CARE HOMES FOR OLDER PEOPLE
Lound Hall Nursing Home Town Street Lound Retford Nottinghamshire DN22 8RS Lead Inspector
Mary O`Loughlin Key Unannounced Inspection 2nd October 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 DS0000063130.V302533.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 DS0000063130.V302533.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Lound Hall Nursing Home Address Town Street Lound Retford Nottinghamshire DN22 8RS 01777 818082 01777 818084 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) MPS Care Homes Ltd Monica Elizabeth Kewarth Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29), Physical disability (29) of places Lound Hall Nursing Home DS0000063130.V302533.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The Registered Provider will provide external support from within the organisation to the home Service users shall be within categories OP or PD (over 50 Years) Date of last inspection 24/02/06 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. The range of fees are: £379.00 to £705.00 Lound Hall Nursing Home DS0000063130.V302533.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out on 2nd October 2006 for the duration of five hours. The main method of inspection was case tracking, which involved selecting three residents and examining their care records. Case tracking is used to establish if the needs of the residents are being appropriately assessed by the home and their needs are being catered for. Discussion took place with 3 residents, 3 staff and 1 relative as part of the case tracking methodology. Indirect and direct observation of practice and interaction between staff and residents was also carried out as part of the inspection methodology. The inspector viewed some areas of the building that included the communal areas, 1 bathroom, laundry, treatment room and three bedrooms. The garden area was also viewed. Residents were briefly observed during lunch. Other documentation including health and safety records were also examined. The management of medication was assessed for three residents. During the course of the inspection the Inspector spoke with three residents, and one relative, the feedback was positive about the level of care received. The Registered Manager was not on duty but the manager from a home within the registered group of homes attended to assist the nurse in charge. Three members of staff were spoken with and three staff files were viewed. The focus of the inspection was to concentrate on the key standards, which were assessed under the new methodology of Inspecting for Better Lives (IBL). 18 responses were received from the Commission for Social Care Inspection pre-inspection surveys sent to the residents. These responses were used to inform this report. Residents were seen to be happy and interacting with each other and staff. What the service does well:
Lound Hall provides a quiet rural setting in which residents receive supervision from trained nurses throughout the day and night. The home is fully accessible for people with mobility problems and residents are able to come and go as they wish following appropriate assessment of the risks to their safety. The environment is generally well maintained and is clean and hygienic. The care residents receive is generally well managed and all the residents case tracked were receiving appropriate care.
Lound Hall Nursing Home DS0000063130.V302533.R01.S.doc Version 5.2 Page 6 Shortfalls exist in completing written records such as care plans, however there was no impact identified on the outcome of the care that residents were actually receiving. The staff team are qualified and experienced to work with the needs of the residents and residents said they felt safe and well cared for. Staff were observed to make every effort to provide residents with the opportunity to try out the home for short stays to assist them in making a more permanent arrangement. One resident comment received: “ the home is beautiful, no unpleasant smells at all. My visitors always comment on the happy atmosphere. The nursing staff are marvellous, medical attention is always available” One resident commented: “ being deaf, the staff are very good to me, they are always on hand to help the vulnerable, no job is too much for them, they treat everyone with dignity” The outcomes of the care received by residents at the home is considered to be good. The service has more strengths than areas for improvement. The key National Minimum Standards are generally met but there are areas for improvement that we feel the provider can manage. Previous weaknesses identified at the last inspection were managed well. What has improved since the last inspection? What they could do better:
Lound Hall Nursing Home DS0000063130.V302533.R01.S.doc Version 5.2 Page 7 The manager must ensure that admissions to the home are not made until a full needs assessment is undertaken or obtained through care management arrangements and they can then confirm in writing that they are able to meet the needs of the individual through the service they deliver as detailed in the statement of purpose. Once admitted the manager must ensure that all aspects of the persons health, personal and social care needs are used to develop a plan of care that staff can follow which will ensure that even those not familiar with the resident, are able to deliver appropriate care. Where residents receive nursing care from a district nurse it is also necessary to include these areas within the person’s care plan. It would be good practice to ensure that a social care plan contains evidence of the preferences of the resident and the services that the home are providing to meet the person’s preferences. There needs to be significantly more safeguards and audit in the way medicines are managed in the home. The shortfalls in the monitoring of cold storage medicines could present a risk to the life of the medicines and compromise the effects. Where oxygen is in use appropriate safeguards must be in place to control the flammability risk, warning signs must