showed discretion and were knowledgeable and sensitive to residents’ needs. They spoke to residents in a caring manner and informed them of what they were doing. All residents have their own room so they can have privacy if they wish. ‘The staff working on this unit are brilliant and they have looked after me as well as my husband’ said one visitor. On the ‘general nursing’ unit of the home staff practices did not always treat residents with respect. Residents were asked ‘personal’ questions in front of other residents whilst at breakfast, and staff spoke about residents in disrespectable ways such as ‘when we’ve got them up’, ‘then we put them in the lounge’ and ‘we toilet them before dinner’. Referring to the person as an object rather than an individual. Lansbury Court Nursing Home DS0000018199.V312074.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in this outcome is adequate. This judgment has been made from evidence gathered both during and before the visit to this service. Opportunities to participate in activities and promotion of social interests is limited for residents so that not all needs are met. The home has good link with families and other visitors and they are welcomed into the home at any time. This ensures that relationships are maintained. The quality of food is good and ensures that residents are offered and receive varied and nutritious meals. Lansbury Court Nursing Home DS0000018199.V312074.R01.S.doc Version 5.2 Page 13 EVIDENCE: An activity organiser is in post to provide activities for residents and to support them in developing new interests and maintaining skills. With the development and enlargement of the dementia unit the time allocated every week needs to be re-evaluated to allow the necessary expansion of activities and stimulation required to meet residents’ needs. On the day of inspection the activities organiser was not there so residents in the dementia unit watched television and videos throughout the day, helped by care staff, as did residents in the general unit. There are some activities planned for the future but these may not meet the needs of the majority of residents. Staff need to be supported and receive specialist training so that they can identify the social needs of residents and to provide a stimulating recreational service to all residents. Visitors came and went throughout the day. The home operates an open door policy so there are no set visiting times enabling residents to have visitors whenever they want. One visitor said ‘I enjoy coming here, there are no strict rules and I can just pop in when I’m passing.’ Lunch was shared with the residents who live in the dementia unit. The dining room is pleasantly decorated but appears cramped when all the residents are together. Residents are asked to choose what they want to eat for lunch the evening before so many could not remember what they had picked. There was a very small A4 printed menu showing the menu for a seven day week propped up on a sideboard but residents were unable to see it so that they were not given any memory triggers. The hot trolley is taken to the small kitchen situated opposite the dining room and care staff then plate up meals and carry them into the dining room for residents. This limits residents’ ability to make choices and retain skills. Tables were laid with appropriate cutlery and tablemats. The food was hot and tasty. One resident asked for seconds as he was hungry and his needs were catered for. Due to staff serving meals in the kitchen there were long periods through the meal when residents were not supervised so that they were potentially at risk. The atmosphere was calm and staff talked to residents in a polite manner when offering bread or drinks. Residents who needed help were offered this in a discreet way so that their dignity was promoted and respected. ‘I enjoyed my meal’ said one resident, another said ‘I always have to ask for salt and pepper but they do bring it.’ Breakfast was observed in the general unit. Residents were offered drinks and a hot breakfast if they wanted it, when they arrived in the dining room. There was a member of staff in the dining room giving assistance to residents if they required it, however once residents had finished breakfast they appeared to wait a long time before being helped from the dining room to wherever they were to spend the day. One resident, who was seated in a wheelchair, did not have footplates attached to the chair so that they were uncomfortably seated and potentially at risk. Another who needed assistance was not offered a choice of meals and their need to use a thickening agent was loudly discussed Lansbury Court Nursing Home DS0000018199.V312074.R01.S.doc Version 5.2 Page 14 in front of other residents. Staff must be trained to assist people with their meals in a way that retains their dignity and so that the experience is pleasurable. Comments from residents included ‘They feed you pretty well and ‘It’s not bad.’ Lansbury Court Nursing Home DS0000018199.V312074.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome is poor. This judgement has been made from evidence gathered both during and before the visit to this service. The complaints system is robust and ensures that concerns are dealt with quickly and resolved satisfactorily. Staff are not adequately trained or updated in how to recognise or deal with suspected or actual abuse so that residents are potentially at risk. EVIDENCE: The complaints procedure is available to residents and their visitors telling them how to make a complaint and who to. The register was up to date, response timescales had been met and solutions found so that residents can be confident that if they have a complaint it will be dealt with quickly and investigated thoroughly. Training records indicated that the last Protection of Vulnerable Adults training for staff was given two years ago so that residents may be at risk from staff being unable to identify and deal with any suspected or actual abuse. Staff have access to written policies and procedures that are available to guide them if required. Staff need to be trained so that residents can be confident that they are protected and kept safe from harm. Lansbury Court Nursing Home DS0000018199.V312074.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home offers residents a pleasant, comfortable place to live however further improvements are needed to enable people with dementia to lead more independent lives. Lansbury Court Nursing Home DS0000018199.V312074.R01.S.doc Version 5.2 Page 17 EVIDENCE: Residents are encouraged to bring personal items into the home with them when they come to live there. The dementia unit was being decorated at the time of the inspection. Primary colours have been used for bedroom doors however signage is poor so that residents may have difficulty in finding their way around and to their rooms. The walls at present are bare and do not present residents with anything to look at or any tactile areas so that they can be stimulated or occupied. There is a small quiet room available but on the day of inspection all the residents were seated in a large circle in the lounge around the television. Maintenance records were complete and all necessary checks such as water temperatures had been carried out on time so that residents can be confident that the building is safe to live in. Door signage in the general unit indicating bedrooms, toilets and bathrooms should be developed so that residents are directed and helped to find their way around. The standard of cleanliness in some parts of the home, in particular the kitchen used on the dementia unit, and ornamental metal shelving in bathrooms throughout the building were not regularly cleaned. The control of infection policy was not being properly adhered to and may have put residents at risk of infection. Staff must ensure that emergency pull cords around the building are free hanging. Where residents have problems with this risk assessments must be in place so that other residents are not put at risk. Lansbury Court Nursing Home DS0000018199.V312074.