Inspection on 19/06/07 for Lansbury Court Nursing Home

This inspection was carried out on 19th June 2007.

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 12/10/06

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 Mrs Irene Bowater Key Unannounced Inspection 19th June 2007 09:00 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.V336645.R02.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.V336645.R02.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.V336645.R02.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. 12th October 2006 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. Fee rates range from £359 to £407 per week. There are no “top ups”. Extras include hairdressing, chiropody, clothing., outings and newspapers Lansbury Court Nursing Home DS0000018199.V336645.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Before the visit: We looked at: • Information we have received since the last visit on 12 October 2006 • How the service dealt with any complaints and concerns since the last visit • Any changes to how the home is run • The provider’s view of how well they care for people • The views of people who use the service and their relatives, staff and other professionals The Visit: An unannounced visit was made on date 19 June 2007 During the visit we: • Talked with people who use the service, relatives, staff, the manager and visitors • Looked at information about the people who use the service and how well their needs are met • Looked at other records which must be kept • Checked that staff had the knowledge, skills and training to meet the needs of the people they care for • Looked around the building to make sure it was clean, safe and comfortable • Checked what improvements had been made since the last We told the manager what we found. What the service does well: Clear information is provided about the home so that residents know what to expect before they go to live there. The staff collect information together about the person before anyone moves into the home to make sure they can meet their needs. Staff involves the residents, their representatives and other professionals in the care planning to makes sure their needs can be met. The staff have formed good relationships with the residents and make sure their rights to privacy and dignity are met. Lansbury Court Nursing Home DS0000018199.V336645.R02.S.doc Version 5.2 Page 6 There is good communication with other professionals to ensure peoples health care needs are met. Visitors are made welcome and there are good links with the local community. Residents and relatives said they would be able to use the complaints procedure if they had a concern. The activities organisers work hard to provide activities inside and outside of the home. The meals are nutritious, nicely presented and choices are available. Residents said: The food is good I get plenty to eat I can choose whatever I want to eat. The recruitment policies are followed. Comments from the surveys that were returned to the Commission included: My relatives’ health care needs have been met by the nursing staff and there have been various entertainments provided. My relative is always cared for. The staff are very caring and there is a friendly happy atmosphere. The staff are very approachable. If my relative takes poorly they let me know straight away I have no complaints or concerns The staff are good They show affection care and concern What has improved since the last inspection? Staff have completed training and now complete detailed assessments. The staff follow safe working practices when administering medication. Staff make sure they treat residents, relatives and visitors in a professional respectful manner. The social activities have improved. The staff on this unit has completed training in dementia care and the care provision has become more “person centred” A unit manager has been appointed for the dementia care unit Some redecoration has taken place throughout the home. Lansbury Court Nursing Home DS0000018199.V336645.R02.S.doc Version 5.2 Page 7 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. Lansbury Court Nursing Home DS0000018199.V336645.R02.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 Lansbury Court Nursing Home DS0000018199.V336645.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 (Standard 6 is not applicable to this service.) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are given information about the service before being admitted. This means that they can be sure the home can meet their individual needs. The admission assessments ensure the residents care needs will be met. EVIDENCE: The service user guide makes sure people who use the service have all the information they need to make choices about the home. The guide includes information about how peoples’ rights will be respected regardless of age, gender, sexual orientation, race and religion. Lansbury Court Nursing Home DS0000018199.V336645.R02.S.doc Version 5.2 Page 10 All people who use the services have an agreed contract. They give information about any charges in the home. Care plans show that the manager carries out comprehensive assessments before any resident is admitted. The care managers’ and nurse assessments were also available. Information is also available about residents’ previous lifestyles, including background, cultural, religious or other needs and how this will help residents to settle into the home. The assessment looks at what each person can do to take of themselves and what support they will need with the tasks of daily living and personal and health care. Where possible the relatives and representatives are involved in this process. Lansbury Court Nursing Home DS0000018199.V336645.R02.