Inspection on 21/08/07 for Lound Hall Nursing Home

This inspection was carried out on 21st August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Lound Hall Nursing Home 15/11/06

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 21st August 2007 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.V349274.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.V349274.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 Mrs Julie Elaine Smith 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.V349274.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 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 £375.00 to £650.00 weekly depending on the accommodation and the dependency of the resident. These fees 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.V349274.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 looking at the core standards for care of older people took place on a weekday between 10.00 and 16.00. The registered manager was on annual leave but the managing director and the commercial director were both there throughout the day and assisted the inspection process by providing files and information. This report has been compiled with information available prior to the inspection and evidence found on the day. During the day a tour of the home was undertaken with the commercial director but all areas were re-visited later. A number of staff and residents were spoken with and care practice was observed. Three new residents files, care plans and daily records were seen, as were four new staff files. The duty rotas, the menus, some medication administration records (MAR sheets), maintenance records and the complaints log were all inspected. Part of a medication administration round was followed and the serving of lunch was seen. CSCI received a number of completed survey forms from residents, relatives/representatives and staff prior to the inspection. Residents were using all areas of the home and looked relaxed and comfortable. The home was clean and tidy with no unpleasant odours. The lunch looked and smelled appetising and residents spoken with afterwards said they had enjoyed it. Staff demonstrated a good knowledge of individual resident’s preferences and encouraged independence with gentle verbal prompting. There were cheerful, appropriate interactions between staff and residents. What the service does well: Lound Hall offers a good standard of support to people with a range of physical and mental abilities. Residents are treated as individuals and likes and dislikes are respected. Record keeping is of a good standard with daily records of residents being informative about the resident’s experience of the service. Consultation with residents and their representatives is regularly undertaken and suggestions for additional activities are seriously considered. The menus and the standard of food with the choices given are very good, with many home made dishes and cakes. Input from a dietician is used when menus are planned to ensure there is suitable nutritional content to meet the needs of older people. Lound Hall Nursing Home DS0000024439.V349274.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Lound Hall Nursing Home DS0000024439.V349274.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.V349274.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): 1, 3, 6. Quality in this outcome area is good. People who use this service can expect to have sufficient information to make an informed choice about the home and have their needs assessed prior to entry. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a well-produced Statement of Purpose that is kept up to date and available in the entrance hall for any visitors. Prospective residents are given a copy when they visit or an enquiry is made. In the surveys received by CSCI local knowledge of the home is evident as one resident commented, ‘A friend whose parent spent his last years here was impressed as they were so happy here’, and another said, ‘The home has a good report and the location is lovely’. The service does not offer intermediate care. Lound Hall Nursing Home DS0000024439.V349274.R01.S.doc Version 5.2 Page 9 The Statement of Purpose says prospective residents will have an assessment of need done by a qualified person prior to admission to the home. The files of three newly admitted residents were seen and each one had a pre-admission assessment completed by the registered manager. The assessment covered areas of health needs such as diet, continence, mobility, skin integrity, night needs, personal hygiene and communication. The residents’ psychological state and level of anxiety had been assessed and information recorded about family involvement and any known allergies. Lound Hall Nursing Home DS0000024439.V349274.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 their health needs met and be protected by the medication administration practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The files seen for three newly admitted residents all contained an individual plan of care to help carers support the resident, as they would wish. The plans all contained information about the resident’s preferences around meeting personal hygiene needs and their level of mobility, their continence and night needs. Individual entries for some residents covered wound care or prevention of falls, weight loss or gain, pressure area care and fluid intake. One care plan had an entry around helping the resident settle in the home and manage their anxiety. Another plan had interventions for the management of the resident’s chronic pain. There was evidence that all the care plans had been reviewed with the resident or their representative. Lound Hall Nursing Home DS0000024439.V349274.R01.S.doc Version 5.2 Page 11 The files contained contact details of any health professional involved with the resident including their GP, chiropodist and optician. There were records of visits to or by the GP and notes of any treatment prescribed or any changes to care. Risk assessments for moving and handling, skin integrity and nutrition were completed and updated. The daily records were well written and gave a comprehensive account of the resident’s daily experience. There was a record of whether the resident had had a bath or shower and a note if they had been offered one but refused. Wound care was recorded with