Inspection on 11/08/05 for Lound Hall Nursing Home

This inspection was carried out on 11th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Lound Hall Nursing Home 15/10/08

Lound Hall Nursing Home 15/10/07

Lound Hall Nursing Home 02/10/06

Lound Hall Nursing Home 26/02/06

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Lound Hall Nursing Home Town Street Lound Retford Nottinghamshire DN22 8RS Lead Inspector Mary OLoughlin Unannounced 11 August 2005 at 10:00 am th 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 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. Lound Hall Nursing Home C53 C03 S63130 Lound Hall V241831 110805 Stage 2.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Lound Hall Address Town Street Lound Retford Nottinghamshire DN22 8RS 01777 818082 01777 818084 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) MPS Care Homes Limited Vacant Care Home with Nursing - Private 29 Category(ies) of OP Old Age 29. registration, with number PD Physical Disability - 50 Years and Over 29. of places Lound Hall Nursing Home C53 C03 S63130 Lound Hall V241831 110805 Stage 2.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1, The Registered Provider will: a, Provider external support from within the organisation to the home. b, Review the current management arrangements within the home within three months of purchase to determine the employment of a manager for registration. 2, Service Users shall be within categories OP or PD (over 50 Years). 3, One named Service User may be within DE(E). Date of last inspection 17/03/05 Brief Description of the Service: Lound Hall Care Home is situated in the village of Lound close to Retford. The home provides Nursing and Residential Care for up to 29 older people. The categories of registration include 2 beds for people with a Terminal Illness and 6 beds for people with a physical disability. The provider was registered with the Commission in May 2005. There are single and double rooms, all ensuite. The home is suitable for people with mobility problems, provides a passenger lift and level access. The gardens are accessible to wheelchairs and provide a range of seating within a mature well maintained garden. Lound Hall Nursing Home C53 C03 S63130 Lound Hall V241831 110805 Stage 2.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted unannounced over 3.5hrs. The acting manager was present and demonstrated an in depth knowledge of the residents and the homes policies and procedures. The acting manager has applied to register with the Commission. The main method of inspection was to case track, this means looking at the care plans of 3 residents to determine if their needs are being assessed, reviewed and met by the home. The home was found to meet all the standards inspected on this occasion. The numbers of staff on duty were able to meet the needs of the residents at this time. The present registration category that allows one named person to be admitted with Dementia is no longer required and will be removed from the new registration certificate. What the service does well: The care plans examined demonstrated that staff complete a thorough and comprehensive assessment of the needs of each resident. The assessments are reviewed monthly or as conditions change, which ensures that the residents are receiving timely and responsive care. The residents are able to exercise choice and control over their lives; those spoken with informed me of being able to live independently within the home and staff supporting their independence wherever possible. Residents, who are able, go out shopping or visiting by themselves following risk assessment. For residents leading a less active life there are good resources at the home to ensure they are occupied in fulfilling activities. A clean well maintained home with a very happy atmosphere. The acting manager is working hard to implement new paperwork since the new ownership in 2005. Lound Hall Nursing Home C53 C03 S63130 Lound Hall V241831 110805 Stage 2.doc Version 1.40 Page 6 What has improved since the last inspection? 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. Lound Hall Nursing Home C53 C03 S63130 Lound Hall V241831 110805 Stage 2.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection Lound Hall Nursing Home C53 C03 S63130 Lound Hall V241831 110805 Stage 2.doc Version 1.40 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3-6 Residents receive an assessment of their needs prior to admission and are assured that the home are able to meet their needs. EVIDENCE: The records of three residents show that a trained person completed a preadmission assessment for all prospective residents to ensure that the home was able to meet the person’s needs before agreeing admission. Records also contain the assessments undertaken by external professionals such as the social worker if they are involved in the admission, which is good practice and provides all the required information on which to base the home’s assessment and care plan. Intermediate care is not provided by the home. Lound Hall Nursing Home C53 C03 S63130 Lound Hall V241831 110805 Stage 2.doc Version 1.40 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7-8-9-10 Residents receive evidence based care from trained staff that maintains their optimum level of physical and psychological functioning. Residents receive their medicines and treatments under the supervision of trained staff that follow appropriate procedures and minimise any risks. EVIDENCE: The new care plans are presently being implemented, the resident’s case tracked all had the new care plan in place. Care plans include all areas of need following a comprehensive assessment of the physical, psychological and social needs. The plans are easy to read and contain excellent information on which staff are to provide care. The care plans are being drawn up wherever possible with the resident or the relatives and there is a record held of the signatures of those involved in the care planning. Risk assessments cover all the pertinent areas and exceed the minimum standards. Lound Hall Nursing Home C53 C03 S63130 Lound Hall V241831 110805 Stage 2.doc Version 1.40 Page 10 Falls risk assessment is based on current good practice and guidance issued by the Department of Health. All residents have a pressure-relieving mattress on their bed, all are assessed monthly or as their conditions change to ensure that any increased risk of developing a pressure sore is identified and appropriate support is provided. There are no residents with pressure sores at this time. Wound care plans are completed and a complete record pf each dressing change is held. There is also the involvement of the Tissue Viability Nurse Specialists from the local primary care team and the specialist hospital team. The manager is also a link nurse in Tissue Viability that enables her to be informed of all up to date practice. Pressure relieving seat cushions are also provided. The residents receive a monthly health screen that includes their blood pressure and weight. Diet and catering forms are completed to ensure that kitchen staff are aware of the appropriate dietary needs of the residents. Oral care is recorded and for those people requiring mouth care, a record sheet is completed of each mouth care provided. There was evidence that a chiropodist visits the home regularly and treatment is recorded within the care plan. Medicines are