be displayed. There needs to be a robust system for recording medicines into the home to provide an appropriate audit trail which will safeguard any misuse of medicines. Suitably managed stock control of sterile products should also be in place to replace old, out of date equipment. The staff must be fully aware of the procedures for the management of medicines and be able to locate all the policies for medicines. The manager can source the Royal Pharmaceutical Guide to the Management of Medicines in Care Homes, which will provide the evidence base for the home’s practices. Residents would benefit from the complaints procedure being in large print. The management of health and safety requires review with regard to the efficiency of the hot water supply to residents’ rooms and the control of hot water to safe temperatures. Review of the home’s fire risk assessments are required and more adherence to the home’s practices with weekly fire testing. There should be evidence that residents are consulted on the provision of a door key with risk assessment to determine their safety in its use. The quality monitoring system that surveys the views of the residents should be used to inform the practices of the home and evidence or feedback provided to those participating. The manager must review the home’s induction standards in line with National Standards introduced in September 2006.
Lound Hall Nursing Home DS0000063130.V302533.R01.S.doc Version 5.2 Page 8 There was no evidence seen that the registered person had consulted with the Environmental Health Department with regard to the provision of suitable sluicing equipment, which is now outstanding from the last inspection and must be addressed. The present arrangements around the provision of suitable office space must also be addressed to ensure that the environment is suitable in achieving its objectives. 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 DS0000063130.V302533.R01.S.doc Version 5.2 Page 9 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 DS0000063130.V302533.R01.S.doc Version 5.2 Page 10 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 the following standard(s): 1-2-3 Quality in this outcome area is good. This Judgement is made using available evidence including a visit to this service. Prospective residents have the information they need to choose a home that will meet their needs. Each resident receives a contract which tells them about the services they will receive. Residents are admitted without appropriate assessment of their needs or assurance that these can be met. Intermediate care is not provided by the home. EVIDENCE: The records of three recently admitted residents were examined, none of the three residents had evidence within their files that a suitably trained person had completed an assessment of their needs prior to admission. Each file contained an assessment that was completed on the day of admission.
Lound Hall Nursing Home DS0000063130.V302533.R01.S.doc Version 5.2 Page 11 Through the process of tracking the care of the three residents it was evidenced that the home had been able to meet their needs appropriately. Records indicate that relatives or advocates of these residents had visited the home and provided some initial information on the person prior to admission. Staff spoken with said they had received some information on clients before they were admitted but had completed the assessment document on the day of admission. Two residents and one relative confirmed that they had been able to visit the home prior to admission and had received a comprehensive information pack which told them about the home, its facilities and services.This complies with the recommendation set at the last inspection and meets the National Minimum Standard. Each resident had a signed copy of their statement of terms and conditions of occupancy within their files.This complies with the recommendation set at the last inspection and meets the National Minimum Standard. Lound Hall Nursing Home DS0000063130.V302533.R01.S.doc Version 5.2 Page 12 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 the following standard(s): 7-8-9-10 Quality in this outcome area is good. This Judgement is made using available evidence including a visit to this service. There needs to be improved care planning which informs staff of how the residents health and social care needs are to be met. The personal care that residents receive is planned for and their privacy and dignity is managed well. The management of medicines does not fully protect residents and requires review of the procedures staff undertake to suitably and safely manage them. EVIDENCE: Four residents files were examined and show that an assessment of their needs is completed and provides a basis for the care to be delivered. The care plans of each resident were insufficient to ensure that care staff knew of the actions they should take to meet the health, and social care needs of the person. 100 of the residents responses received by the Commission said they had medical attention when they needed it. Comments included how one resident “required a lot of attention for a leg ulcer and that the staff were marvellous”
