Inspection on 15/11/06 for Lound Hall Nursing Home

This inspection was carried out on 15th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 21/08/07

Lound Hall Nursing Home 06/03/06

Lound Hall Nursing Home 01/04/05

Lound Hall Nursing Home 20/09/04

Lound Hall Nursing Home 18/06/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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 Jay Lane Lound Lowestoft Suffolk NR32 5LH Lead Inspector Jane Offord Unannounced Inspection 15th November 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 Lound Hall Nursing Home DS0000024439.V320559.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. Lound Hall Nursing Home DS0000024439.V320559.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lound Hall Nursing Home Address Jay Lane Lound Lowestoft Suffolk NR32 5LH 01502 732331 01502 732331 loundhall@yahoo.co.uk 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) Lound Hall Ltd Post vacant Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (43) of places Lound Hall Nursing Home DS0000024439.V320559.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th March 2006 Brief Description of the Service: Lound Hall is a care home with nursing, accommodating a maximum of 43 service users, aged 65 years and over. The home offers long term, short term and respite care. The accommodation consists of twenty-nine single rooms and seven shared rooms. Thirty of the rooms have en suite facilities. The main part of Lound Hall is a listed building and has accommodation over three floors. Access to the upper floors is provided by a passenger lift. There are a number of assisted baths and shower rooms throughout the home. There is a choice of four separate lounges and two dining rooms that all overlook the attractive gardens. The ground floor rooms all have direct access to the gardens. Lound Hall is situated in the small village of Lound in north Suffolk. There is a long private drive to the house and a stand of mature trees around the front of the building. Ample car parking space is available. Fees for the home range from £378.00 to £550.00 weekly. These do not include chiropody, hairdressing, newspapers/magazines, dry cleaning, postage, a private telephone or the cost of staff accompanying residents to appointments. Lound Hall Nursing Home DS0000024439.V320559.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection focussed on the core standards for care of older people and took place on a weekday between 10.00 and 16.00. The report has been written using accumulated evidence gathered prior to and during the inspection. The responsible individual, the commercial director and the deputy manager were all present during the day and assisted with the inspection process. During the day a tour of the home was undertaken and a number of residents, staff and relatives were spoken with. Three new residents’ files and care plans, three new staff files, the policy folder, the complaints log, the menus, duty rotas and minutes of staff meetings were all inspected. Part of a medication administration round was followed and the medication administration records (MAR sheets) were checked. The serving of the lunchtime meal was seen and care practice during the day was observed. On the day the home was warm and clean. Residents looked comfortable and were dressed appropriately for the weather conditions. Interactions between staff and residents were friendly. The meal looked appetising and was clearly enjoyed by residents. What the service does well: What has improved since the last inspection? Lound Hall Nursing Home DS0000024439.V320559.R01.S.doc Version 5.2 Page 6 There were no requirements or recommendations left at the last inspection however the registered persons continue to build on good practice and offer wide training opportunities to the staff. A sensory garden has been completed and spring bulbs have been planted to maintain the garden’s appeal. 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. Lound Hall Nursing Home DS0000024439.V320559.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Lound Hall Nursing Home DS0000024439.V320559.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6. Quality in this outcome area is good. People who use this service can expect to have an assessment of needs and assurance that those needs can be met prior to admission. The service does not offer intermediate care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The files of three recently admitted residents were seen and each one contained evidence of a pre-admission assessment completed before the resident arrived at the home. The assessments were completed by a senior member of staff and covered areas of care such as mobility, continence, nutrition, skin integrity, oral health and communication. Information about past medical history was recorded, the contact details of the next of kin and the prospective resident’s hobbies and interests. One assessment had a note that it had been completed in the presence of a friend/advocate. It was also noted that the resident wished to continue having visits from their dog. Lound Hall Nursing Home DS0000024439.V320559.R01.S.doc Version 5.2 Page 9 The statement of purpose and service users guide were both seen and are very attractively presented. They contained all the information required by the regulations in an easy to read format. It has already been updated following the departure of the registered manager just over a month ago. One small oversight was that the address for the Commission for Social Care Inspection (CSCI) office was given but the telephone number referred to National Care Standards Commission (NCSC). The responsible individual made a note to correct that as soon as possible to avoid confusion. Lound Hall Nursing Home DS0000024439.V320559.R01.S.doc Version 5.2 Page 10 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. People who use this service can expect to have a plan of care to help meet their needs and be treated with respect but they cannot be assured that all assessed needs will have interventions in the care