Inspection on 22/11/07 for Lansdowne Retirement Home

This inspection was carried out on 22nd November 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

Lansdowne Retirement Home 14/12/06

Lansdowne Retirement Home 24/01/06

Lansdowne Retirement Home 23/08/05

Lansdowne Retirement Home 14/12/04

Lansdowne Retirement Home 12/08/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Lansdowne Retirement Home 35 Liphook Road Lindford Bordon Hampshire GU35 0PT Lead Inspector Jan Everitt Unannounced Inspection 22nd November 2007 09:15 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.V350057.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lansdowne Retirement Home DS0000058657.V350057.R02.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) bunwold@tiscali.com 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.V350057.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th December 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. Fees are between £379 - £550 Lansdowne Retirement Home DS0000058657.V350057.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced, inspection visit to Lansdowne Retirement Home, took place over a one-day period on the 22nd November 2007 and was carried out by Mrs Everitt Regulatory Inspector. The registered manager, Mrs Nicola Withers was present in the home and assisted throughout the inspection. The visit to the home formed part of the process of the inspection of the service to measure the service against the key national minimum standards. The manager had returned the Annual Quality Assurance Assessment (AQAA) to the CSCI and the focus of this visit to the home was to support the information stated in this document and other information received by the CSCI since the last fieldwork visit, which was a key inspection, made to the home in December 2006. Documents and records were examined and staff working practices were observed. The inspector looked around the home and spoke to all of the residents and staff to obtain their perceptions of the service the home provides. Those spoken to were generally complimentary about the their home and the care they receive. Surveys had been distributed to service users, relatives, care managers, GP and other visiting professionals. Nine service user surveys, five relative/carer surveys, eight staff and one GP surveys were returned to the CSCI. The outcome of the surveys indicated that there was a high level of satisfaction with the service and that generally residents and relatives were pleased with the care the home provides. The district nurse visiting the home was spoken with and who confirms she supports the home to meet resident’s general health needs. There were 16 residents living in the home, and one resident from an ethnic minority group. Lansdowne Retirement Home DS0000058657.V350057.R02.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? All requirements have been met since the last inspection. In particular the training programme has been further enhanced by broadening its subjects recognising the needs of service users with a dementia. The care plans are more detailed and identify the care needs of the service users, acknowledging the care needs of those service users who have a degree of dementia. The health care needs of the service users are now fully assessed and care plans are in place to guide the management of these. The records of administration of medication are now audited weekly by the manager to ensure that all records of medication are documented along with reasons why prescribed medication has not be administered. The dietary needs of those with diabetes are now being documented and monitored appropriately. The home is fresh and clean with no offensive odours. Lansdowne Retirement Home DS0000058657.V350057.R02.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Lansdowne Retirement Home DS0000058657.V350057.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lansdowne Retirement Home DS0000058657.V350057.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 Standard 6 is not applicable to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The pre admission process contains adequate information to ensure the needs of the service user can be identified and addressed and staff are adequately trained to meet their needs. EVIDENCE: A sample of four pre-admission assessments was viewed. The tool used covers all the areas of physical and emotional needs as well as a snap shot social history. The manager will receive a referral or enquiry from care managers or relatives and will arrange to undertake a pre-admission assessment in the person’s current setting. The information gathered to support the assessment is sourced from information from the service users, relatives, hospital records and from care managers, if there is one involved. The pre-admission assessment has been updated to cover all areas of needs. Lansdowne Retirement Home DS0000058657.V350057.R02.S.doc Version 5.2 Page 10 The previous inspection record stated that mental health needs were not consistently addressed in care plans. This was discussed with the manager who reports that she ensures that she only admits to the home people who have no significant mental frailty. However, this does not detract from the fact that a number of residents living in the home have a degree of dementia, which has manifested itself subsequent to their admission. The records evidence that staff have received training in dementia awareness and this, the manager reports, is ongoing in their training needs. Some residents spoken with, although able to speak for themselves, had been unable to visit the home due to physical frailty and a number said that their relatives had visited the home before their coming to live there. Another service user described his day visit to the home before his admission. Comment cards received from relatives indicated that they felt that the admission process had worked, that they had been given adequate information to assist with the decision making process and that their relative’s needs could be met at the home. Lansdowne Retirement Home DS0000058657.V350057.R02.