Lound Hall Nursing Home DS0000063130.V302533.R01.S.doc Version 5.2 Page 13 Personal care needs were well documented and provided staff with sufficient information to deliver this care. Risk assessments were completed for those people who were at risk of falling. There was evidence that some areas of the initial assessments had been signed by the resident or their representative, however the care plans were not signed and residents spoken with had not seen their plans. There were suitable risk assessments completed for the nutritional and pressure sore risks to the residents, however the outcomes of the risks assessments had not been used to draw up a plan of care that would describe how the staff were to support the resident in these areas of need. From observation and talking to the residents it was clear that they felt their needs were being met and they did have access to any required equipment and the district nurse input to manage their health care as required. Suitable pressure relieving equipment was seen in use where this was required. The records of medicine administration showed that residents received their prescibed medicines at appropriate times. Since the last inspection the manager has obtained a suitable medicines fridge, however there were no written records of the temperature of the fridge to ensure medicines were being stored at the required temperature as is recommended.The fridge was found to have been switched off and staff did not know how long this had been for, there were no medicines that would be affected by this, that were being stored at the time. Presently the home uses the dining area in which to store the medicine trolley and medicines fridge. The medicine trolley was secured to the wall and locked as required. The medicine fridge was not locked. The small treatment room on the first floor contains suitable storage of controlled medicines. Sterile equipment was seen to be out of date in the treatment room. Oxygen was in use without suitable signage to inform people of the flammability risk. Medicine records indicated that medicines were not always recorded into the home, which is required to ensure appropriate controls and an audit trail are in place. Hand written medicines had no signature of the person writing up the medicine and no signature of the person checking this written record. A record of the last pharmacy inspection in February 2006 found the home to have satisfactory systems in place for the management of medicines at the home. Lound Hall Nursing Home DS0000063130.V302533.R01.S.doc Version 5.2 Page 14 Residents were able to self medicate and records examined show that risk assessments are conducted to ensure they are safe to undertake this procedure. The staff were unable to locate the procedure for the actions in the event of a medicine error, staff were able to descibe their responsibilities in this event satisfactorarily. Residents spoken with confirmed that staff were responsive to their needs and maintained their dignity when delivering care. A resident commented, “ being deaf, the staff are very good to me, they are always on hand to help the vulnerable, no job is too much for them, they treat everyone with dignity” Lound Hall Nursing Home DS0000063130.V302533.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12-13-14-15 Quality in this outcome area is good. This Judgement is made using available evidence including a visit to this service. Residents social interests are met by suitable activities inside and outside of the home. Residents are able to maintain contact with their family and friends as they wish. Residents can exercise choice and control over their lives. Residents receive a choice of meals in accordance with their nutritional needs. EVIDENCE: Following the last inspection the management of food safety is improved. Records were seen that show kitchen staff record all the storage and delivery temperatures of foods as required. Staff were seen to be using appropriate protective clothing in the food preparation and serving areas. Residents have a choice at each meal and all those spoken with were happy with the meals provided. Lound Hall Nursing Home DS0000063130.V302533.R01.S.doc Version 5.2 Page 16 One resident commented that “they had been unable to eat a normal diet due to medical problems and staff provided a pureed diet, doing their best to offer variety” The home has an activities person employed during each afternoon who facilitates a range of activities for the residents. There were no records seen of the social or recreational activities that a resident is involved in or have preferences in. Those spoken with were able to participate in activities such as board games and had access to daily newspapers. Residents comments received demonstrate that they were happy with the activities available both inside and outside of the home. Residents had a right to refuse to participate in the communal activities and one resident described how they prefer not to join in and how staff support their choice. Residents are able to receive visitors at any time, in private if they wish. Residents were seen to have their own telephone fitted in their rooms. Visiting clergy from the local churches provide visits to those who request this, residents told me they are able to attend a communion at the home that is provided by the Anglican Communion Service each month. Residents’ rooms were fully personalised with their own belongings from home. Lound Hall Nursing Home DS0000063130.V302533.R01.S.doc Version 5.2 Page 17 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16-18 Quality in this outcome area is good. This Judgement is made using available evidence including a visit to this service. Residents have access to a complaints procedure which could be more user friendly if available in large print. There are robust systems in place to protect residents from abuse. Staff are trained in the Protection of Vulnerable Adults. EVIDENCE: The homes complaints procedure is made available to all residents and their representatives at the point of admission. There have been no complaints received by the Commission since the last inspection. All 18 responses received by the Commission from the pre-inspection surveys sent out to the residents, stated that they always knew how to complain and who they could speak to if they had a concern. Comments such as the staff are always on hand to help and no job is too much for them the staff deserve special praise, were received from residents taking part in the Commissions survey. A copy of the complaints procedure is posted on the main notice board within the home.The procedure is in very small print and not suitable for the resident group to effectively read it. Copies of the local procedures regarding the protection of vulnerable adults were seen available to staff. Records of staff training demonstrated that staff have received training in protection of vulnerable adults during 2006.
