Inspection on 22/06/08 for Lansbury Court Nursing Home

This inspection was carried out on 22nd June 2008.

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

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 19/06/07

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 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Lansbury Court Nursing Home Parkhouse Avenue Castletown Sunderland SR5 3DF Lead Inspector Nic Shaw Key Unannounced Inspection 22nd & 23rdJuly 2008 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.V368832.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.V368832.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 www.schealthcare.co.uk Southern Cross Care Management Limited Mrs. Norene Ann Johnson Care Home 56 Category(ies) of Dementia (27), Old age, not falling within any registration, with number other category (56) of places Lansbury Court Nursing Home DS0000018199.V368832.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP, maximum number of places: 56 2. Dementia - Code DE, maximum number of places: 27 The maximum number of service users who can be accommodated is: 56 19th June 2007 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 £402 to £417 per week for residential. For nursing care the weekly rate is £402 £101. Extras include hairdressing, chiropody, clothing, outings and newspapers. Lansbury Court Nursing Home DS0000018199.V368832.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 2 star. This means that the people who use this service experience good quality outcomes. Before the visit: We looked at: • information we have received since the last full visit on 19th June 2007. • how the service has dealt with any complaints & concerns since the last visit • any changes to how the home is run The Visit: An unannounced visit was made on 22nd & 23 July 2008. During the visit we: • talked with people who use the service, relatives and staff • joined residents for a meal and looked at how staff support the people who live here • 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 parts of the building to make sure it was clean, safe and comfortable • checked what improvements had been made since the last visit. • We asked relatives who were visiting to complete a survey. Three completed surveys were returned to us. We told the manager what we found at the end of the visit. What the service does well: There are good admissions procedures so residents know that Lansbury Court will be able to meet their needs. The resident’s health and personal care needs are met to a good standard and there are good medication administration procedures in place. Residents are treated with dignity and respect. And relatives and friends can visit the home any time they wish. Lansbury Court Nursing Home DS0000018199.V368832.R01.S.doc Version 5.2 Page 6 The food is good and the home is clean and fresh. Everyone spoken to said that they would have no hesitation in approaching the manager if they wanted to make a complaint. There are good safeguarding procedures in place, which protect people, and every one said they felt safe in the home. Staff training is good. As well as NVQ level 2 and 3 training in care being provided, most of the staff have had specialist training in the needs of people with dementia. The home is well managed. The manager is qualified and approachable and has worked hard to make sure that residents receive a good service. Residents said: “you get what you want here” “the foods good” “I feel well looked after” “its like your own home” “the manager is nice” “the staff always accompany you to hospital”. Relatives said: “I notice staff making a fuss of the residents” “this home has a nice feel” “she (the manager) runs a good home. What has improved since the last inspection? There were ten requirements made at the last inspection and most of these have been addressed. For example: • care plans are more person centred (this means treating each person as an individual and valuing and respecting their similarities and differences). The manager has introduced “life histories” and residents, relatives and staff have all been involved in writing these. Staff now check and record when some medicines are opened to make sure that they are given this before the expiry date. Handwritten directions also now have two witness statements to make sure residents receive their medicines safely. Staff are being provided training in the protection of vulnerable adults so that they know and understand about abuse, and who this should be reported to should they witness this. They are also being provided with training in infection control. • • Lansbury Court Nursing Home DS0000018199.V368832.R01.S.doc Version 5.2 Page 7 • There have been lots of improvements to the environment including new flooring in bathrooms and en-suites and the replacement of worn carpets in bedrooms and the smoking room. New dining room tables and chairs have also been provided and extractor fans cleaned and repaired. The interest from resident’s money is not put into a centralised welfare fund. Residents accrue interest on their individual savings. All staff now receive a supervision at least six times a year. The kitchenettes on the dementia unit are now thoroughly cleaned on a daily basis and the handyman now carries out in house maintenance checks. • • • 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.V368832.