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had care plans in place to ensure the personal and healthcare needs of residents are identified and met. The practices and policies of the home ensure that the home manages medication safely and effectively. The home’s ethos and staff working practices ensure that residents’ privacy and dignity is promoted. EVIDENCE: A sample of four service users’ care plans was viewed. Two being the most recently admitted residents. Contracts, assessments, care plans, reviews, daily records, accident recording were all evidenced in the personal files. The care plans are well documented and detailed and risk assessments are in place to support the service user’s needs. Lansdowne Retirement Home DS0000058657.V350057.R02.S.doc Version 5.2 Page 12 The inspector saw that care plans are reviewed monthly and changed as needs alter. There are monthly weight charts, a mini mental health assessment and two other assessment charts completed monthly. The service user signs the care plans after they are consulted on any changes or reviews of the plans. A letter is also sent to the next of kin to inform them of any reviews or changes in their relatives’ condition and inviting them to make comment. The requirements from the previous inspection have been addressed and it was observed that the monitoring of blood sugars of those with diabetes is now documented regularly and in conjunction with the district nurse, who undertakes more complex blood tests quarterly; their diabetes status is monitored appropriately. The district nurse was spoken with at the time of this visit and said that she is confident with the staff are competent to monitor the blood sugars and record of them and checks them on each visit to ensure they remain within the stated parameters. The AQAA states that staff have received care plan training. Staff spoken with at the time of this visit said that the care plans do inform them of how the resident should be cared for and they are confident in writing in the care plans and reviewing them. The home has several GPs who visit the home when requested but the manager says that she wishes this could be on a more frequent basis. One resident commented that she felt well cared for and that she saw the doctor when she needed. Records also evidenced that residents have access to opticians and dentists as needed. The comments returned on the surveys from service users and relatives indicate that they feel their health needs are met. The district nurse called at the home and said that she visits if requested to monitor diabetics and also to dress any wounds that need to be assessed by her. She reports that she has a good relationship with the home and staff are responsive to any directions given them. She also reported that the home does well to maintain service users’ end of life care and that the primary care team do become involved and visit the home daily to give support and monitor the needs of the resident. Equipment is also readily available to support the home if necessary. The Community Psychiatric Nurse (CPN) does visit the home if the home requests a visit or needs advice on any resident that suffer mental frailty and who is taking medication prescribed by the psychiatrist. The manager said there were no residents with challenging behaviours at the present time and that she considered that the home could meet the needs of the current residents who have a degree of dementia. The records evidence that all visits from health professionals are recorded in the care plans with any outcome from the visit or change of treatment. Lansdowne Retirement Home DS0000058657.V350057.R02.S.doc Version 5.2 Page 13 The chiropodist was in the home at the time of this visit and he reports that he visits regularly. The policies and procedures of the home guide the home in the management of medication. 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 one resident. The records in the register were checked and the balance recorded agreed with the number of tablets stored. Prescriptions are checked before they are taken to the pharmacy for dispensing, this is considered to be good practice as stated in the Royal Pharmaceutical Society guidelines. The MAR sheets were viewed and these were well recorded. The manager monitors these weekly and signs as evidence that she has audited these. It was observed that those residents managing their own prescribed skin creams, the MAR sheets clearly state that these are self-medicating and checked by the staff that they have been used. There was no residents self-medicating oral medication at the time of this visit. The manager told the inspector that refresher training on the monitored dosage system and administration of medication has been organised for the new year (2008). It was observed 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. Staff were observed to have good rapport with the service users and were familiar with their daily routines, which were being respected. Lansdowne Retirement Home DS0000058657.V350057.R02.