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Inspection on 14/12/06 for Lansdowne Retirement Home

Also see our care home review for Lansdowne Retirement Home for more information

This inspection was carried out on 14th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

There is a `homely` feel to the home, with what appears to be a good rapport between the residents and the staff. The staff were able to verbalise their understanding of the needs of the residents with some staff having experience of meeting the needs of those with confusion and memory loss. There is a clear complaints process which has been used by people to voice their concerns and which the manager has been seen to respond to. There are some areas of health and safety such as fire prevention that have been regularly updated for staff and equipment has been maintained.

What has improved since the last inspection?

The requirement from the previous visit regarding self medication has been actioned.

What the care home could do better:

It was noted that of the care plans and assessments reviewed, there were several who had had mental health tests and had a score that indicated that there was some, and in one case severe, memory loss. For another resident there was evidence that their mental well-being was being supported by mental health professionals. This was raised with the manager by telephone, as the home is not currently registered as a service that can accommodate and meet the needs of individuals, with specific needs in mental health; and this is being addressed separately to this report. The areas in which improvement and action are needed are as follows: Assessment of need should look at all possible needs of an individual including falls, physical and mental well being. There was a lack of care planning and of action staff must take to meet all identified needs. This was evident for example in the lack of information for staff to take action where an individual suffered allergic reactions. The residents must be protected by the home`s policies and procedures in dealing with medicines; this includes records of giving medicines. Some rooms lacked call bells for residents to summon assistance. The home should be clean and malodour free. Staff should be trained in the safe use of equipment such as the dryer in the laundry. Staff should follow the safe handling of soiled linen so that they protect themselves and residents from cross infection. The manager / owner has written and informed the CSCI of action that has been taken or that is planned in relation to these issues since the visit.

CARE HOMES FOR OLDER PEOPLE Lansdowne Retirement Home 35 Liphook Road Lindford Bordon Hampshire GU35 0PT Lead Inspector Val Sevier Unannounced Inspection 14th December 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lansdowne Retirement Home DS0000058657.V320013.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 Retirement Home DS0000058657.V320013.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lansdowne Retirement Home Address 35 Liphook Road Lindford Bordon Hampshire GU35 0PT 01420 475448 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) N/A Mrs Nicola Anne Withers Mr Rowland Phillip Withers Mrs Nicola Anne Withers Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Lansdowne Retirement Home DS0000058657.V320013.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th January 2006 Brief Description of the Service: Lansdowne retirement home is a care home providing personal care and accommodation for 17 older people. The home is located in the village of Lindford, which is approximately two miles from Bordon. The home is situated close to local amenities and public transport. All bedrooms are single and have en suite facilities. There is a communal lounge and communal dining room. The home has an established enclosed garden with seating that is accessible to the service user. The level of fees for the home is in the region of £525. Lansdowne Retirement Home DS0000058657.V320013.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the inspection was to assess how well the home is doing in meeting the key National Minimum Standards and Regulations. The findings of this report are based on several different sources of evidence. These included: an unannounced visit to the home, which was carried out on the 14th of December 2006, during which there was discussions with staff, residents, relatives and visitors to the home. In addition 4 relatives had completed questionnaires prior to the visit. During the visit to the home a tour of the premises was carried out with where possible, permission of the residents at the home, this also included their rooms. Staff and care records were sampled and in addition to speaking with staff and residents, their day-to-day interaction was observed. All regulatory activity since the last inspection was reviewed and taken into account including notifications sent to the Commission for Social Care Inspection. The manager / owner was not at the home on the day of the visit and would like the reader to know that her absence was due to serious personal circumstances not due to lack of wish to be present. However the inspector was able to speak to her on the phone, and some feedback of the days findings were given. The inspector was assisted throughout the day by the senior care staff and cook, who were very helpful. There were 16 residents accommodated at the home on the day of the visit. As part of this unannounced inspection the quality of information given to people about the care home was looked at. People who use services were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service user’s guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk. What the service does well: Lansdowne Retirement Home DS0000058657.V320013.R01.S.doc Version 5.2 Page 6 There is a ‘homely’ feel to the home, with what appears to be a good rapport