Lound Hall Nursing Home DS0000063130.V302533.R01.S.doc Version 5.2 Page 18 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 the following standard(s): 19-26 Quality in this outcome area is good. This Judgement is made using available evidence including a visit to this service. Residents live in a safe well-maintained environment that is clean, pleasant and hygienic Residents experience problems with interruptions in suitable hot water supplies. 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. All floors are accessible via a passenger lift. Lound Hall Nursing Home DS0000063130.V302533.R01.S.doc Version 5.2 Page 19 Three residents rooms were seen and found to be clean, warm and suitably furnished. The rooms were personalised and homely. Each resident has access to a suitable toilet and bathroom that is able to meet their physical needs safely. The laundy room is fitted with suitable machines that will wash clothing at safe temperatures to control infection. Staff have access to appropriate clinical and sharps waste disposal to control any waste hazards. The laundy room provides a sluice sink to dispose of waste material safely. Residents comments received were very complimentary about the cleanliness of the home. One resident said that laundry is always perfectly washed and ironed and then returned to their room, saying a real credit to the laundry workers Another resident said The home is beautiful, no unpleasant smells and my visitors always comment on the happy atmosphere The last inspection required that the manager consult with the Environmental Health department regarding sluicing facilities, this could not be validated during the inspection. No records were seen regarding the wishes of the residents in making a key to their rooms available following risk assessment, those residents case tracked did not feel they needed a key. Hot water in two of the rooms examined was cold. The residents said they had problems with the supply on a daily basis. There was no evidence that hot water control valves were in place. Lound Hall Nursing Home DS0000063130.V302533.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27-28-29-30 Quality in this outcome area is good. This Judgement is made using available evidence including a visit to this service. Robust recruitment procedures protect the residents from unsuitable staff. The numbers of staff are able to meet the needs of the residents. Staff receive a programme of learning but records were unable to evidence the numbers of people who are on a programme of learning that leads to a qualification in care. EVIDENCE: The records of the arrangements around staff recruitment were examined and provided evidence that in all three examples looked at, suitable checks were made prior to employment which safeguards vulnerable adults from staff who may be unsuitable. The numbers of staff on duty are calculated using the dendency levels of the residents and evidence of this was seen. Trained nurses are on duty throughout the 24hr period. The cleanliness of the home and the management of meals and laundry show that the numbers of staff employed in these areas are sufficient to provide suitable services for the residents. 100 of responses received from residents completing the Commissions survey said the home was always fresh and clean. Lound Hall Nursing Home DS0000063130.V302533.R01.S.doc Version 5.2 Page 21 The residents commented that they always have staff available to them and had no concerns about shortages. The manager has supernumery hours of work to undertake her role. Induction and foundation training standards were unclear. No completed records of induction were available that could determine the suitability of the training provision. Lound Hall Nursing Home DS0000063130.V302533.R01.S.doc Version 5.2 Page 22 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31-33-35-38 Quality in this outcome area is good. This Judgement is made using available evidence including a visit to this service. A suitably qualified and competent person manages the home. More robust arrangements for document management must be implemented to allow suitable access arrangements and appropriate storage and office space. The home is run in the best interests of the residents, improvements in the feedback and action taken as a result of quality monitoring and participation by the residents is required, this will ensure that residents’ comments are used to improve the service provided. Residents’ financial interests are safeguarded. Improvements are necessary in the review of risk assessments to ensure that the health and safety of residents is fully protected. Lound Hall Nursing Home DS0000063130.V302533.R01.S.doc Version 5.2 Page 23 EVIDENCE: The previous inspection found that staff files were not accessible when the manager was not on duty. This inspection found that no suitable arrangements were in place as yet. The manager was not on duty at the time of this inspection but was able able to deliver the keys to the staff files during this inspection which allowed