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 are wholesome and well balanced and offer choice and alternative diets. EVIDENCE: The home does not employ a person specifically for organising activities. The carers take on that responsibility on a day-to-day basis and usually in the afternoon before tea. The AQAA states that one dedicated member of staff is in the process of gathering additional ideas for social activities. A social history is recorded of all residents and also their likes and dislikes and preferences are recorded during the assessment process. This should give the home information that would allow the activities to be tailored to previous Lansdowne Retirement Home DS0000058657.V350057.R02.S.doc Version 5.2 Page 15 recreation activities and hobbies. However, there is no specific programme tailored around this and activities are chosen each day. The manager showed the inspector a programme of activities that was advertised on the notice board and evidenced a variety of activities and entertainment. The activities take place on an ad hoc basis and residents choose what they wish to do each day. There was evidence that records are kept of what activities take place and if the service user participated or chose to not take part. A game of throwing the bean balls was observed to be playing on the afternoon of this visit, some residents being more enthusiastic than others to take part. Residents spoken to at the time said that they are satisfied with the activities, and the comments returned on the surveys to CSCI indicated that generally service users consider that the activities are arranged ‘usually’ and ‘sometimes’. Some commenting that they do not wish to ‘take part’. Another comment from a service user was the ‘I prefer to watch TV in my own room’. One comment on comment card returned by a relative stated that ‘perhaps more could be done to encourage intermixing of residents as I feel father misses someone to talk to’. The visitor’s book was recorded and evidenced that a steady flow of visitor visit the home. Service users are able to receive visitors in the privacy of their own room, the home having all single accommodation. At the time of this visit the clergy was at the home to give communion to those who wished to participate and there were about six residents that attended. The local Methodist church also visits the home to do a sing-a-long with residents. The manager said that various other visiting entertainers come to the home. The home has open visiting and comments from relatives indicate that they are made welcome one stating on a survey ‘There is a social and friendly atmospheres and I am always made most welcome when I call to visit’. A comment from a GP stated that ‘the home has no provision for taking residents out’. Also three staff surveys returned commented that ‘It would be nice if the residents had trips out of the home from time to time’, ‘Residents could have a few outings out whenever possible’ and ‘arrange outings for the service users by mini bus’. These comments were discussed with the manager who said that she acknowledges that outings would be nice but she has in the past arrange for transport to take residents out and at the last minute they do not wish to go if other residents have pulled out. The AQAA states that this is one of the areas that the home wishes to improve in the coming year and barriers to overcome are that of financial. Service users were seen to be mobilising around the home freely. The home has improved the access to the garden and one service user told the inspector Lansdowne Retirement Home DS0000058657.V350057.R02.S.doc Version 5.2 Page 16 that she spends a great deal of time sitting in the garden during the better weather and does so enjoy this. Staff were observed enabling residents to maximise choice about their daily lives with regard to clothing, activities and meals. The AQAA states that service users are encouraged to bring with them personal items to make their rooms homely and individual, It was observed that rooms have been personalised with residents own belongings and family photographs, which residents were happy to talk about. Residents told the inspector they were very happy with their rooms, one stating that she chose to stay in her room because ‘it has such a lovely outlook and the sun shines in and I am very happy here’. Staff comments in surveys and those spoken with acknowledge that service users have ‘rights to privacy, confidentiality and equality and should be treated as individuals and their confidentiality respected at all times’. Most of the residents were reported to be up for breakfast in the dining room. The inspector asked some residents if this was expected of them or if there was a degree of choice. There were mixed answers from service users. When care plans were viewed it was noted that it was documented that people’s preferences of time of rising and going to bed were recorded and that most stated what time they wanted to rise. One service user spoken with late in the morning had just got up and admitted to enjoy lying in bed and getting up late morning every day, and the staff respect this. Observation throughout the visit