Inspection on 13/08/07 for Lansdowne Care Home

This inspection was carried out on 13th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Lansdowne Care Home Claremont Road Cricklewood London NW2 1TU Lead Inspector Margaret Flaws and Sue Mitchell Key Unannounced Inspection 09:30 13 and 14 August 2007 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 Lansdowne Care Home DS0000068281.V343419.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. Lansdowne Care Home DS0000068281.V343419.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lansdowne Care Home Address Claremont Road Cricklewood London NW2 1TU 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) 020 8830 8444 020 8830 8555 Four Seasons (No 10) Limited Natasha Lazovic Care Home 92 Category(ies) of Dementia - over 65 years of age (32), Old age, registration, with number not falling within any other category (60) of places Lansdowne Care Home DS0000068281.V343419.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One specified service user who is under 65 years of age may be accommodated in the home. The home must advise the registering authority at such times as the specified service user attains 65 years of age and vacates the home. Date of last inspection Brief Description of the Service: Lansdowne Care Centre is a purpose built care home. It opened in 1998. The is registered to provide nursing care for a maximum of 92 older people. It is a care home owned by Four Seasons. The aim of the service is to be a centre of excellence offering a warm, homely comfortable and safe environment for all who live in it. The building has three floors with separate units on each floor. The reception, manager’s office, kitchen and laundry are all on the ground floor. Pembroke Unit has 28 beds and is on the ground floor. Merrion Unit has 32 beds and is on the first floor. These provide general nursing care for older people. The third unit, Kennilworth, provides nursing care for 32 older people who have dementia. Until 2006, the Kenilworth dementia unit operated under a separate registration but all three units have now been combined under one registration. There is one registered manager for the home, supported by a Deputy Manager. All bedrooms at Lansdowne are single and have en-suite facilities consisting of a toilet and a wash hand basin. There are two passenger lifts. Each unit has a choice of lounge areas as well as a separate dining room. Assisted bathrooms and shower rooms are provided within each unit. There are two attractive paved garden areas with a range of plants and shrubs. Seating is available for service users. Lansdowne Care Centre is near Cricklewood railway station and is well served by local shops and amenities. Brent Cross shopping centre is approximately a mile and half to the north of the home. The provider must make information available about the service, including reports, to service users and other stakeholders. The fees for the home range from £580-£850. Lansdowne Care Home DS0000068281.V343419.R01.S.doc Version 5.2 Page 5 Lansdowne Care Home DS0000068281.V343419.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days. It was undertaken by Inspector Margaret Flaws and CSCI Regulation Manager Sue Mitchell as part of the routine schedule of inspections. The Registered Manager was on holiday at the time of the inspection but the Deputy Manager and the nurses in charge of the units very ably assisted us. Over the two days, we were able to speak to most staff on duty, either individually or during handovers. We also spoke to many people living in the home and their visitors. Tours of the buildings and grounds and inspections of the residents and staff records, general home records and policies and procedures formed the rest of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Two requirements and six recommendations were made at this inspection. One maintenance requirement covers a number of areas. Ground floor bathrooms need door repairs; a rucked carpet needs fixing and two ground floor shower rooms require redecoration. CSCI must receive a copy of a refurbishment plan and a risk assessment done for the kitchen refurbishment. A night time fire drill must be held, in a way that does not disadvantage the residents. Recommendations are made that the home informs relatives if the GP is not available and the receipt of medication recording is reviewed. It is also recommended that protective covering is placed on doors to prevent Lansdowne Care Home DS0000068281.V343419.R01.S.doc Version 5.2 Page 7 wheelchair damage; that dependency levels continue to be reviewed; that supervision recording be reviewed and that old information in health and safety folders be archived. 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. Lansdowne Care Home DS0000068281.V343419.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 Lansdowne Care Home DS0000068281.V343419.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 People who use this service experience good outcomes in this area This judgement has been made using available evidence including a visit to this service. People living in the home benefit from full assessment and pre-admission processes to ensure that their needs can be met. EVIDENCE: Prospective residents are fully assessed by either the Registered Manager or Deputy Manager before they move into the home. Placing authorities also compete full pre-admission assessments. All assessments were in place on the files of all new service users which were examined. The home continues to have block booking arrangements with three North London boroughs and has a number of private clients. All residents have contracts in place and, generally, the placing authorities review these annually. The London Borough of Brent has generally been inconsistent and slow at completing reviews. Staff noted that the dependency levels of new admissions are increasing. The home has one vacancy at the time of the inspection. Lansdowne Care Home DS0000068281.V343419.R01.S.doc Version 5.2 Page 10 Lansdowne Care Home DS0000068281.V343419.