the size of the area and a detail of the condition of the wound together with progress in healing. The records in some cases recorded the resident’s activities during the day and their mood. The policy folder is being completely reviewed by the new registered manager but some policies have already been done. The one relating to medication storage, administration and disposal is comprehensive and clear. It gives guidance on the administration of ‘homely’ remedies, a refusal by a resident to take medicine and covert administration of medicines. Part of a medication administration round was followed during the lunch period. The home uses a monitored dosage system (MDS) so tablets are dispensed by a local pharmacy into prepared blister packs for individual residents. The trolleys are purpose made and kept securely in the clinic room when not in use. The nurse locked the trolley each time they left it to give medicines to residents. The nurse helped residents with their tablets sensitively and asked them if they required pain relief when the prescription was ‘as required’. The MAR sheets all had a recent identification photograph of the resident attached and on inspection there were no signature gaps except for topical preparations. In discussion with the senior nurse on the day it was clear that there was no recognised procedure to ensure that prescribed topical preparations were given correctly and signed for properly. The controlled drugs (CDs) register was seen and some stocks were randomly checked. The stocks tallied with the records. The CDs are correctly stored in a double locked cupboard in the clinic room. It was noted that there was a small oxygen cylinder in the room but there was no warning notice on the door. This was brought to the notice of the managing director who agreed to rectify the omission immediately. During the day care practice was observed and staff gave choices to residents about where they wished to sit and whether they wished to return to their rooms after lunch for a rest. Interactions between staff and residents were cheerful and friendly. Staff knocked on doors prior to entering rooms and were observed to adjust clothing to maintain residents’ dignity. Lound Hall Nursing Home DS0000024439.V349274.R01.S.doc Version 5.2 Page 12 The care plan interventions seen showed that residents were encouraged to manage as much for themselves as they were able to maintain independence. Some comments from the surveys received reflect that. One from a relative says, ‘My parent came to Lound Hall a year ago and at that time they could not walk or stand alone. With care and help from staff ------ they can now stand and take a few steps’. One resident has written, ‘So grateful that they allow me to help myself whenever possible so that I can redeem some independence and self esteem’. Lound Hall Nursing Home DS0000024439.V349274.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 people important to them and be offered meaningful pastimes and a wellbalanced diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The residents’ files seen all contained contact details of the next of kin and people important to the resident. Daily records noted when a resident spent time with a relative or went on a visit out of the home. Visitors were seen to come and go in the home during the day. Staff greeted most of them by name and directed them to the area where the resident they were visiting was spending time. The surveys received by CSCI from relatives indicated that the staff kept them updated with information about their relative or they were free to ask when they visited the home. ‘I visit my parent on a regular basis as do my family. If there are any concerns then staff will contact me’. ‘I try to visit on a daily basis’. Lound Hall Nursing Home DS0000024439.V349274.R01.S.doc Version 5.2 Page 14 As well as day-to-day activities arranged by the staff, such as board games, cards, bingo, quizzes, flower arranging and reminiscence, there is an annual programme of special events and outings organised. These are discussed and agreed at residents’ meetings, minutes of which are available to those residents unable to attend. The programme for this year included a boat trip from Beccles, a visit to the Sea Life Centre in Great Yarmouth and lunch on the seafront at Lowestoft. A cream tea was arranged to celebrate Mothering Sunday and other special days were St. George’s day, Red Nose day, Bonfire night, and Easter was marked with an Easter bonnet parade. In the residents’ files seen the spiritual beliefs of the resident were noted if they held any. The home has ties with both the Church of England and the Roman Catholic churches locally and Holy Communion is celebrated at the home regularly. The Salvation Army also visits on special occasions such as Christmas and Easter. The menus were seen and showed that there is a choice of main meals and desserts each day. On the day of inspection the choice was turkey and ham pie or egg and chips followed by spotted dick or trifle. When the meal was served it was observed that some residents had further alternatives such as fish or a salad. Residents spoken with said they had enjoyed their lunch. One resident said, ‘The trifle was lovely. I could have eaten a second one but mustn’t or I will get fat’. Comments in the surveys included, ‘A fine selection of meals are available’, and, ‘With the choice available (I) am happy with my menus’. The kitchen was visited and was clean and tidy. There are plans to upgrade some of the equipment and make some alterations to the layout. There is to be a new range and dishwasher fitted. External consultants visited on the day for a pre-installation survey of the work to be done the next week. Stores in the kitchen were varied and there was a good supply of fresh fruit and vegetables. Temperatures for the refrigerators and freezers showed that they were functioning within safe limits for food storage. Some food stored in the refrigerators was not correctly covered or labelled. The cook said they cater for some special diets such as diabetic and glutenfree. The menus offer a cooked snack for tea such as sardines on toast or cheese and broccoli bake with a dessert and/or cakes but in addition there is a supper menu for anyone who wishes for a late snack. The supper includes cheese and biscuits, sweet biscuits, soup, fruit or yoghurts. The cook said they had taken advice from a dietician when planning the content of the menus to ensure they contained sufficient nutrients to meet the needs of older people. Lound Hall Nursing Home DS0000024439.V349274.