demonstrated that staff have a good relationships with the service users and that they are familiar with their preferences of how they wish to undertake their activities of daily living. The menu was displayed in the front hallway. The menu demonstrated a choice of a wholesome variety of meals. A number of residents spoken with could not remember what was on the lunch menu and were reminded by the care staff. The kitchen was visited and the cook spoken with. The kitchen was clean and well organised and the cook was preparing a roast dinner for that day. She said that if the service user chooses not to have what is the main menu there are alternatives available and the inspector viewed the records that document alternative meals and if service user had fortified food or supplements. The cook reported that she is familiar with alternative diets and is able to provide for alternative diets as requested. Diabetic requirements are recorded on the menu. 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. It Lansdowne Retirement Home DS0000058657.V350057.R02.S.doc Version 5.2 Page 17 was thought by some residents that the table in the lounge area was always ‘last’ to be served. The manager has put a system in place so that meals are served to each table first, on a rotational basis, which appears to have solved the problem. General comments from service users and relatives and from observing the lunchtime meal being served, evidenced that there is a high level of satisfaction with the quality of food being served. ‘The home provides excellent meals’. ‘Excellent food’. ‘I enjoy the food’. All residents have a nutritional risk assessment in place and for those identified as being at risk a care plan is devised and monthly weights are recorded. These were evidenced in the care plans. The dietician has given advice to the home on special diets and is available via a referral from the GP. The home does not currently have any residents that require an alternative diet due to their cultural needs. Lansdowne Retirement Home DS0000058657.V350057.R02.S.doc Version 5.2 Page 18 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. This judgement has been made using available evidence including a visit to this service. Residents and relatives can be confident that their complaints are listened to and are fully taken into account. Staff have knowledge and understanding of safeguarding issues which protects residents from abuse EVIDENCE: Lansdowne has a complaints procedure displayed on the wall in the reception area. The CSCI did receive communication from a relative, wishing to remain anonymous, about concerns with her relative’s belongings. This has subsequently been resolved. The manager does keep a log of all complaints and records the action outcomes from these concerns. She does audit these regularly to identify any issues that emerge frequently. The AQAA records that three complaints have been received by the home in the last twelve months. Comments on surveys returned to the CSCI indicate that service user know who to talk to and how to complain. Those spoken to at this visit said they would speak to a carer or the manager. Relatives surveys returned also indicate that they are aware of the procedure and would know who to talk to. One commenting ‘Mother has never complained about her care’ Lansdowne Retirement Home DS0000058657.V350057.R02.S.doc Version 5.2 Page 19 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. The staff are also aware of the Whistle Blowing policy and the training matrix demonstrated that training has been provided for abuse awareness and further training is planned for the coming year. (2008) Lansdowne Retirement Home DS0000058657.V350057.R02.S.doc Version 5.2 Page 20 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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, comfortable and well maintained and meets residents’ needs. EVIDENCE: The home is clean and well maintained. The home has recently installed a new kitchen and refurbished the laundry room with equipment fit for purpose. The manager has put in place procedures for staff using the laundry and equipment. The manager advised the inspector since she has become responsible for the home a great deal of work has been undertaken to improve the environment Lansdowne Retirement Home DS0000058657.V350057.R02.S.doc Version 5.2 Page 21 and they have just completed the redecoration of the whole house. This includes all of the bedrooms, which have been redecorated with new carpets, curtains and all furniture has been replaced. All rooms are en-suite and have had new sanitary ware installed. The bathrooms have been ‘significantly improved’, and both the lounge and dining room have been redecorated and refurbished. New carpet has been fitted throughout. At the time of this visit the new extension to provide three extra en-suite rooms and another communal area was nearing completion and the owners are in the process of registration to increase their numbers of service users. Risk assessments are in place for all individual rooms. The inspector saw these. All rooms were visited and were observed to be very comfortable and homely. The previous report identified a shortfall in the call bell system and this has now been rectified and the manager records weekly checks to ensure all rooms have alarm call bells present and in working order. Ramps have been installed at the front and rear exits to make easier access to the gardens