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 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home can be confident that their health, personal and social care needs will be assessed, well documented and reviewed and met. They will also be supported to access a range of health care services to meet their varied needs. Medication practices are safe and protect the people living in the home. People living in the home can be assured that they will be treated with respect by staff. EVIDENCE: Fifteen care plans and files were inspected and we spoke to most people living in the home and many visiting relatives over two days. I also spoke to most staff, either individually or in handover. The care plans and accompanying files were comprehensive and focussed on peoples’ individual needs. Care plans have been restructured, are generally well written and are more outcome Lansdowne Care Home DS0000068281.V343419.R01.S.doc Version 5.2 Page 12 focussed, with attention to each person’s individual needs. There is a model life history available to staff to enable them to write up a personal story about each individual. Staff were able to describe how they support the residents and work to meet their needs. I viewed the healthcare care records of six residents (Pembroke and Merrion floors). These were very detailed and contained information on all health care assessments carried out by the home, health care professionals as well as multidisciplinary contact with GP, physiotherapist, occupational therapist, speech therapist, dentist, optician, chiropodist etc. Further records inspected the following day on Kenilworth Unit reflected the same detail and standard, although there could still be some improvement in describing the mental health needs of the people with dementia. The home uses a new dependency rating tool, which identifies specific health care needs which form part of the individual’s care plan. Staff are trained to use this tool and are able to use it to assess outcomes and changes for residents. All assessments were seen to be reviewed monthly: these included, tissue viability, nutrition, falls, mobility etc. All residents are weighed monthly; those whose weight is of concern were seen to be weighed weekly. The home has six people with pressure sores, five were admitted from hospital with pressure sores and one developed them due to being bed bound. There were five people who were receiving wound care treatment. The manager is a qualified tissue viability nurse and carries out assessments of all people admitted with pressure sores. There are also good links with the tissue viability nurse at Barnet General hospital. I looked at the records of treatment of two people with pressure sores; these were detailed with body maps and photographic evidence. The nurses spoken to were very proud of the fact that they were able to ensure that the residents had good treatment and their wounds were healing well. The home provides a range of pressure relieving equipment for the residents, this was evident in the bedrooms inspected. All residents have a continence assessment carried out by one of nurses whose responsibility this is. The home supplies continence pads etc. The home has one GP who comes to the home weekly to see the residents that are referred by the staff and family. On the day of the inspection one relative was upset to find his relative had not seen the GP that day as the GP was on holiday. He had requested that his relative be seen that day. Staff explained to him why the GP wasn’t visiting and said they would contact the surgery to get his relative seen as soon as possible. It is recommended that the home notify relatives when the GP is unavailable and ensures that alternative arrangements are made clear to both residents and relatives. Staff informed me that referrals for speech therapy, physiotherapy etc are made via the GP; this was seen to be recorded in the residents records. One resident has been referred for speech therapy assessment due to swallowing Lansdowne Care Home DS0000068281.V343419.R01.S.doc Version 5.2 Page 13 difficulties. I spoke to the visiting physiotherapist who said that she comes once a week to work on rehabilitation with some residents who need it and to advise staff on good practice. I was informed that the dentist and the optician visit the home every six months. There was a record of these visits and outcomes in the files sampled. The chiropodist visits every two months and residents have access to both NHS and private treatment. As noted at the previous inspection the home is gradually phasing out the use of bed rails and using alternative methods of support. Relatives and residents are consulted and asked to sign a consent form for the withdrawal of the use of bed rails. These were seen on the files sampled. A couple of relatives had refused their consent preferring that bed rails continue to be used. The new beds have integrated support, can be lowered to minimise risks from falls and have pressure pad alarms. A complementary system of using a mattress on the floor to prevent injury if a person falls demonstrated that the home is another way the home is creatively managing these risks. In some cases, the accident and incident records indicated that some residents have had a high number of falls from their beds to the mattress but staff were able to describe how this was monitored, reviewed and risks reduced. The clinical room on each floor was inspected. The home had received its monthly supply of medication at the weekend. The home uses a monitored dosage system (MDS) supplied by Boots. The home uses a receipt book as well as recording on the MAR sheets that the medication has been received. Two staff do this and I was informed that it takes about 2 hours to complete for each floor. I discussed the need to duplicate receipt of the medication, the majority of which is in MDS packs. I consulted the CSCI pharmacy inspector who agreed that the MAR sheets are the usual way of recording receipt of regular medication and a second record although good practice