plan or that all medication recording and the medication policy will protect them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The assessments and care plans of three newly admitted residents were seen. They showed assessments were undertaken on admission and covered areas of care for mobility, continence, nutrition, personal hygiene, skin integrity, sleep pattern and psychological needs. The care plans generally had interventions to show how support was to be given where a need was identified. Some omissions were noted in that a risk assessment that scored a resident at risk of tissue damage had no intervention for pressure area care, although they had no broken skin areas at the time. Lound Hall Nursing Home DS0000024439.V320559.R01.S.doc Version 5.2 Page 11 One resident with a small broken area of skin had no care plan for the dressing they required. The community nurses were managing the wound care but interventions to alert the carers to the need to take precautions when moving the resident would have been good practice. There was evidence that care plans were reviewed and updated. One resident who had been admitted with a diagnosis of immobility had an updated intervention on their care plan that showed they could now stand with support and had a new mobility risk assessment completed. Two of the three files had recorded the residents’ final wishes. In the case of the third resident they had been in the home only a matter of days and the deputy matron said an appropriate time had not presented yet to discuss such a delicate subject. In discussion with staff it was clear that care planning is nurse led but carers have input as a result of interactions with residents. Relatives and residents are also encouraged to have input if they are able. There is a recognised process of re-assessment for any resident whose health deteriorates and needs to transfer from residential care to nursing care the deputy manager said. Care practice was observed during the day and carers treated residents with friendly respect. Residents were offered choices about where they wanted to be and it was noted that clothing was discreetly adjusted to maintain dignity. Staff knocked on bedroom and toilet doors before entering. Part of a medication administration round was followed. The medication trolley was locked securely in the clinic room when not being used and locked each time the nurse left it during the round. The medication administration records (MAR sheets) were kept in a folder but there were no dividers or photographs of the residents for identification. The registered manager recently left the home and the deputy manager is also leaving in the next few weeks. The owners talked about their plans to cover the shortfall until they could appoint to both posts. They intended to try and secure the services of regular agency staff. They agreed that identification photographs under those circumstances would be a security. The MAR sheets seen were correctly signed with no gaps noted. Prescriptions that had a choice of dose i.e. one tablet or two, 5-10 mls. did not have the amount given recorded. Insulin and some eye drops were stored in a refrigerator in the clinic room and records of the temperature showed it was checked daily and was functioning within safe limits for the storage of medicines. The controlled drugs (CD) register was seen and some CDs randomly checked. They tallied with the records. One resident spoken with said they thought they were being given another resident’s tablets. They did not think the tablets they were receiving were the ones they had been prescribed. Lound Hall Nursing Home DS0000024439.V320559.R01.S.doc Version 5.2 Page 12 On checking the MAR sheet it was clear that the resident was not receiving the dose of analgesia the GP had prescribed for them but a lower dose. This was brought to the attention of the owners and the deputy matron. The deputy matron explained the home had run out of the higher dose tablets so until a new supply was received from the pharmacy the lower dose tablets, that had previously been supplied for the resident, were being used. The owner said that an investigation would be commenced that afternoon and the deputy manager would speak with the resident and explain what action was being taken. It was agreed this practice was unacceptable and plans were made to review the ordering system. The owner has since supplied CSCI with a copy of their investigation of the incident and the apology tendered to the resident. The medication administration policy was seen. It did not contain guidance on administering medication covertly or in a format not licensed by the manufacturers i.e. crushing tablets or opening capsules. Lound Hall Nursing Home DS0000024439.V320559.R01.S.doc Version 5.2 Page 13 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. People who use this service can expect to be encouraged to maintain contact with family and friends, to be offered meaningful activities and receive a balanced diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Evidence was seen that the residents are consulted at the start of the year about what activities they would like to do during the year so the service can plan a programme of outings. The daily records for residents showed that they had had a variety of outings during the year. They had visited seaside towns such as Great Yarmouth and Lowestoft, been swimming and on a boat trip, had a mystery tour, visited garden centres and pets corner. Activities within the home are organised most afternoons. On the day of inspection the plan was for a session of bingo but people spoken with said quizzes, story telling, board games and baking are all pastimes that take place from time to time. Entertainers are sometimes booked for a musical afternoon, a mobile library visits the home and there are monthly visits from Church of England and Roman Catholic priests. Lound Hall Nursing Home DS0000024439.V320559.R01.S.doc Version 5.2 Page 14 Visiting is encouraged at any reasonable time and staff ensure the resident meets their visitor in a setting