between the residents and the staff. The staff were able to verbalise their understanding of the needs of the residents with some staff having experience of meeting the needs of those with confusion and memory loss. There is a clear complaints process which has been used by people to voice their concerns and which the manager has been seen to respond to. There are some areas of health and safety such as fire prevention that have been regularly updated for staff and equipment has been maintained. What has improved since the last inspection? What they could do better: It was noted that of the care plans and assessments reviewed, there were several who had had mental health tests and had a score that indicated that there was some, and in one case severe, memory loss. For another resident there was evidence that their mental well-being was being supported by mental health professionals. This was raised with the manager by telephone, as the home is not currently registered as a service that can accommodate and meet the needs of individuals, with specific needs in mental health; and this is being addressed separately to this report. The areas in which improvement and action are needed are as follows: Assessment of need should look at all possible needs of an individual including falls, physical and mental well being. There was a lack of care planning and of action staff must take to meet all identified needs. This was evident for example in the lack of information for staff to take action where an individual suffered allergic reactions. The residents must be protected by the home’s policies and procedures in dealing with medicines; this includes records of giving medicines. Some rooms lacked call bells for residents to summon assistance. The home should be clean and malodour free. Staff should be trained in the safe use of equipment such as the dryer in the laundry. Staff should follow the safe handling of soiled linen so that they protect themselves and residents from cross infection. The manager / owner has written and informed the CSCI of action that has been taken or that is planned in relation to these issues since the visit. Lansdowne Retirement Home DS0000058657.V320013.R01.S.doc Version 5.2 Page 7 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 Retirement Home DS0000058657.V320013.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 Retirement Home DS0000058657.V320013.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): Standards 1 & 3 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 informative statement of purpose and service users guide, enabling prospective purchasers to make an informed choice. The home has a satisfactory understanding of some of the residents needs using the assessment process. EVIDENCE: The inspector looked at 5 care plans and each individual had had an assessment prior to moving to the home. The assessments contain information about some of the needs of the individuals. It was observed that the information gained through the assessment had been used to complete the care plans. The exception to this was where individuals who need support with their mental well being; there was a record of their support needs in the assessment however this was not followed through in the individuals care plans. Lansdowne Retirement Home DS0000058657.V320013.R01.S.doc Version 5.2 Page 10 Relatives spoken with on the day, explained what had happened in the decision-making process regarding the home and how they had been involved. Some residents spoken with although able to speak for themselves had been unable to visit the home due to physical frailty. The relatives spoken with felt that the admission process had worked, that they had been given adequate information to assist with the decision, making process. The relatives felt that the needs could be met at the home. Lansdowne Retirement Home DS0000058657.V320013.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): Standards 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. There is a lack clear and consistent care planning to adequately provide staff with information they need to satisfactorily meet all residents’ needs. The health needs of residents are met with access to health care opportunities. The systems for the administration of medication have declined since the last visit and potentially place residents at risk. EVIDENCE: The inspector sampled all the care plans looking in detail at 5. The care plans onsite of two main sheets, one briefly identifies area of need and support, and the second briefly identifies action to be taken by staff to give the support. The inspector saw that these care plans are reviewed monthly and changed as needs alter. There are also risk assessments, monthly weight charts, a mini mental health assessment and two other assessment charts completed monthly. The risk assessments identify some risks however it was noted that for one individual the risks for them were around falls which had been associated with Lansdowne Retirement Home DS0000058657.V320013.R01.S.doc Version 5.2 Page 12 poor diet and dehydration, the action being taken by the home: using nutritional records and monitoring of weight and fluid intake, were not evident on the risk assessments. Several residents were diabetic and this was managed through diet and medication; whilst noted on part of the care plan there was no evidence of the action or support that staff were taking. It was also noted that blood sugar levels were to be monitored for these individuals, there was no indication of how often this should be carried out and only evidence on one individual’s daily notes that it had been done. The manager has advised the inspector since the inspection that the District Nurse monitors the blood sugar levels for these individuals. This was not evident on the care plans. Another individual is prescribed medication (Digoxin) for a heart complaint; there was no