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lansbury Court Nursing Home DS0000018199.V368832.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. We have made this judgement using a range of evidence, including a visit to this service. Good assessment processes ensure that potential residents’ needs can be met at Lansbury Court. EVIDENCE: The manager always obtains a copy of the social work or nurse assessment before a person is admitted to the home for either residential or nursing care. In addition to this, wherever possible, the manager meets with prospective residents before their admission to the home. This is so that she can complete the home’s assessment documents with them. On the day of the visit, as the manager was involved with the inspection, she made sure that the deputy manager was available to take her place and visit a prospective resident to undertake this task. Lansbury Court Nursing Home DS0000018199.V368832.R01.S.doc Version 5.2 Page 10 One resident said they had lived near to the home and that it had been their choice to move to Lansbury Court. A relative spoken to said that their family member had lived in another nearby home. As they were dissatisfied with the care provided there they said “we looked around loads, this one had a nice feel”. Lansbury Court Nursing Home DS0000018199.V368832.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9&10 Quality in this outcome area is good. We have made this judgement using a range of evidence, including a visit to this service. The health care needs of residents are fully met to a good standard. And although the health and personal care needs of residents are generally reflected in the care plans, which are beginning to be written in a person centred way, some lacked detail, which is important to ensure that continuity of care is provided to everyone in the way that they prefer. Staff care practices preserve the dignity and privacy of residents. And medication administration procedures fully protect people. EVIDENCE: Assessments cover a range of health and personal care issues such as continence, moving and handling, falls, nutritional needs and risk of developing a pressure ulcer. From these assessments the care plans are developed. Lansbury Court Nursing Home DS0000018199.V368832.R01.S.doc Version 5.2 Page 12 In one person’s file there were care plans for “wandering”, “falls”, “vision”, “personal hygiene”, “mobility”, and “mental state”. Some of these were not person centred. For example; the care plan for wandering stated “encourage to stay in bed”, instead of considering the individual, why they may be awake at night- is this linked to their past history and therefore should the plan be developed to incorporate this, or alternatively strategies to help the person sleep, such as offering a milky drink or sitting with night staff until sleepy. Another care plan stated “encourage to eat”. During lunch this resident was observed to regularly get up from the table but this was not reflected in their care plan, nor was there information about how staff should “encourage” them to eat, for example; what type of foods should be offered and whether staff should sit with them to offer support. In one care plan looked at, however, there was good step by step guidance about how the resident preferred to be assisted with their personal care, which included the type of soap they preferred to use, the importance of making sure their head is tipped slightly back, so that water does not go into their face, and of talking to the person explaining the process throughout. This person has advanced dementia and in the plan there was good information about how staff should communicate with them and the importance of staff spending 1:1 time with them in their bedroom. Care plans are regularly evaluated and reviewed every six months. Life history work has been introduced. Some residents have written their own life history. This information is very important, particularly for people with dementia, as it helps staff to understand why a person may be behaving in a certain way now and can be used to develop person centred care plans as suggested above. Where people have been assessed as nutritionally at risk, charts are used to monitor their food and fluid intake. Everyone’s weight is monitored monthly to show if there has been any significant weight loss or gain. Everyone said that they felt that their health care needs were met at Lansbury Court. There is no one currently with a pressure sore. People who are at risk of developing these have been provided with special pressure relieving cushions and their skin condition closely monitored through the care plan evaluation and review process. One relative commented about their family member, who has advanced dementia and high care needs, that they wouldn’t be here if it wasn’t for the care they received at the home. They also said that the staff always made sure that their family members hair was kept “nice”. There are regular visits from GP’s and other health professionals including, district nurses (for people in receipt of residential care), optician and chiropody services. Lansbury Court Nursing Home DS0000018199.V368832.R01.S.doc Version 5.2 Page 13 Senior staff or nurses are responsible for ordering and administering medication, which is kept in secure areas of the home. The majority of medication is pre-packaged and dispensed