was not always necessary except for one off or irregular prescriptions. It is recommended that the receipt of medication recording is reviewed with the dispensing pharmacy and the organisation. Boots do not carry out regular audits of the homes medication systems and storage. The home carries out its own internal audits of its medication at least monthly. I inspected this process and found it to be very proactive. The audit form records identified issues, the person responsible for addressing the issue and gives a timeframe for completion. Staff then write on the form what they have done and this is kept on the noticeboard. Each clinical room was secured and medication locked in the trolley and cabinets. There was a record of fridge temperatures. There is a record of staff authorised to administer medication. The nurses spoken to informed me that they had had medication training from Boots in December 2006, which they found helpful and informative. They also said that they have regular professional training to keep their nursing skills updated. Lansdowne Care Home DS0000068281.V343419.R01.S.doc Version 5.2 Page 14 All residents spoken to were very clear that the staff treated them very respectfully. They all said that they were addressed appropriately; that the staff respected their privacy and wishes – this was also observed in staff interactions with them. Lansdowne Care Home DS0000068281.V343419.R01.S.doc Version 5.2 Page 15 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 People who use this service experience good outcomes in this area This judgement has been made using available evidence including a visit to this service. The home has a reasonable range of activities for the residents’ benefit. Relatives are free to visit at any time and do. Peoples’ choices are supported and encouraged. The home provides a varied diet and supports people to eat their meals at their own pace. EVIDENCE: Activities in the home follow a similar pattern to previous inspections. A volunteer assists the Acting Activities Coordinator with unit based activities take that place daily. These include karaoke, bingo, music and art sessions, reflexology, reading discussion groups, visits to local pubs and coffee shops, and to religious facilities. The home also facilitates and supports religious and cultural visits. Many people living in the home prefer to pursue their own interests, often in their own rooms, including reading, watching television and doing arts and crafts. Others are not well enough or chose not to participate in formal Lansdowne Care Home DS0000068281.V343419.R01.S.doc Version 5.2 Page 16 activities. Trips outside of the home are organised by the Acting Activities Coordinator. On the second day of the inspection, I spent some time observing people in the lounge areas of the dementia unit. There was always a staff member on duty in the lounge, spending time with the residents there. People were chatting and watching television and speaking to visitors. Prior to this, there had been an organised karaoke session. A significant number of relatives and friends visited over the inspection days and I was able to speak to most of them. They were mostly very positive about the home. Several relatives particularly noted that the home was very good at rehabilitation and helping people recover after hospitalisation – they all said that their relative was doing very well in Lansdowne; that the care was very good and the staff responsive and kind. Several also said that their relative’s cultural needs were considered and addressed. This was observed in the way that several people with specific cultural dietary needs were provided for. Relatives’ meetings are held regularly and the notes of the last meeting indicated a constructive process in place. All people living in the home who were able to talk to me said they chose how they spent their time and exercised control, as much as they could, over their lives. I met the chef who showed me the home’s four week rolling menus, which provided a choice of main meals as well as alternatives. The staff ask each resident their preferred choice of meal each day. A list is then sent to the kitchen. The choices were varied on the lists seen. Some people need to have their food pureed or liquidised and be supported to eat their meals. This was observed on the day of inspection. Nursing staff told me that the proportion of people needing assistance to eat their meals has increased with approximately up to ten or more people needing this support on each floor. The meals are sent up to each floor in heated trolleys and then staff serve the residents. The chef explained that he caters for specialist diets such as diabetics. The kitchen was noted to be in urgent need of refurbishment. The chef stated that this was planned for August / September this year. There would be some disruption to the ground floor as the kitchen would be moved into the Pembroke unit and residents would have take their meals in their rooms, the lounge or the other units. Lansdowne Care Home DS0000068281.V343419.R01.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 and 18 People living in the home experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a sound complaints procedure and the service users, their relatives and advocates can be assured that complaints will be actively investigated and followed up. They can also be assured of protection by the home’s adult protection policies and procedures and from staff trained to respond appropriately. EVIDENCE: We were unable to inspect the complaints file on this occasion because it could not be located. However, I had inspected the complaints records in the random inspection in January and found that all complaints received were properly recorded, fully investigated and followed up. People living in the home and relatives said that they knew how to complain if they needed to and said that the home was responsive to them. Staff are regularly trained in adult protection and there is a good policy and procedure in place. Staff could describe what they understood to be safeguarding issues and what actions they would take to address these. There Lansdowne Care Home DS0000068281.V343419.R01.S.doc Version 5.2 Page 18 has been one adult protection investigation since the last inspection, which was satisfactorily investigated and found to be unsubstantiated. Lansdowne Care Home DS0000068281.V343419.R01.