acknowledgement of this in the care plan or of any action or support that staff may need to take on behalf of this individual. It was noted that since admission another individual has suffered from allergic reactions, whilst there was evidence in the daily notes, that staff had taken action recently, there was no care plan for the action that staff should take, or what measures should be in place to lesson the risk of a reoccurrence; for example it was noted that medication has been prescribed to assist with the treatment should another reaction occur, however this has not been included in a care plan. There was concern expressed to the manager / owner that there are at least two individuals at the home who are receiving support from other professionals such as community psychiatric services, for their mental health needs. One individual has a mental health score of ‘0’ and who becomes agitated and confused. The second individual has depression and anxiety. There was no care plan indicating how staff should support these needs. Where the individual had a confusion and memory loss, there was a risk assessment dated 2005, regarding the individual’s relationship with another resident, action was written on how this would be managed however, and this has not been reviewed. When asked the staff on duty on the day said that the level of risk had decreased however, behaviours of the two people altered if the other was not in the home. There was no indication on how staff should support or manage these behaviours. The manager has supplied information since the inspection to advise that staff have attended a half-day training on Dementia care given by the Alzheimer’s society in 2005. It was seen in the care plans that some physical health needs are addressed with recent residents having moved to the home with information from health and other specialists; this information has been incorporated into the care plan at this home. It was also seen that residents have access to opticians and Lansdowne Retirement Home DS0000058657.V320013.R01.S.doc Version 5.2 Page 13 dentists as needed. One resident commented that she felt well cared for and had seen the dentist and was sure that she was due to see the optician. Relatives spoken with were involved in the care planning having meetings with the manger. They felt this was important, as the residents although involved, due to their personal issues are not always able to give information or informed consent. The consultation was also appreciated, as the relatives spoken with had been the carers for in some cases years, and they felt that this kept them involved in the care. It had been seen on care plans that the preferred choice of name had been recorded and staff were heard to speak to residents by the name they wished and staff were observed to interact with residents with respect. The inspector looked at the medication administration records, storage and control of stock. The records evidenced that there was good stock control with adequate supplies. It was noted that there is a returns medication book, which is signed and dated by the chemist. There are Controlled Drugs prescribed for residents these were seen to be recorded and stored as guidelines suggest. There were 33 gaps in the Medication Administration Record (MAR), where it was unclear whether the medication had been given. Generally there was no evidence where a ‘as needed’ medication was given as to the reasons it had been administered and whether the outcome was effective. There were several residents who have been prescribed creams and eye drops that should be applied daily and in some cases more often. There was little or no record of these creams or eye drops having been administered. Where an individual is self caring and administers their own cream or ‘soap replacement’ that has been prescribed, this should be clear on the MAR charts and an assessment and record completed for that individual. The inspector observed the staff in handling and administering medication to some residents at lunchtime and this was seen to be carried out appropriately and with dignity for the residents. Lansdowne Retirement Home DS0000058657.V320013.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): Standards 12, 13, 14, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home offers a variety of activities that are suitable for the needs of the residents. The home assists residents to maintain social contacts with the community and family. The meals in the home were balanced and offered a choice; except where there were specific dietary needs EVIDENCE: There are links maintained with the community with visits to the home from ministers and others. There is an activity daily with information being posted on the notice board in the hallway. There are no individuals at the home currently managing their own finances. However, staff were seen enabling residents maximise choice about their daily lives with regard to clothing, activities and meals. Some residents had bought personal belonging to their rooms to individualise them and happily explained their history and meaning to the inspector. Lansdowne Retirement Home DS0000058657.V320013.R01.S.doc Version 5.2 Page 15 The home has a dining room that cannot accommodate all the residents; therefore one table is in the lounge where five residents take their meals. One resident commented that they are always left to last, and complained of the time taken to serve their meal, ‘lunch is at 12.30 and its nearly one o’clock’. There was Christmas music playing at the time which one resident said was lovely, as she had asked for it specifically. The inspector asked what was for lunch no one knew, two residents commented that ‘it is always a surprise’ and these residents seemed unaware of the menus being available in the hallway. The inspector saw that there were samples of menus on display in the hallway and which offered choice and variety, however there was no indication on how the dietary needs of those with diabetes were being addressed. The staff asked told the inspector that ‘ they can all eat the same’. There was evidence that the residents are asked what they would like for their meal although this is done two meals in advance, and may be why some could not remember. The manager / owner has informed the inspector since the inspection that records have been amended, recording the alternatives and supplements that residents are offered. Lansdowne Retirement Home DS0000058657.V320013.