suitable access for the inspector. The manager is registered with the Commission and is suitably qualified and experienced to undertake her role. The external management facilitates access to a regional nurse advisor for the manager and regular meetings with other managers within the group of care homes. Documented evidence of the registered provider visits to the home were seen and on a monthly basis the registered person completes an audit of the home. The personal monies of the residents are not managed by the home staff, only cash floats are secured and suitable records are held. Residents have the opportunity to participate in annual quality assurance questionnaires and the results of these are displayed in the main entrance, however the actions taken following these quality monitoring reports were not clear. The manager does not have an office, she works from a desk at the main entrance and has very poor storage space.Many records are held on the floor in boxes. Confidential records are securely locked away. The area and records access was disorganised and not condusive to suitable access. On this occassion the records of fire maintenance were examined. There was suitable provision of fire equipment in place and adequate means of escape. Equipment maintenance was in place and weekly tests on the system recorded; some gaps in these dates were evident. There were suitable arrangements for staff to receive training in fire prevention and this was validated through certificates of staff training in 2006. The present fire risk assessments to ensure appropriate evaluation of the risks to all persons in the care home did not reflect current good practice and require review. Lound Hall Nursing Home DS0000063130.V302533.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 2 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X 2 2 Lound Hall Nursing Home DS0000063130.V302533.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES 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 OP3 Regulation 14 Requirement Timescale for action 30/11/06 2 OP9 13 3 OP25 23 4 OP26 12,1 3, 16, 23 The registered person must not provide accommodation to a resident unless the needs of the person have been assessed, a copy of the assessment is obtained and there is appropriate consultation with the prospective resident or their advocate. The registered person must 30/11/06 make suitable arrangements for the recording, handling and safekeeping of medicines at the home. This includes the review of the present policies and procedures. The registered person must 30/11/06 ensure that the water supply to the residents’ accommodation meets the relevant environmental health and safety requirements and the needs of the individual residents. Seek advice from the 30/11/06 Environmental Health Officer in relation to the requirement for nursing homes to provide an appropriate sluicing disinfector. Evidence that this has been achieved was not available at this inspection. Previous timescale 26/04/06.
DS0000063130.V302533.R01.S.doc Version 5.2 Lound Hall Nursing Home Page 26 5 OP37 17 6 OP38 23 Ensure all records required for regulation to be inspected [apart from staff personal records] are available/accessible to the person in charge of the shift. This requirement was not met within the timescale 26/03/06. Action must be taken to ensure appropriate arrangements are in place. The registered person must ensure that adequate precautions are in place against the risk of fire. 30/12/06 30/11/06 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 OP3 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. The registered person should ensure that all aspects of the residents’ health and social care needs are included within the care plans. Where residents receive care from the district nurse, this information should be used in the homes own care plan records. The registered person should record the social needs of the residents and how they are meeting those needs. The registered person should provide the complaints procedure in large print. The registered person should ensure that the present arrangements around office provision are reviewed to ensure they are suitable for the purpose of meeting the aims and objectives of the home. 2 OP7 3 4 5 OP12 OP16 OP19 Lound Hall Nursing Home DS0000063130.V302533.R01.S.doc Version 5.2 Page 27 6 OP24 7 8 9 OP26 OP30 OP33 The registered person should include evidence within care plans that service users have the option to hold keys for their room, or a risk assessment is in place where this is needed. The registered person should ensure the home has suitable sluicing facilities. The registered person should review the induction process to ensure this meets with National Guidance on Induction Standards. The registered person should demonstrate how they use information through Quality monitoring to ensure the home is meeting its stated objectives. Lound Hall Nursing Home DS0000063130.V302533.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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