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): 19,20,21,22,26 People using this service experience an adequate outcome in this area. This judgement has been made using available evidence including a visit to this service. While the environment is continually under review and refurbishment, some work needs to be done at this stage. The home provides a clean and safe environment for people to live in. EVIDENCE: We toured the premises with the home’s handy person .He is responsible for general maintenance such as painting, decorating and minor repairs as well as ensuring that services to equipment are carried out regularly and doing fire safety checks and drills. The home was clean with no offensive odours. There were cleaners working on each floor. The home has bought a new washing machine which is consistent for washing at high temperatures. There is a red Lansdowne Care Home DS0000068281.V343419.R01.S.doc Version 5.2 Page 20 bag system in place for those clothes that need to washed in this way for infection control. A number of people were in their bedrooms. Rooms were seen to be spacious and a number had specialised beds for the residents’ comfort. These new electric beds can be raised up and down and the ends adjusted using a remote control. They also have integrated protection for those at risk of falling out of bed. The home has a minimum expectation for what should be in a room (furniture, layout, welcoming elements) and there is a photo on each unit’s noticeboard to guide staff setting up the rooms on this basis. Rooms have ensuite facilities consisting of toilet and wash hand basin. There are showers and bathrooms on each floor. It was noted that two of the ground floor shower rooms required redecoration. The handy person stated that he was due to start this work soon. One of the ground floor bathrooms had a damaged door caused by wheel chairs. It is recommended that kick plates or some form of protective covering be placed on the doors to prevent damage by wheelchairs. The carpet on the ground floor was rucked in places and needs to be stretched to ensure it doesn’t present as a tripping hazard. The deputy manager stated the carpet was to be replaced on the ground floor. An action plan with details of the planned refurbishment to the home must be sent to CSCI within the stated timescales. As stated in the section Daily Life and Social Activities the kitchen is due to be replaced and the kitchen to be temporarily moved in to the ground floor unit. A risk assessment must be carried out to ensure residents safety during the proposed works. Because of their increased use and because of an incident in which a sling broke, the home is now carrying out monthly safety checks on all hoists and slings used in the home. A record of these checks was made available for inspection. All equipment and aids used in the home have the required services and checks carried out. A record of these was made available and found to be in order. Some of the residents were sitting out with staff in one of the enclosed gardens during the morning enjoying listening to music. The patio area was well kept with plants and flowering containers in abundance. The other garden area was not used and appeared to need of some work to trim back bushes etc. Lansdowne Care Home DS0000068281.V343419.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 People using this service experience good outcomes in this area This judgement has been made using available evidence including a visit to this service. People living in the home are well supported by competent, well trained and supervised staff team. There are robust recruitment procedures in place for the protection of the people living in the home. EVIDENCE: I looked at a sample of six of the most recently employed staff the home. Twenty eight people had been appointed since the last inspection in July 2006 with fifteen still in post. The files were well organised and contained all the required checks needed. A person requiring a visa to remain in the country had had this renewed, documentation on this was on the file. All CRBs had been carried out by the organisation on appointment. We discussed staffing levels with the deputy manager. She said that the manager has being reviewing this as the dependency needs of the people being admitted to the home have increased with more people requiring nursing and personal care as well as assistance to eat their meals. There are also more bedbound residents on continuing care. Extra support has been provided at key times such as the morning shift and during meal times. Staff spoken to said that the extra support has been beneficial as more residents can be assisted to get dressed and have their breakfast in a timely manner rather than having to wait some time before staff are free to assist them. Staff spoken to in handover times also confirmed that the increasing dependency Lansdowne Care Home DS0000068281.V343419.R01.S.doc Version 5.2 Page 22 levels were impacting on their ability to deliver care and support. It is recommended that a review of the dependency levels is carried out on a regular basis in order for there to be sufficient staff available at all times to meet these increasing dependency needs. It was positive to see that training continues to be offered to all staff regularly. Staff spoken to stated that they have good and regular training not only in mandatory areas but also for their professional development. Training undertaken by staff in the past year included: use of the dependency rating tool, health and safety, moving and handling, fire safety, customer care, infection control, POVA, challenging behaviour, death and dying and terminal care, wound care, tube