by the chemist in a monitored dosage system (MDS). Senior staff or nurses read the instruction on the Medication Administration Record (MAR) and check this against the information on the MDS before they administer medication. This was done in a discrete, careful, sensitive way. There were no gaps on the MAR sheets seen and clear records were maintained. Where residents are able to look after their own medication this is encouraged by staff. One resident looks after their own inhalers. Staff treated the residents in a dignified, respectful manner. For example, residents were not rushed when staff supported them and their preferred name was used. One relative said that the staff always made sure that the resident’s dignity is maintained. One resident commented “I feel like I’m treated with dignity and respect, they (the staff) realise that you are a human being”. Relatives, when asked in the surveys about whether they felt the care home meets the needs of their family member, all commented “always”. Lansbury Court Nursing Home DS0000018199.V368832.R01.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): 11,12,13,14&15 Quality in this outcome area is good. We have made this judgement using a range of evidence, including a visit to this service. Residents have opportunities to make choices in daily routines, social and community activities. This ensures that everyone is able to lead a lifestyle that matches their individual preferences. Residents receive a wholesome diet in pleasant surroundings, however, staffing levels need to be reviewed during this time to make sure all residents receive the support they need. EVIDENCE: There is an activities co-ordinator and the activities available to people are displayed around the home. On the day of the visit people with dementia were involved with a ball game to encourage exercise and later a reminiscence session. Other in house activities include singers, an organist and Line dancers as well as a local group called the “Castle Town Divas” who come into the home to provide entertainment. There are also regular trips out. There is one “big” outing a month, such as a trip to the Sunderland Empire to see a show. Lansbury Court Nursing Home DS0000018199.V368832.R01.S.doc Version 5.2 Page 15 Residents talked about a recent trip to Harry Ramsdon’s for fish and chips. A summer fete has been arranged to take place in August, there are “pamper” sessions where residents can enjoy having a foot spar and manicure, and some residents help with the garden. A hairdresser also visits twice a week. A monthly newsletter is published which tells people about what has been happening in the home and this is displayed on the home’s notice board. A Priest visits the home every week. A member of the local Church also visits each week to bring communion for some of the residents who are Catholic. Friends and relatives are able to visit their family member at any time. They can have a meal with their family member if they want to and in this way are encouraged to stay in the home as long as they want. Residents commented positively about the quality of meals. There is a choice of main meal and pudding. One resident said that each morning they enjoyed grapefruit, scrambled eggs, tomatoes, fried egg, bacon and a slice of bread. Menus are available in picture format and people with dementia are shown the choice of meal when it is served. This is good practise in dementia care as people with short term memory loss will not remember if asked to choose from a menu some time before the meal. It is also a good way of making sure people with dementia have control over their lives, being supported by staff in a meaningful way to make choices. The tables were nicely presented with table clothes, napkins and condiments. We observed lunch in both dining rooms over the two day visit. On the first day time was spent with people with dementia. During the meal staff offered assistance to those people who needed it in a sensitive, supportive way, however, were interrupted on a number of occasions as they had to offer assistance to at least two other people who, as a result of their short term memory loss, got up to leave the table before they had finished their meal. On the second day of the visit one resident became very agitated during lunch as they had to wait some time for their pudding to be served. People with dementia were given plastic cups instead of a glass. The manager addressed this at the time of the inspection. Lansbury Court Nursing Home DS0000018199.V368832.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16&18 Quality in this outcome area is good. We have made this judgement using a range of evidence, including a visit to this service. There is a good complaints procedure, which ensures people are listened to and their views acted upon. Good safeguarding procedures ensure that residents are fully protected from abuse. EVIDENCE: The complaints procedure is on display throughout the home. Everyone spoken to said that they knew how to complain and would have no hesitation about doing so if they were unhappy. One relative said that they had complained about the laundry and that the manager had sorted this for them. Relatives commented in surveys that they knew how to make a complaint and two of the three relatives said that the service “always” responded appropriately when they had raised concerns. There have been two complaints made since the last inspection. The manager dealt these with appropriately with full records maintained. Lansbury Court Nursing Home DS0000018199.V368832.R01.S.doc Version 5.2 Page 17 The home has a safeguarding policy and procedure. The manager has completed the “alerter” training and is clear of her role and what would happen if there were suspicions of abuse. This was confirmed by a prompt referral made by her following one complaint made which was clearly a potential safeguarding issue. All of the staff are in the process of undertaking training in the protection of vulnerable adults and eight staff have completed this. Lansbury Court Nursing Home DS0000018199.V368832.