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): Standards 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have knowledge and understanding of Adult Protection issues which protects residents from abuse. Residents can be confident that their views are known to staff and are fully taken into account. The manager has begun to establish a sense of openness at the home so that relatives and residents can voice their concerns. Staff also feel that they can voice concerns especially regarding the care of the residents. EVIDENCE: There have been no complaints or allegations of concern made since the last inspection to the CSCI. Relatives spoken with and those who returned comment cards were aware of how to complain and said they felt comfortable in speaking with the new manager or deputy about any issues. Two verbal complaints have been received at the home one from a member of staff and a other from a residents. These were seen to have been investigated and a record of the action taken was available. The home had a copy of Hampshire’s Protection of Vulnerable Adults procedure so that the manager and staff could refer to it when necessary. Staff spoken with were aware of their responsibility to report any incident of abuse and could name the home’s policy that required them to do so. Lansdowne Retirement Home DS0000058657.V320013.R01.S.doc Version 5.2 Page 17 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): Standards !9 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the environment in some areas is poor placing residents at risk, although other areas are well maintained. The situation of the laundry and methods seen of staff carrying soiled items, potentially places both residents and staff at risk of cross infection. EVIDENCE: The manager / owner has advised the inspector since the inspection of the work that has been undertaken since they have become responsible for the home. This includes having the kitchen and laundry rebuilt, 15 of the 17 bedrooms have been redecorated with new carpets and curtains, the bathrooms have been ‘significantly improved’, and both the lounge and dining room have been redecorated. Lansdowne Retirement Home DS0000058657.V320013.R01.S.doc Version 5.2 Page 18 On the day of the inspection the inspector undertook a tour of the home and sampled some resident’s rooms. The inspector found that the edge of the stair carpet at the top of the stairs was worn across and may pose a risk. The manager / owner has advised the inspector since the inspection that there are plans for this to be addressed. It was noted that where windows were open they were open quite wide, the risk assessment for the rooms note for example that the window was ‘clean and openable to a safe angle’. One room had no pull cord attached to the staff call system, and one was there but not plugged in. the manager / owner has informed the inspector since the inspection, that a weekly check has been implemented to ensure that the pull cords for the nurse call are attached and working. In one room the ensuite toilet was accessed through a sliding door, which was off its rail. The owner / manager has informed the inspector since the inspection that this has now been repaired with alterations made to try and prevent it happening again. One window in an ensuite toilet was badly cracked and could be felt from the inside. The owner / manager has informed the inspector since the inspection that this had been noted by her and is due to be replaced, in the meantime a temporary repair has been carried out by covering the crack with an acrylic sheet. The upstairs is accessed either by the stairs or a stair lift. Several residents were seen to be coming downstairs independently with one trying to also carry their walking frame with them. It was noted that there is a bell at the top of the stairs for residents to summon staff to assist them coming downstairs. The residents spoke with the inspector and indicated that they liked to be independent, although they knew that there was a bell to call for help. Most of the home is well decorated with daily cleaning undertaken by either the domestic staff or the care staff. There was a strong malodour in one bedroom. Windows were open in some areas and natural and electric light was available in all areas to which service users have access. Access to the garden is wheelchair friendly and access is adequate though the house, although some door widths in some areas are slightly less than ideal. There is a separate dining room and an L shaped lounge area looking out onto the garden. Private accommodation is furnished with domestic furniture and fittings and some residents have chosen to use items of personal furniture. Residents spoken felt that the home was “homely”. Lansdowne Retirement Home DS0000058657.V320013.R01.S.doc Version 5.2 Page 19 The laundry has been relocated since the last visit and is now accessed by staff by going outside the home. Staff were seen to be carrying armfuls of soiled laundry outside although when asked staff said they had baskets. One member of staff who was new to the home said that she had been shown how to use the hot wash programme but not how to clean the filter for the dryer, although there were sheets to be signed daily by staff using the machines to say that they had been used as instructed and in the case of the dryer, the