insertion/ nasogastric feeding and supervision training. Dementia care training is to be carried out on 16th and 30th August 2007. Advanced dementia training is also offered. The organisation has a training team, which comes into the home to provide training. The manager and several staff are also trainers. There is a rolling programme of mandatory training in place with refreshers for all staff on a six monthly and yearly basis. Seven care staff have achieved NVQ 2 with five more having started the training this year. One person has achieved NVQ 3. The manager has the RMA and the deputy is looking to start this training. A sample of staff induction records was seen. These were comprehensive and are in line with the Skills for Care Induction programme. All new staff are allocated a mentor on appointment from the senior staff team. They provide support and supervision during their induction. They have all attended mentoring training. This is seen as very good practice. I was shown supervision notes for a number of staff. All staff receive supervision with their records kept on each unit. It was evident that supervision had taken place but the dates were not recorded by the supervisors in the folders in the manager office. It was recommended that the manager review the way in which supervisors record when supervision has taken place to provide the manager with an overview of the frequency of supervision. Staff all said that they enjoyed working in their teams and that teamwork helped them do their jobs well. Lansdowne Care Home DS0000068281.V343419.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 People using this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home benefit from proactive management and staff commitment. They also benefit from knowing that they will consulted and their views taken seriously. People living in the home are protected by the home’s robust health and safety policies and checks and by good financial management. EVIDENCE: The management of the home remains very sound and proactive, with clear leadership from Natasha Lazovic and good delegated accountability from the Deputy and nursing team leaders. There are systematic management meeting at all levels. I examined the meeting of Heads of Departments, nursing teams, Lansdowne Care Home DS0000068281.V343419.R01.S.doc Version 5.2 Page 24 and other staff meetings. There is clear follow-up and consistent messages at all levels. I spoke to the Administrator about how the home manages finances. The home is not responsible for resident’s accounts but invoices for services supplied. All certificates and service records for appliances and equipment used in the home were made available for inspection. These were seen to be up to date with no outstanding works required. The two folders had a lot of old information going back a few years. It is recommended that the old information held in the folders be archived so that only the most recent checks i.e. for the last year are held in the office. Fire drills and weekly checks to the alarm, call bell, emergency exit and lighting system are recorded. The home has carried out drills during the day time only. The home must carry out a night time drill once a year. The time of the drill needs to be recorded on the records to ensure that this is varied each time. I was informed that night staff have fire safety training quarterly and day staff six monthly. This is very good practice. Training records seen evidenced that staff have had all the mandatory health and safety training required. COSHH materials are stored safely in locked cupboards on each floor. The home is prompt in reporting any Regulation 37 incidents to CSCI. Lansdowne Care Home DS0000068281.V343419.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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 3 3 X X x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 2 Lansdowne Care Home DS0000068281.V343419.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP19 Regulation 23(4) • Requirement the ground floor bathrooms with a damaged door must be repaired The carpet on the ground floor was rucked in places and needs to be stretched to ensure it doesn’t present as a tripping hazard. two of the ground floor shower rooms require redecoration. An action plan with details of the planned refurbishment to the home must be sent to CSCI within the stated timescales. A risk assessment of Pembroke unit must be carried out to ensure residents safety during the proposed kitchen refurbishment The home must carry out a night time drill once a year. Timescale for action 30/11/07 • • • • 2 OP38 23(4) • 30/11/07 Lansdowne Care Home DS0000068281.V343419.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 OP8 Good Practice Recommendations It is recommended that the home notifies relatives when the GP is unavailable and ensures that alternative arrangements are made clear to both residents and relatives It is recommended that the receipt of medication recording is reviewed with the dispensing pharmacy and the organisation It is recommended that kick plates or some form of protective covering be placed on the doors to prevent damage by wheelchairs. It is recommended that a review of the dependency levels is carried out on a regular basis in order for there to be sufficient staff available at all times to meet these increasing dependency needs. It is recommended that the manager review the way in which supervisors record when supervision has taken place to provide the manager with an overview of the frequency of supervision. It is recommended that the old information held in the health and safety checks and fire safety folders be archived so that only the most recent checks i.e. for the last year are held in the office. 2 3 4 OP9 OP19 OP27 5 OP27 6 OP38 Lansdowne Care Home DS0000068281.V343419.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Harrow Area Office 4th Floor, Aspect Gate 166 College Road Harrow London HA1 1BH 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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