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,24&26 Quality in this outcome area is adequate. We have made this judgement using a range of evidence, including a visit to this service. The home provides a physical environment that is generally well maintained and meets the needs of people who live there. EVIDENCE: Within the home there are two separate units, one for people with general nursing or residential needs and one for people with dementia. Each of these areas operates independently to one another with separate dining rooms, lounges, bathing and toilet facilities. There were no unpleasant odours in the general nursing/residential unit and relatives visiting their family members who live in this part of the home said “I Lansbury Court Nursing Home DS0000018199.V368832.R01.S.doc Version 5.2 Page 19 find the home clean” and “the bedroom is always immaculate”. One resident said that their bedroom was always kept clean as the domestics come in daily. However, there was an unpleasant odour in one part of the home where people with dementia live. There have been some good attempts to adapt the environment for people with dementia. For example: the long corridors have been altered to look like streets by being given street names with street lamps and “door” furniture, which has the effect of bedroom doors resembling the front door of a house. This is recognised as good practise in dementia care as helps people with dementia, some of whom, as a result of their illness, may believe they are still living at home and not understand that they are living in a care home environment. All communal facilities and bedrooms are at ground floor level and in each unit there is a door, which leads into an enclosed garden area with a greenhouse and garden furniture where people can enjoy sitting in pleasant weather. The door was open so that people living in the general nursing/residential area could freely use this. This was not the case where people with dementia live as the door was locked. Staff said that they sometimes supported people with dementia to use the garden, however, this was dependent upon staff suggesting or being available for this. This was discussed with the manager who agreed it would be beneficial for people with dementia to independently use the garden. Everyone has their own bedroom and many of these benefit from an en-suite toilet facility. Those bedrooms seen were personalised. There are beautiful fresh flowers displayed in the entrance foyer of the home. Menus are displayed at a low level so that people who use a wheelchair can easily read them. A bird box has been placed above the door to the garden where people with dementia live. This is to encourage birds to this area so that people with dementia can enjoy watching them. The bathrooms are fitted with appropriate aids and adaptations to meet the needs of the people who use the service. However, one of the bathrooms where people with dementia live is not being used with a sign above the bath taps stating “this equipment is unsafe”. This bath was broken at the last inspection. In the other bathroom in this part of the home there was dirt lodged down the side of the bath panel and the toilet bowel in one toilet was badly stained. The manager agreed to address these cleaning issues at the time of the inspection. There is a separate laundry area. This was clean, but there was some damage to the walls from trolleys, which would make effective cleaning in this area difficult. The manager confirmed that she has arranged for the handyman to fit plastic sheeting where necessary to protect the walls. Lansbury Court Nursing Home DS0000018199.V368832.R01.S.doc Version 5.2 Page 20 Nine staff have completed training in infection control and arrangements are in place for the rest of the staff to undertake this training. Lansbury Court Nursing Home DS0000018199.V368832.R01.S.doc Version 5.2 Page 21 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. We have made this judgement using a range of evidence, including a visit to this service. Staffing levels are generally sufficient. This ensures residents receive person centred care. Staff training is good, including specialist training to meet the diverse needs of the residents. This enables staff to effectively meet the care needs of everyone living in the home. Staff recruitment procedures need to improve to fully protect the residents. EVIDENCE: On duty when we visited were a Registered General Nurse (RGN) and 5 care staff on the general nursing/residential unit, currently there are 28 residents living here. And 3 care staff in the dementia care unit where 19 people live. Although these staffing levels are generally sufficient, as