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care planning documentation is comprehensive and person centred. However, lack of detail prevents the system from being fully effective. This means that residents’ needs may not be recognised and fully met. The systems for the administration of medicines are not sufficiently robust to make sure resident’s wellbeing is fully met. Personal support is currently promoting residents rights to privacy and dignity EVIDENCE: Each resident has a care plan which is based on the preadmission assessments which are carried out by care managers, home manager and when necessary the nurse assessor. The assessment tools include pressure sore risk Lansbury Court Nursing Home DS0000018199.V336645.R02.S.doc Version 5.2 Page 12 assessments, dependency, moving and handling, nutritional, continence and fall risk assessments. Care plans are reviewed and updated according to changes in social, personal and health care needs. Residents who have reduced appetite or low weights are y weighed and intervention sought from dieticians. Following the recommendations from the Speech and Language Therapists a care plan was not detailed. This means that the staff would not be able to give the appropriate care to that person. Up to date information regarding changes in wound care is documented on a regular basis and regular reviews take place with residents’, their relatives and care managers to make sure the home is still meeting their needs. The evaluations and daily progress records are still not detailed. For example “safety maintained”, “continue with encouragement”, “functions well”. The staff have started to complete “life histories” for individual residents. Residents social and spiritual care needs are now being promoted especially on the dementia care unit. The nursing staff still focus on the health care needs of residents so that the care plans to not reflect a person centred approach to care delivery. The residents have access to all NHS facilities to ensure their healthcare needs are met. There are regular visits from GP’s and other health professionals including, dentists, opticians and chiropody services. The home has comprehensive medication policies and procedures for staff to use. Records are in place for all medicines received, administered and disposed of. An audit of Controlled Drugs and the Medicine Administration Records (M.A.R.) showed no discrepancies. There is a register of staff who are authorised to administer medication. The staff are not recording when eye drops are opened and some were found to be out of date. Two signatures are needed on the M.A.R when staff are handwriting directions. The senior care staff and unit manager administer medication to residents who live on the dementia care unit. The non-nursing staff have completed a “Safe Handling of Medicines” course. Residents spoken to felt that they are treated with respect and their right to privacy is upheld. Residents spoke about their personal wishes and preferences, which are respected by staff and documented. Examples include locking their bedroom doors, receiving their mail and being addressed by their preferred name. Lansbury Court Nursing Home DS0000018199.V336645.R02.S.doc Version 5.2 Page 13 There was a good rapport between staff, residents and relatives, which was friendly and professional. Care was delivered in private and staff were seen to knock on doors and wait for permission before entering. Comments from relatives included: “The staff are very caring and it is always happy and friendly” “I am always notified even if X is off colour”. Lansbury Court Nursing Home DS0000018199.V336645.R02.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of social activities is provided which offer stimulation and interest for residents living in the home. Support from relatives and representatives provide residents with good opportunities to maintain their previous lifestyles. Residents are well supported to make choices and take control over their lives. Choices of nutritious and appetising meals are available to ensure individual dietary needs and preferences are met. EVIDENCE: The home has a nominated activities person who arranges events both inside and outside of the home. Lansbury Court Nursing Home DS0000018199.V336645.R02.S.doc Version 5.2 Page 15 The notice board in the reception shows what events have taken place and those that are planned. The staff also produce a monthly newsletter that is freely available in the reception area. Events include coffee mornings, visits to the community centre, in house entertainment and going out to the pub for lunch. On the day of inspection some residents enjoyed baking, watched television, played some board games and chatted with the staff. Some people have complex health needs and cannot or do not wish to join ingroup activities. Once all staff have completed the training “Yesterday Today and Tomorrow” a more person centred approach to daily life should happen especially on the nursing unit. The completion of life histories will help improve this part of the service. Comments included: “There has been various entertainments provided which the residents s seem to enjoy” “It would be nice if the people could have a day out once a month” “Staff have raffles for days out and parties”. Visitors were seen to come and go throughout the inspection. They