handled according to the Medicines Act. Medicine record sheets for those residents case tracked show that they were receiving their prescribed medicines appropriately. There were appropriate records of all controlled medicines and care plans contain evidence that pain is assessed and controlled by referral for medical opinion. The new environmental waste disposal requirements for the disposal of medicines has been considered by the provider and appropriate waste collection of all unwanted medicines is in progress. Appropriate precautions are in place, providing individual lancet devices for people requiring blood sugar testing. Residents were observed to be treated respectfully by staff during the inspection. Residents spoke of how good the staff were and that they were very considerate. Some spoke of the staff being their friends. Training policies highlighted that staff receive training on confidentiality and how to treat people with respect. Care plans also contain Life potential assessments including spiritual and social fulfilment. There are also elements of health promotion, which is good practice. Lound Hall Nursing Home C53 C03 S63130 Lound Hall V241831 110805 Stage 2.doc Version 1.40 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12-13-14-15 Residents are supported to be as independent as possible and maintain control over their lives. The diet provided is flexible and suitable for the needs of the residents. EVIDENCE: Residents were spending time within different areas of the home; some were out in the garden, happy and chatting between themselves. They spoke of their independence and the staff supported them in areas they felt they needed help. Residents said they attended local shops and independently attended local towns using their bus passes. One favourite was the evening visits to the local public house. The overall residents’opinion on the diet provided was excellent, one resident having swallowing problems was clearly informed of his condition and discussed the liquid diet that he received. The meal of the day was a traditional lunch with 2 choices available. Lound Hall Nursing Home C53 C03 S63130 Lound Hall V241831 110805 Stage 2.doc Version 1.40 Page 12 All meals are cooked fresh on the day and no cook/chill foods are used. Residents spoke of receiving fresh grapefruit at breakfast and the manager informed me that fresh fruit was available each day. Home baking is also provided. There is a four-week menu in operation that is changed to address seasonal changes and individual choices. The dining room was welcoming and provided plenty of space around the tables for wheelchair accessibility. Meals are in two sittings; one sitting is for those residents requiring help to take their meals. The manager spoke of supporting residents to achieve their potential and working with them to improve their abilities and ultimate goals. All residents spoken with received visitors without restriction, some were taken to see their relatives and friends by staff at the home. Lound Hall Nursing Home C53 C03 S63130 Lound Hall V241831 110805 Stage 2.doc Version 1.40 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16-18 Residents are confident that their concerns will be listened to and acted upon. EVIDENCE: The home has a complaints procedure in place that meets the minimum standard. The policy in place for responding to allegations or suspicions of abuse informs staff of all the necessary actions to take including the involvement of external agencies involved in adult protection. The Commission have received no complaints or Adult Protection referrals since the new registered provider in May 2005. Residents spoke of feeling that staff always listened to them and responded appropriately. Lound Hall Nursing Home C53 C03 S63130 Lound Hall V241831 110805 Stage 2.doc Version 1.40 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19-20-21-2223-24-25 A comfortable and homely environment is provided for residents with suitable equipment to manage the needs of each person accommodated. EVIDENCE: The home was clean, warm and well maintained. The internal facilities provide a safe environment. The gardens are accessible to wheelchairs although they are not enclosed and residents that may be at risk from wandering would require supervision outdoors. The bedrooms of each of the resident’s case tracked were inspected. All rooms were fully carpeted, personalised and welcoming. Rooms are lockable and keys can be provided. There is also a lockable drawer space in each room for money or valuables. Lound Hall Nursing Home C53 C03 S63130 Lound Hall V241831 110805 Stage 2.doc Version 1.40 Page 15 There was a range of good quality furnishings and some residents had brought their own furniture from home. All rooms are en-suite and there are toilets and assisted baths close by. The rooms are fitted with a nurse call bell. The equipment necessary to support each resident was in place. Some radiators are in the process of being covered to provide safe surface temperatures and prevent people from accidental burns. The room temperature can only be controlled by turning off the radiators. Thermostatic valves that keep the hot water at a safe temperature control all hot water. Hot water is stored at the correct temperature to control Legionella. Lound Hall Nursing Home C53 C03 S63130 Lound Hall V241831 110805 Stage 2.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27-29 The home provides appropriate numbers and skill mix of staff to meet the needs of the residents. The pre-employment checks for staff provide safeguards for residents who may be vulnerable to abuse. EVIDENCE: The records of staff on duty were examined and the numbers of trained and care staff were able to meet the needs of the residents at this time. Two staff files were examined and contained all the required checks prior to employment to safeguard the residents from people who may be unsuitable to work with vulnerable adults. Lound Hall Nursing Home C53 C03 S63130 Lound Hall V241831 110805 Stage 2.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36-38 Staff are appropriately supervised to ensure all aspects of their practice are meeting the aims of the care home and providing the residents with staff who are trained in their role. EVIDENCE: All staff receive supervision and appraisal by the manager monthly and as needs arise. The home has a health and safety policy in place. Staff have attended a health and safety course in 2005. Fire precautions are well documented and meet fire safety standards. Qualified nursing staff provide first aid. Lound Hall Nursing Home C53 C03 S63130 Lound Hall V241831 110805 Stage 2.doc Version 1.40 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 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 3 3 3 3 3 3 3 x STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x 3 x 3 Lound Hall Nursing Home C53 C03 S63130 Lound Hall V241831 110805 Stage 2.doc Version 1.40 Page 19 N/A Are there any outstanding requirements from the last inspection? 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 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. 1. Refer to Standard 3 Good Practice Recommendations The registered person should retain a copy of the letter provided to each prospective admission that informs the person that following the assessment the home are able to meet their needs. 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