previously mentioned earlier in the report, staffing levels at mealtimes needs to be reviewed. In addition to the NVQ level 2 qualification in care, which all but 2 staff have achieved, and the level NVQ level 3 qualification in care, which 8 staff have, all Lansbury Court Nursing Home DS0000018199.V368832.R01.S.doc Version 5.2 Page 22 staff have been provided with “Yesterday, Today, Tomorrow” training. This is specialist training to help them understand the needs of people with dementia. There has been a low turnover in staff, which is good for continuity of care. There was an evident warmth between the staff and residents and everyone spoke positively about the staff. Staff files showed that a job application is completed and two written references and a POVA first check obtained, whilst awaiting the Enhanced Criminal Records Bureau check, prior to a new person working in the home. However, the manager did not, in one instance, obtain a reference from one person’s most recent employer and one reference was not from the manager but from another RGN. The manager addressed these issues at the time of the inspection. The manager makes sure she checks the Personal Identification Numbers (P.I.N.) of qualified nurses with the Nursing and Midwifery Council to make sure nurses are registered. Lansbury Court Nursing Home DS0000018199.V368832.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35&38 Quality in this outcome area is good. We have made this judgement using a range of evidence, including a visit to this service. Overall the home is well-run, in a way that upholds the best interests of the people who live here, and ensures their health, safety and welfare are protected. EVIDENCE: The manager has many years experience as a manager of a care home. She is a Registered General Nurse (RGN) and has completed the NVQ level 4 qualification in management. Relatives said “I know Noreen (the manager) comes in and makes checks so I’m spot on with her”. The manager has a Lansbury Court Nursing Home DS0000018199.V368832.R01.S.doc Version 5.2 Page 24 monthly surgery on a Wednesday evening so that relatives unable to visit during the day can meet with her. There are regular staff meetings. Staff also confirmed that they receive regular supervisions which they said were useful as they had the opportunity to talk about the care plans and the needs of the residents. There are clear lines of accountability within the home. There is a deputy manager who takes charge in the manager’s absence. Residents’ views are sought via satisfaction surveys. The home also holds regular resident/relative meetings. The maintenance man does weekly and monthly health and safety checks of the building, and the manager does her own audit of the service each month. The home’s line manager also carries out a “validation” audit every other month to ensure that standards are maintained. A detailed report is completed following this audit with an action plan for the manager identifying any areas that need to improve. Staff receive training in statutory health and safety matters, so that they know how to support residents in a safe way. There are also regular fire drills and tests carried out. An appropriate record is maintained of accidents. The manager also monitors the occurrence of these which helps to identify any themes or trends for which preventable action could be taken. The personal allowance records demonstrated that receipts and double signatures are maintained for all transactions. Lansbury Court Nursing Home DS0000018199.V368832.R01.S.doc Version 5.2 Page 25 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 2 X X 3 X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Lansbury Court Nursing Home DS0000018199.V368832.R01.S.doc Version 5.2 Page 26 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. 2. Standard OP15 OP27 OP21 Regulation 18(1)(a) 23 Requirement Timescale for action 31/10/08 3. OP26 13,16,23 4. OP29 19(1)(a) Staffing levels must be reviewed to ensure people receive the support they need at mealtimes. The bath in the dementia care 01/12/08 unit must be replaced or repaired. This is to ensure people with dementia live in a well maintained environment. Previous timescale not met 01/11/07 The registered person must 01/10/08 ensure that the bathrooms are kept clean and that where people with dementia live is kept free from offensive odours. This is to ensure that people live in a pleasant, clean environment. Previous timescale not met 01/10/07 The manager must obtain a 01/10/08 reference from the staff member’s previous employer. This reference must be provided by the manager. This is to ensure that only suitable staff are employed to work in the care home. Lansbury Court Nursing Home DS0000018199.V368832.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations Care plans should continue to be developed, providing step by step guidance to staff to ensure continuity of care is provided. They should continue to be written in a person centred way. Lansbury Court Nursing Home DS0000018199.V368832.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region 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. Extracts may not be used or reproduced without the express permission of CSCI Lansbury Court Nursing Home DS0000018199.V368832.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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