for residents. The garden has been redesigned and was seen to be well maintained and pleasant. Service users commenting that they enjoy sitting in the garden in the finer weather. The home employs house keeping staff of domestics, cook and laundry, but the cleaning staff are supported by the care staff in the mornings to help with the cleaning of the home. Staff spoken with said that this does sometimes detract from their care role but they work as a team to maintain the high standard of cleanliness. Cleaning chemicals (COSHH) were kept in a locked cupboard and cleaning containers were not left unattended. The home has an infection control policy and it was observed that hand washing facilities of soap dispensers and paper hand towels were available in all toilets and bathrooms. The staff have received training on infection control and this was evidenced on the training matrix. Gloves and protective aprons were available to staff. Service users spoken to at the time of this visit and survey comments returned demonstrated that the people living in the home are happy with their environment and consider it to be ‘very homely’. ‘I have got a nice room’. ‘I would not want to be anywhere else now’. Lansdowne Retirement Home DS0000058657.V350057.R02.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 28 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Robust recruitment procedures and good opportunities for training for staff help to safeguard service users The number of staff provided is generally adequate to meet the needs of the service users. EVIDENCE: The manager prepares staff rotas four weeks in advance and the inspector saw these. These demonstrated that two staff are on duty throughout the twentyfour hour period. The manager told us that she is also at the home three or four days a week and the staff know when she will be there. She is on-call other days and will attend the home if need be. Also on duty each day is a domestic, cook and laundry lady. On the day of this visit there were sixteen people in residence. The home had sufficient care staff on duty to meet the care needs of the service users in residence at the time of this visit. However, although only for a short period in the morning, care staff were giving support to the housekeeper with cleaning. This did not appear to have a detrimental effect on Lansdowne Retirement Home DS0000058657.V350057.R02.S.doc Version 5.2 Page 23 service users as the care staff were observed responding to call bells quickly and service user’s needs were being met. The comment surveys indicate that the service users and relatives consider that sufficient staff are on duty and that their needs are met. ‘The staff care for the residents with patience and compassion’. ‘It is a superb establishment and staff are very professional and helpful could not be improved in any way’. ‘The home works well’. ‘As far as I am concerned it is perfect’. Staff comments on surveys did indicate that: When caring for a resident with dementia, who need a lot of time and understanding, the other member of staff is then left on their own for other residents’. ‘It would be nice to have extra help at certain times of the day’. These comments were shared with the manager who said that once the three new rooms are commissioned the staffing levels would be reviewed appropriately. The AQAA identifies that the staff group employed is of a mixed ethnic minority. The manager has created a training matrix that can identify what training staff have undertaken and when their mandatory training took place and the due date of the refresher course. The matrix evidenced that staff are receiving appropriate training, much of which has taken place in the past twelve months. All staff, except one, has now achieved the NVQ level 2 qualification or above. Staff training needs are discussed at staff supervision, at which time the manager said, the staff would request specific training. The manager will supply and fund the training as long as it appertains to the client group accommodated, and enhances staff skills. Staff supervision with the manager takes the form of one to one meetings or observational practice. The records of the meetings are recorded and a sample of these were evidenced in the staff personnel files. The staff spoken to and comments received on staff surveys indicate that staff consider they are well supported in their roles and that the manager is very supportive and approachable. One staff member saying: ‘If I need to explore anything which I feel I need to know more about, I would ask the manager’. ‘We get plenty of training’. ‘Training has been better since the new management has taken over’. Another survey identified that: Lansdowne Retirement Home DS0000058657.V350057.R02.S.doc Version 5.2 Page 24 ‘More dementia training and understanding dementia was needed to enable staff to understand those client’s need’s. The Alzheimer’s Society attended the home and gave information and training to the staff on dementia awareness. 