suitable for them. Visitors were seen coming and going during the day and staff welcomed them. One visitor spoken with said they had always been made welcome, they added that, ‘Everyone should live in Lound Hall. The staff are so good’. Copies of the menus were supplied to CSCI with the pre-inspection questionnaire and showed that there is a choice of main meal and dessert every day. Each Sunday there is a roast dinner with the option of salad if preferred. Tea menus also offered a choice of hot snacks such as fish cakes, cauliflower cheese or soup and a roll. Residents spoken with said the food is ‘lovely’. The meal on the day of inspection was shepherds pie and vegetables or sausages, with rhubarb crumble or blancmange for dessert. The kitchen was visited and the cook showed off well-stocked dry goods cupboards and a good supply of fresh fruit and vegetables. They said there were three deliveries a week of green grocery. New menus were being discussed with residents and planned for the New Year. Records of temperatures of refrigerators and freezers showed they were functioning within safe limits for food storage. In discussion with the cook they said a number of special diets were being offered at present such as diabetic, high protein and low fat to meet particular residents’ needs. They said a dietician is consulted at times for advice about special diets. Evidence was seen in the minutes of a trained staff meeting that the dietician had been consulted. Lound Hall Nursing Home DS0000024439.V320559.R01.S.doc Version 5.2 Page 15 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. People who use this service can expect to have complaints taken seriously and be protected by staff knowledge from abuse but they cannot be assured that the written guidance is up to date. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints policy was seen and meets the standard required. The complaints log showed two complaints had been made since the last inspection. Both contained evidence to show that they had been investigated. One was about the attitude of a member of staff and was not proved, the other was about a visiting hairdresser and although not proved there was evidence that options had been given to the resident if they remained dissatisfied with the service offered. Staff spoken with were clear about their duty of care to residents and said they had had protection of vulnerable adults (POVA) training. The training matrix supplied with the pre-inspection questionnaire confirmed this. POVA is also covered in the induction records seen. The home has the up to date guidance from the inter agency committee for protection of vulnerable adults of Suffolk but their own policy did not reflect that guidance. There is also a whistle blowing policy to protect staff who exercise their duty of care. Lound Hall Nursing Home DS0000024439.V320559.R01.S.doc Version 5.2 Page 16 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, 21, 22, 26. Quality in this outcome area is good. People who use this service can expect to live in a safe, comfortable home that has specialised equipment available if needed and sufficient baths and toilets to meet residents’ needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the day a tour of the home was made with the deputy manager. The home was clean and tidy with no unpleasant odours present. Residents were using all areas of the home. Some had remained in their own rooms, others were using the lounges. One resident was sitting in the smallest, quiet lounge doing a jigsaw. One lounge had a television programme on and another had some music playing. One resident told the deputy manager they had just had, ‘a lovely bath and hair wash in the Jacuzzi bath’. The deputy manager said a lot of the residents enjoyed the Jacuzzi bath. Lound Hall Nursing Home DS0000024439.V320559.R01.S.doc Version 5.2 Page 17 The baths in the en suites do not have fitted bath hoists so would be used only by residents who were independent. The home has no resident at present who can manage to get into and out of a bath independently. There are plans to enlarge some en suites and decommission others. The home has sufficient communal bathrooms and showers with hoists and bath chairs to meet the needs of the residents. Pressure relieving equipment is available if it is required by assessment. The home has one electric profiling bed and a number of hospital beds that can be raised and lowered to help with the moving and handling of residents. The laundry was visited and had washing machines with an automatic product feed to prevent additional handling of products by the laundry workers. Soiled linen is brought to the laundry in alginate bags that are placed directly in the machines to minimise the risk of cross infection. Protective clothing is available if required and staff were seen using it for some tasks. Lound Hall Nursing Home DS0000024439.V320559.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. People who use this service can expect to be supported by adequate numbers of correctly recruited, well-trained staff. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The duty rotas were sent to CSCI with the pre-inspection questionnaire and showed that for each day shift there were two trained nurses on duty supported by seven carers in the morning and six carers in the evening. The deputy manager was supernumerary. In addition there was administrative support four days a week and a team of ancillary staff to manage the kitchen, laundry, cleaning and maintenance. Staff spoken with said they felt there were sufficient staff to meet the needs of the residents. Residents spoken with said they did not have to wait long for attention and during the day it was noted that bells were responded to quickly. The files of three new staff members were seen and contained evidence of full work histories, two references, and interview questions and responses. There was also evidence that documentary evidence had been seen of the person’s identity. Criminal record bureau (CRB) checks had been undertaken and in the case of