are able to use the lounges or residents bedrooms for visits. It was confirmed that there are no restrictions regarding visiting times. Information about advocacy is available on the reception notice board. Residents have brought small items with them making their rooms personalised and reflective of their previous lifestyles The meals are transported to the dementia care unit by a “hot lock trolley” The staff then serve the meals from the small kitchen opposite the dining room. The tables were nicely set and drinks were readily available. Residents did not know or could not remember what was for the lunchtime meal. Staff said that they choose from a menu the day before but they always ask residents what they would like when they are sitting ready to be served. The menus were not in large print or picture style. The lunchtime meal consisted of sausages, onions, gravy, Yorkshire pudding, potatoes, swede and green beans. Alternatives included assorted salads, sandwiches, and various baked potatoes. Dessert choices included sultana sponge and custard, ice cream or yoghurts. The dining room on the nursing unit is next to the kitchen and meals are served directly from there. Again the tables were set and drinks were readily available. Lansbury Court Nursing Home DS0000018199.V336645.R02.S.doc Version 5.2 Page 16 The meals were nicely presented and of ample portion size. Staff on both units assisted residents in a quiet unhurried manner, making sure everyone had sufficient to eat and drink. Residents said “Food is good” “There’s plenty to eat here”. One comment was that there was too much food put onto the plate and then it could not be managed. This comment was passed to the manager for her to look at. Comments from surveys said: The meals are very nice and are enjoyed by our relative. The evening meal could be better although there is no shortage. Hot and cold drinks, snacks and fresh fruit were available and served throughout the day. The home has introduced the “Nutmeg Gold” menu planner, which gives a nutritional analysis of the menus provided. This is to make sure the residents have a balanced diet based on their preferences. . Lansbury Court Nursing Home DS0000018199.V336645.R02.S.doc Version 5.2 Page 17 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): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information about making a complaint is clear and accessible. This contributes to residents’ and relatives’ views and concerns being voiced. Staff have not received training in Safeguarding Adults so residents are potentially at risk. EVIDENCE: The home has detailed complaints procedures, which clearly sets out how and to whom to make a complaint. The procedure is available in the Statement of Purpose, Service User Guide and is displayed in the home. Comments from surveys included: If I need any help or information I can ask any of the staff who are always willing to listen and try their best to sort things out. No complaints. Good notices are available. I go to the head of staff, then to the manager to complain. I have never had need to be concerned. Lansbury Court Nursing Home DS0000018199.V336645.R02.S.doc Version 5.2 Page 18 The records show that two complaints have been received since the last inspection. One has been resolved and the regional manager is investigating one. There are policies and procedures in place to safeguard the people living in the home. The registered manager has completed the “alerter” training with Sunderland Local Authority. She was clear of her role and what would happen if there were suspicions of abuse. Staff have still not competed this training nor had updates since September 2005 although it is covered during the induction period. Without this training staff may not identify and deal properly with any allegation of abuse in the home. There has been one safeguarding alert, which has been investigated by the Adult Protection team. Lansbury Court Nursing Home DS0000018199.V336645.R02.S.doc Version 5.2 Page 19 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): 19,20,21,24,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The building is kept in an adequate state of cleanliness, repair and decoration. Further improvements will ensure that the environment is comfortable and safe for residents. EVIDENCE: The home is a single storey building with enclosed central courtyard and garden area. There are two separate units one of which is accessed by a secure entry system. The units are self-contained with dining rooms, lounges, a smoking room, and bathing and toilet facilities. Lansbury Court Nursing Home DS0000018199.V336645.R02.S.doc Version 5.2 Page 20 The communal areas on both units were pleasantly decorated and furnished. The carpet in the smoking room is covered in cigarette burns. The chairs in this room are worn and split with the extractor covered in nicotine stains. All corridors, doors and paintwork were showing signs of damage, wear and tear especially from wheelchairs and trolleys. Signage especially on the dementia care unit is improving. Doors are painted in primary colours and there are tactile and collages on the walls. Further thought could be given to improve signage on both units especially on residents’ rooms, bathrooms and toilets. This may make it easier for residents to find their own room without any help. The small kitchenette off the lounge in the dementia care unit was dirty. There was food debris everywhere and the fridge had not been cleaned for some time. The flooring was grimy, un swept and unwashed on a