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The staff recruitment procedure is operated in a robust manner safeguarding the residents from potential harm. The home is staffed to a level to ensure residents’ needs are met and there is a training programme in the home for staff. EVIDENCE: The rota reflected the number of staff on duty in the home on the day of inspection. At present the home does not have a deputy manager and this post is being advertised. The Company should consider development of the activities organiser role so that they can adequately meet the needs of the residents, particularly for the increased numbers living in dementia unit. Also as this unit is offering specialised dementia care, the Company should consider employing a unit manager that is suitably trained so that the needs of residents can be fully met. Staff files were well organised and easy to follow. All contained evidence such as application form, references and Criminal Records Bureau checks so that residents were protected from potential harm. Lansbury Court Nursing Home DS0000018199.V312074.R01.S.doc Version 5.2 Page 19 Staff records confirm that training has taken place for food hygiene, fire safety, safe handling of medicines, NVQ 2 and Coping with difficult behaviour. There is still the need for specialised dementia training for all staff in the home so that they will have the skills to properly care for residents with this illness. Lansbury Court Nursing Home DS0000018199.V312074.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 38 Quality in this outcome is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The manager is registered with the Commission for Social Care Inspection and has all the required qualifications plus extensive experience to manage the home. Systems are in place to determine the quality of the service provided by the home, and ensure that it is run in the best interests of the residents. Clear and well-organised systems are in place that safeguard residents’ personal finances. Staff do not always follow safe working practices so that residents’ welfare is sometimes put at risk. Lansbury Court Nursing Home DS0000018199.V312074.R01.S.doc Version 5.2 Page 21 EVIDENCE: The Registered manager has the appropriate nurse qualifications and experience to manage the home and has completed the Registered Managers Award. However, as the client group has changed and the service has developed, the management team has not changed to reflect this and provide appropriate support for the manager. The Company’s quality assurance systems are in place in the home. Monthly audits are carried out either monthly or bi-monthly that look at medication, care files, personal finances, maintenance, catering and domestic services and health and safety. Monitoring and analysis of complaints and accidents is also carried out. These audits had been completed recently and all were up to date. The Regional Manager also carries out bi monthly checks as well as completing Regulation 26 documentation. Staff meetings have been held recently however the supervision programme for staff is not available to all. Some staff have not received supervision and records are sparse. Staff should be offered supervision six times in a year so that they are given an opportunity to discuss their work and any related issues. The majority of residents have their personal allowances held by the home and these are looked after by the administrator. Each resident has an individual statement of all accounts and transactions that is held on computer. Residents are able to obtain a print out at any time during office hours. Monies are at present held in one non-interest account, however the home is looking towards setting up individual accounts. The home holds a significant float and receipts with two signatures support transactions when a resident requires money. Inspection of the storage arrangements and transaction records for residents’ personal monies were appropriate, safe and accurate. The regional administrator, head office and the manager audit monthly reconciliation reports. Conversations with staff confirmed that they receive training in health and safety matters. Fire safety training was up to date and records are clear and well kept. Housekeeping staff confirmed that they had enough materials to satisfactorily keep the home clean and that they had received training in COSHH five weeks ago. However, a trolley that held cleaning substances was found unattended so that residents were potentially at risk. Some labels that identify cleaning solutions were old and hard to read but staff confirmed that they are waiting for new labels. Moving and assisting procedures by the staff with residents was observed to be good with appropriate practices being followed, however attention must be paid to residents who use wheelchairs, as some footplates were not attached so that residents were potentially at risk. Lansbury Court Nursing Home DS0000018199.V312074.R01.S.doc Version 5.2 Page 22 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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 Lansbury Court Nursing Home DS0000018199.V312074.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 18 Requirement Staff must receive training in the implementation of the assessment for people with dementia. (Previous timescale of 31/01/06 not met) Care plans need to reflect positive outcomes for residents and not just be problems based. (Previous timescale of 31/10/05 and 31/01/06 not met) Medicine trolleys must be locked at all times when unattended and staff must follow safe working practices and procedures. Staff must ensure they treat residents and visitors in a respectful manner at all times. (previous timescale of 31/12/05 not met) Timescale for action 31/12/06 2. OP7 15(1) 31/12/06 3. OP9 13(2) 30/11/06 4. OP10 12(4) 31/12/06 5. OP12 16(2)(n) Activities and choices for 31/12/06 residents must enable them to lead fulfilling lifestyles and be relevant to the individuals needs. (Previous timescale of 31/01/06 not met) DS0000018199.V312074.R01.S.doc Version 5.2 Page 24 Lansbury Court Nursing Home 6. OP15 12(4)a 16(2)(g) 18 13(6) 18(1) 12, 20 (1) 7. 8. OP18 OP35 All staff must be made aware of 31/12/06 the correct methods for feeding residents, in particular in relation to upholding their dignity. All staff must receive updated 31/12/06 training in protection of vulnerable adults. The Registered Provider must 31/12/06 ensure that residents are aware that interest form their personal finances is put in to a centralised welfare fund and that they have given consent to this.(Previous timescale of 31/01/06 not met) All staff must receive supervision at least six times a year and a programme developed and recorded. 31/12/06 9. OP36 18(2) 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 OP19 Good Practice Recommendations Satisfactory arrangements need to be in place to ensure that odour control is implemented at all times throughout the building. Lansbury Court Nursing Home DS0000018199.V312074.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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