trained nurses there was evidence that their personal identification number (PIN) with the Nursing and Midwifery Council (NMC) was valid. Lound Hall Nursing Home DS0000024439.V320559.R01.S.doc Version 5.2 Page 19 In the files of staff from overseas there were documents to show valid residence permits and police checks from their country of origin. Each file had evidence of qualifications and previous training undertaken. The induction programmes seen covered fire procedures, care plans, confidentiality, the policy folder, infection control, food hygiene and POVA. Staff spoken with confirmed they had had an induction period covering these areas of care. Staff performance is reviewed at six weeks after commencement, then three months and six months. Copies of the reviews were seen and are kept securely in the office. The home employs twenty-five care staff of whom thirteen have achieved NVQ level 2 or over. This gives a figure of 13 , which is above the figure in the national minimum standards. Lound Hall Nursing Home DS0000024439.V320559.R01.S.doc Version 5.2 Page 20 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, 36, 38. Quality in this outcome area is good. People who use this service can expect to have their opinions sought, their personal monies safeguarded and their health and safety protected. They cannot be assured that there is a manager in charge at present or that staff are supervised as individuals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager left the home’s employ a month ago and the deputy manager undertook the role until a suitable candidate could be found for the post. However the deputy manager is also going to leave the home in early December. The owners are aware of the implications of the situation and making plans to manage the service until they can appoint someone. Lound Hall Nursing Home DS0000024439.V320559.R01.S.doc Version 5.2 Page 21 The residents’ personal monies are managed in the office and kept securely in the safe. The owner explained the system of recording used. It was thorough and afforded an audit trail. Previously the system used has met the standard and it has not been altered. As noted earlier in this report residents are consulted at the beginning of the year about their preferences for activities and outings. In August 2006 the home consulted with staff, residents and relatives about the service. Evidence was seen of meetings held with groups of staff. The minutes showed a wide range of topics including care practice, infection control, Inspecting for Better Lives (the methodology of CSCI inspections) and information about changes planned for the service that would affect all staff and residents. Staff spoken with said they received regular supervision with senior staff. Supervision notes were inspected. They showed that senior staff held supervision sessions for several staff on the same day and clearly had a particular topic to discuss such as infection control or chart completion. Supervision should be more directed to individual needs and identifying strengths and learning deficits with input from the supervisee to the agenda. The home has a rolling programme of maintenance and redecoration. The preinspection questionnaire says that since the last inspection four bedrooms and the kitchen have been painted and the first and second floor landings have been redecorated. The areas seen on the day looked clean and fresh. During the day it was noted that cleaning products were left unattended by the domestic staff around the home, where residents could have access to them. Certificates for routine maintenance of equipment were seen and included planned maintenance of the passenger lift in May ’06 and repairs that were carried out in September ’06, also maintenance of the boiler in March ’06 and Arjo baths in November ’06. The fire log was checked and showed emergency lighting and fire alarms were tested weekly, external consultants tested fire equipment in May ’06 and a fire lecture for staff was given in July ’06. Lound Hall Nursing Home DS0000024439.V320559.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 2 3 X 3 3 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 2 Lound Hall Nursing Home DS0000024439.V320559.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NONE 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) Requirement The registered persons must ensure that if an assessment identifies a care need for a resident an appropriate care plan is generated to show how that need should be met. The registered persons must expand the medication policy to include guidance about altering medicines from the format licensed by the manufacturer and on the covert administration of medicines. The registered persons must ensure that identification photographs are affixed to the MAR sheets. The registered persons must ensure the correct recording of the number of tablets or amount of medicine given when the prescription offers a choice of dose. The registered persons must update the POVA policy to reflect guidance provided by the Vulnerable Adults Committee of Suffolk. Timescale for action 15/11/06 2. OP9 13 (2) 15/12/06 3. OP9 13 (2) 04/12/06 4. OP9 13 (2) 15/11/06 5. OP18 13 (6) 15/12/06 Lound Hall Nursing Home DS0000024439.V320559.R01.S.doc Version 5.2 Page 24 6. OP31 38 (1) (2) 39 (a) (b) 7. OP38 13 (a) (c) The registered persons must keep CSCI informed in writing of management arrangements and changes during the period when there is no registered manager in post. The registered persons must ensure COSHH regulations are observed to protect residents. 15/11/06 15/11/06 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 OP36 Good Practice Recommendations The registered persons should consider the present approach to staff supervision and develop a more individual format. Lound Hall Nursing Home DS0000024439.V320559.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Lound Hall Nursing Home DS0000024439.V320559.R01.S.doc Version 5.2 Page 26 - 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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