14 of the 18 staff currently employed at the home have completed training as Appointed Persons for First Aid. The induction programme was discussed with the manager. She said that the home is registered with the Skills for Care Council and the induction programme is based on the Skills for Care Common Induction Programme and comes in the form of a workbook to go through. The newest recruit showed the inspector her induction workbook that she is in the process of completing. She has already achieved NVQ level 2 but considers this is a good exercise to refresh her knowledge. The manager has an in-house induction programme, which familiarises the staff with the home and clients, and all staff undertake this on their first day. A sample of 4 personnel recruitment files was viewed. Two being the most recent recruits to the home. All records were in place and information required to be recorded for all personnel was in place. The manager receives references and CRB including POVA checks before she will commence employment. The personnel files also evidenced employment contracts that had been signed and interview notes that are recorded. Staff surveys returned and speaking to staff indicated to the inspector that the recruitment process is robust and that the staff consider they receive good support when they first start employment at the home and work alongside a more experienced carer through their induction period or until they feel confident in their role. Lansdowne Retirement Home DS0000058657.V350057.R02.S.doc Version 5.2 Page 25 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. This judgement has been made using available evidence including a visit to this service. The home is well managed and quality is monitored effectively. Service users’ financial interests are safeguarded. Service users’ health and safety is appropriately protected. EVIDENCE: The registered manager has achieved the NVQ level 4 and Registered Managers Award. She is competent to manage the care home and demonstrates good management skills in what she has achieved in the last twelve months. It was observed that she interacts well with staff and staff spoken with say she is very supportive to them, is very approachable and will Lansdowne Retirement Home DS0000058657.V350057.R02.S.doc Version 5.2 Page 26 work as a member of the team as necessary. Staff are generally very happy with their roles. The manager told the inspector that she has undertaken a variety of training in the last year and is about to undertake the train the trainer course for adult protection to enable her to deliver the training in house to all members of staff. The manager is about to have a new computer system installed to aid management and administration as, at the present, all administration work is being done manually. The manager monitors the quality of the home in various ways. She has a suggestion and comment book in the reception area that she looks at weekly. She said that she welcomes comments if the home is falling short of the standards and welcomes suggestions to improve the service. The manager monitors the MAR sheets weekly to ensure they are recorded appropriately. The care plans are also audited weekly by the manager and signed as evidence of this taking place. Service user and relative surveys are distributed three monthly and the analysis of the resident’s survey dated was viewed by the inspector who observed very positive comments about the service. The relatives survey dated October 07 also reflected a high level of satisfaction with the service. Staff meetings are held every 6 months and these are recorded. The home does look after some service user’s monies. These are stored in separate containers. Two sets of monies were checked and were observed them to be stored in a secure environment along with records of all transactions. The balance of the monies was checked and the monies held agreed with that stated on the records. The home has a health and safety policy and procedures. All staff attend mandatory health and safety training annually. The fire log was viewed. All checks of alarm and equipment are carried out at appropriate intervals. The last fire evacuation was 6/11/07. Fire training records were seen and these evidenced that all staff attend a formal fire training session six monthly and complete a questionnaire in between this training. The manager said that she is very firm with staff about attending the fire training sessions. The fire officer will visit the home to inspect the fire alarm system and integrity of the building when the new extension is completed. Lansdowne Retirement Home DS0000058657.V350057.R02.S.doc Version 5.2 Page 27 The servicing records of equipment and systems was viewed and demonstrated up to date servicing of lifts, electrical equipment, gas boilers, nurse call system and the fire alarm system and equipment. The home has a risk assessment for all individual rooms and a fire risk assessment is in place. The training matrix evidenced that staff attend regular training in safe working practices. The accident-reporting book was viewed and audit trailed. These records demonstrated detailed recording of all accidents. Lansdowne Retirement Home DS0000058657.V350057.R02.S.doc Version 5.2 Page 28 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 X 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 3 X X X 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 3 X X 3 Lansdowne Retirement Home DS0000058657.V350057.R02.S.doc Version 5.2 Page 29 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. Standard Regulation Requirement Timescale for action 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.V350057.R02.S.doc Version 5.2 Page 30 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.V350057.R02.S.doc Version 5.2 Page 31 - 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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