regular basis. There are sufficient bathing and toilets close to all resident areas. Many of the bedrooms have an en-suite facility Twenty-three bedrooms on the nursing unit and nineteen bedrooms on the dementia care unit have an en-suite facility. The nursing unit has two assisted bathrooms although no shower facility. On the dementia care unit there is one shower and two assisted bathrooms. The flooring in several of the en-suite toilets and communal toilets are showing signs of wear. On the dementia care unit there was damage to the walls in bathroom 1 and bathroom five the assisted bath was broken. Towels were being stored on the bath seat and there was a bag of un named slippers and a bag of clothing on the floor. In all bathrooms there is water damage to the boxed areas around the pipes. This means that it is hard to clean these areas on a daily basis. All of the bedrooms are for single use. Residents have brought small items with them making their rooms homely and reflective of their previous lifestyles. Several of the carpets are showing signs of wear and some rooms had a slight odour. On the day of inspection the home was generally clean and adequately maintained. The dementia care unit had a distinct unpleasant smell. And there were some pockets of odour in some bedrooms. Liquid soap and paper towels were not readily available in resident areas. This means that staff are unable to wash their hands effectively. The sluices were generally clean and tidy and a sluice disinfector has been provided. Lansbury Court Nursing Home DS0000018199.V336645.R02.S.doc Version 5.2 Page 21 The laundry is separate from resident areas. It is small and compact. There is damage to the walls from trolleys, which makes cleaning difficult. It was generally untidy and disorganised as the roller iron had been broken and was just being repaired. Once soiled clothing comes to the laundry it is sorted into piles ready for washing. Putting general soiled clothing onto the floor can cause cross contamination. The staff appropriately manages infected laundry. Infection control training is provided, however some staff could not be sure when they had received training. Lansbury Court Nursing Home DS0000018199.V336645.R02.S.doc Version 5.2 Page 22 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 current staffing levels is sufficient to meet the residents’ needs. A training programme is in place to make sure staff have the competence to care for the residents needs. The residents are kept safe and supported by comprehensive recruitment procedures to prevent unsuitable people from working in the home. EVIDENCE: The home has two units, which are staffed separately. Since the last inspection a unit manager has been appointed for the dementia care unit. On the day of inspection the unit manager and two carers were working on the dementia care unit. The nursing unit had two qualified nurses and five care staff throughout the day. Lansbury Court Nursing Home DS0000018199.V336645.R02.S.doc Version 5.2 Page 23 There are sufficient ancillary staff employed over a seven-day period. These include, laundry, catering, maintenance and an activity organiser. Currently there is no administrator or deputy manager employed at the home. The Registered Manager is supernumerary to the staffing levels to enable her to carry out her management duties. The home continues with NVQ level two training with 76 holding the qualification. Four staff files showed that the recruitment procedures are followed. All contained evidence of completed application forms, interview records, two written references, terms and conditions of employment and induction records. Criminal Record Bureau and POVA First checks are carried out and these records are held securely. Personal Identification Numbers (P.I.N.) numbers of qualified nurses are checked with the Nursing and Midwifery Council to make sure nurses are registered. Evidence from the files showed that they have received training in moving and assisting, first aid, food hygiene, and fire safety. They were unclear about having completed infection control training and safeguarding adults. Other training includes, safe handling of medicines, naso gastric feeding, tracheotomy care and “Yesterday, Today and Tomorrow” which includes dealing with challenging behaviours. Lansbury Court Nursing Home DS0000018199.V336645.R02.S.doc Version 5.2 Page 24 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has an experienced and proficient manager who provides leadership. This ensures the home is run in the best interests of people using the service. Clear systems for consultation and quality monitoring make sure that the views of residents are sought and acted upon. Centralised arrangements for the management of resident’s finances generally protects their interests. However the pooling of interest might not be in the best financial interest of some residents. Without up to date training and clear record keeping the staff cannot be sure that residents are fully protected. EVIDENCE: Lansbury Court Nursing Home DS0000018199.V336645.R02.S.doc Version 5.2 Page 25 The registered manager is experienced and competent to manage the home. She continues to update her knowledge to continually improve the service for the people who live in the home. The manager holds staff meetings for all grades of staff with records kept. The manager also holds monthly surgery’s where people can meet and discuss any issues on an individual basis. The Company’s’ quality assurance system includes internal monitoring of