filter cleaned. The owner / manager has informed the inspector since the inspection that all staff have been trained in the cleaning of the filter and a monitoring system has been established. Lansdowne Retirement Home DS0000058657.V320013.R01.S.doc Version 5.2 Page 20 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): Standards 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. There appear to be sufficient staff to meet the needs of the residents. The home provides and assists staff with a training programme in order to meet resident’s needs. Staff are clear regarding their role and what is expected of them. Residents report that staff working with them seem to know what to do. EVIDENCE: The staff rotas were seen and it was noted that there are two staff on duty throughout the twenty-four hour period. The staff told the inspector that the manager is at the home three or four days a week and tells them when she will be there. Training was seen to be planned for the New Year with workshops on slips, trips and falls planned for the 25th January; other training to be confirmed included food hygiene and manual handling. The inspector was unable to confirm on the day that there is a first aider for the home and that staff have undertaken the one-day appointed first aider Lansdowne Retirement Home DS0000058657.V320013.R01.S.doc Version 5.2 Page 21 course. Information has been received after the inspection from the manager stating that 14 of the 18 staff currently employed at the home have completed training as Appointed Persons for First Aid. Senior staff on duty advised the inspector that one new member of staff had started at the home since the last inspection. The recruitment process for this individual could not be confirmed on this occasion. The manager has also advised CSCI that additional training on diabetes awareness and medication are being sought for staff. Lansdowne Retirement Home DS0000058657.V320013.R01.S.doc Version 5.2 Page 22 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): Standards 31, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are areas of improvement in the management of the home needed to ensure that all needs of residents can be met. The registered manager is actively seeking the views of residents, relatives and staff and is making decisions based on this information. The homes system for managing residents’ money is robust and safeguards their financial interests. There was some evidence that health and safety is attended to protecting the well being of all at the home. EVIDENCE: Lansdowne Retirement Home DS0000058657.V320013.R01.S.doc Version 5.2 Page 23 The home has carried out work to achieve the requirement made from the last visit to the home. All staff and service users spoken with commented on the approachability of the manager and she “very helpful” and “always willing to listen” The manager has achieved NVQ 4 and the registered managers award. However there are several areas such as care plans and assessment that may suggest that staff are not supervised enough. A service users satisfaction survey is run on a three monthly basis. There was evidence in the Regulation 26 report of October 2006 that two relatives had completed a survey form and that all residents and relatives had been given one to complete. The last Regulation 26 report available at the home was dated October 30th 2006. Service users monies may be held upon their request in small amounts. For those who chose to do so the money is held securely and separately receipts and balances are kept. The records of fire equipment tests, fire drills and teaching are current. A contactor was testing the fire equipment on the day of the inspection visit. A maintenance book is used and signed as work is completed. Staff had attended a fire awareness session on the 11th December 2006. The cook at the home remembered that Environmental Health have been out to the home since she has worked there (3 years). There was evidence that the freezers and fridges temperatures are checked – weekly. Food items are dated when boxes are opened and as they are decanted to other containers. Risk assessment for the home including individual rooms have been carried out this includes a decorating and maintenance assessment. These are done monthly. Lansdowne Retirement Home DS0000058657.V320013.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 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 3 17 X 18 3 2 X X X X X 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 2 X 3 X 3 X X 3 Lansdowne Retirement Home DS0000058657.V320013.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 (1)(2)(b) (c) 12 (1) Requirement The registered provider must ensure that care plans provide clear guidance to enable staff to consistently meet the care needs of residents. The registered provider must ensure that all physical health needs are addressed and there is clear guidance on how this is carried out. The registered person must ensure that medication administration records are kept, detailing what medication has been administered and any reasons why it may not have been given. The registered person must ensure that the dietary needs of diabetics can be met and that records are maintained with regards to this. The registered provider must ensure that all areas of the home are adequately cleaned and maintained to avoid the risk of infection. Timescale for action 31/01/07 2 OP8 31/01/07 3 OP9 12(1),13 (2)18(1) (c) 31/01/07 4 OP15 12(1), 17 31/01/07 5 OP26 12(1),23 (2)(d),13 (3) 31/01/07 Lansdowne Retirement Home DS0000058657.V320013.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Lansdowne Retirement Home DS0000058657.V320013.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Lansdowne Retirement Home DS0000058657.V320013.R01.S.doc Version 5.2 Page 28 - 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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