complaints, maintenance, catering and domestic services. Storage and administration of medication is audited on a regular basis. Care plans are also internally audited with a number being randomly selected each month. The regional manager carries out regular audits and reports with actions and outcomes are available in the home. These include Regulation visits. The home has clear systems in place to make sure residents personal money is kept safe. The administrator was able to identify the amount that each resident has in their account and all transaction require two signatures, which is part of a safeguard to ensure money is managed in the correct manner. Currently, money held for residents is within an interest earning account and collective interest earned is transferred into a residents welfare account. This means that a resident does not receive interest on their own money as it is pooled into the welfare fund, which is used for social activities. Given this system it was not possible to audit individual accounts. Supervision of staff has not taken place at least six times a year. Without formal supervision the registered manager cannot identify how staff’s learning and development needs can be met. Staff have had training in moving and handling. First aid, food hygiene and a fire drill was carried out 12 June 2007. In house maintenance records have not been completed since April 2007. External maintenance certificates were up to date. Accidents are clearly recorded and the manager completes monthly accident analysis to examine and track any trends. Health and safety meetings are held two monthly. The kitchenettes on the dementia care unit are not cleaned on a regular basis and would benefit from some refurbishment. Lansbury Court Nursing Home DS0000018199.V336645.R02.S.doc Version 5.2 Page 26 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 2 2 2 X X 2 X 2 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 2 2 X 2 Lansbury Court Nursing Home DS0000018199.V336645.R02.S.doc Version 5.2 Page 27 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 OP7 Regulation 15(1) Requirement The registered persons must ensure that all residents care plans set out in detail all assessed needs, and how those needs will be met. All care plan documentation must be person centred, clear and free from jargon and abbreviations The registered persons must ensure that the staff write when eye drops have been opened and check that all medication is not out of date. Staff must ensure that handwritten directions on the Medicine Administration Record have two signatures. The medicine room cupboard on the dementia care unit must be recorded to ensure 25C is not exceeded The registered persons must ensure that all staff receives updated training in protection of vulnerable adults. Timescale of 31/12/06 not met. Timescale for action 01/09/07 2. OP9 13(2) 01/08/07 3 OP18 13(6) 18(1) 01/11/07 Lansbury Court Nursing Home DS0000018199.V336645.R02.S.doc Version 5.2 Page 28 4 OP19 13,23 5 OP20 23 6 OP21 23 7 OP24 16,23 8 OP26 13,16,23 The registered persons must ensure that the premises are kept in a good state of repair internally. A planned programme of routine maintenance, refurbishment and redecoration needs to be implemented with records kept. The registered persons must ensure that the carpet and chairs in the smoking room are replaced. The extractor fan must be cleaned and repairs made to the damage made by wheelchairs. The registered persons must ensure that flooring in en-suites toilets and bathrooms is replaced as part of the refurbishment programme. Damage to walls and boxed in pipe work must be repaired The bath in the dementia care unit must be replaced or repaired. The registered persons must ensure that the worn carpets are replaced as part of the refurbishment programme. The registered persons must ensure that the premises are kept clean and free from offensive odours. Suitable bins must be provided for soiled laundry. The damage to the walls and flooring in the laundry must be repaired. Liquid soap and paper towels must be provided in all resident areas so that staff can effectively wash their hands. Staff must have updated infection control training. 01/09/07 01/09/07 01/11/07 01/12/07 01/10/07 Lansbury Court Nursing Home DS0000018199.V336645.R02.S.doc Version 5.2 Page 29 8. OP35 12, 20 (1) 9. OP36 18(2) 10 OP38 13,16,23 The Registered Provider must 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 Timescale of 31/01/06 and 31/12/06 not met) All staff must receive supervision at least six times a year and a programme developed and recorded. Timescale of 31/12/06 not met The registered persons must ensure that the kitchenettes on the dementia care unit are thoroughly cleaned on a daily basis. The in house maintenance checks must be completed on a weekly and monthly basis according to policy with records kept. All staff must receive up to date infection control training 01/10/07 01/10/07 01/08/07 Lansbury Court Nursing Home DS0000018199.V336645.R02.S.doc Version 5.2 Page 30 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 OP15 OP19 OP19 Good Practice Recommendations It is highly recommended that all of the menus be in large print and picture style. It is highly recommended that the signage throughout the home be improved 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.V336645.R02.S.doc Version 5.2 Page 31 Commission for Social Care Inspection South Shields Area Office 4th Floor St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. 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