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 concerns taken seriously and be protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a robust complaints policy that is displayed in the entrance hall and available in the statement of purpose and service users’ guide. The majority of surveys from relatives and residents received by CSCI said they knew how to make a complaint if they needed to. One said, ‘I should hope that I could resolve any complaint by talking first to the staff or matron’. The complaints log was seen and there were two recent entries one concerning missing clothing that was fully investigated but unable to completely resolve, however the complainant was kept fully informed throughout the process. The other concerned staffing levels and was ongoing as the home had had a recent recruitment to fill vacancies and had an almost complete team as a result. The protection of vulnerable adults (POVA) policy was available to staff and cross-referenced to the Suffolk guidelines issued by the Protection of Vulnerable Adult Committee. Care staff spoken with said they had had POVA training and were clear about their duty of care. Some ancillary staff have not had POVA training although they have full access to the home and residents. Lound Hall Nursing Home DS0000024439.V349274.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, 22, 26. Quality in this outcome area is good. People who use this service can expect to live in a clean and well-maintained environment with specialist equipment available if required. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The central building of Lound Hall is a three storey listed Georgian house that has been adapted and added to over a period of years. The building sits in two and a half acres of grounds with a long drive to the entrance and a stand of mature trees in the front. The accommodation consists of seven shared rooms and twenty-nine single rooms most of which have en-suite facilities. There are communal bathrooms and toilets available on each floor. There are two large lounges and two dining rooms on the ground floor. The upper floors are accessed by a passenger lift. All the ground floor rooms have level access to the well-maintained gardens. Lound Hall Nursing Home DS0000024439.V349274.R01.S.doc Version 5.2 Page 17 A tour of the building was undertaken with the commercial director but all areas were revisited later during the day. The home was clean and tidy with no unpleasant odours noted. There is an ongoing programme of redecoration and refurbishment. The Yellow lounge has recently had new carpet laid and is to have new curtains hung. Carpet has been purchased for the Green lounge and will be laid once it has been redecorated. Four residents’ rooms have been redecorated since March 2007 with a further one in the process on the day of inspection. Residents’ rooms that were seen were personalised with photographs, ornaments and pictures. New profiling beds were in evidence in some rooms and on the first floor there was a new electric hoist. The home has recently purchased new pressure relieving cushions and two ‘stand aid’ that staff said has been a great help to maintain residents’ independence. Comments in the surveys received said, ‘Rooms are spotlessly clean and attended to every day’. One relative under the question, ‘What does the home do well?’ responded with, ‘Overall cleanliness and happy atmosphere’. The laundry was visited and found tidy. The washing machines have sluice programmes and there was a good supply of alginate bags for transporting soiled linen. Protective clothing was available and staff spoken with were able to talk about precautions to prevent cross-infection. The infection control policy needs urgently updating, as the guidance on managing soiled linen is outdated and could put staff at risk. Lound Hall Nursing Home DS0000024439.V349274.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. Quality in this outcome area is good. People who use this service can expect to be supported by sufficient numbers of correctly recruited and trained staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The duty rotas were seen and showed that during the early shift there are two registered nurses rostered with seven carers, the late shift has one registered nurse and five or six carers and the night is covered by one nurse and three carers. In addition there are three members of staff called hospitality staff who do domestic and other tasks that do not involve personal care. The kitchen is staffed between 8.00 and 19.00 each day and there is a dedicated laundry worker. In addition there is an administrator and maintenance/gardening personnel. The home has recently had a change of registered manager and a number of staff left at the same time as the previous manager. The new manager has been recruiting to vacant posts and the team is almost complete. A new post of Head of Clinical Services is due to begin in October and there is an advertisement out for an activities co-ordinator and housekeeping supervisor. Recent appointments include three new carers, a kitchen assistant and a further hospitality staff member. Lound Hall Nursing Home DS0000024439.V349274.R01.S.doc Version 5.2 Page 19 The files for four new staff were seen and all contained documentary evidence that the identity of the individual had been verified and two references had been taken up. Each one had a POVA 1st check completed prior to commencing in post and a copy of the terms and conditions of employment. There was evidence of an induction programme that covered fire awareness, care planning, the home’s policies, food handling, moving and handling, recognition of abuse, infection control and health and safety. The notice board in the office had advance notice of training updates that had been booked and included moving and handling, health and safety, food hygiene and fire awareness. Staff spoken with confirmed that the new manager was addressing their training needs. Seventeen of thirty care staff in the home hold an NVQ level 2 award or above. This exceeds the standard of fifty per cent required by standard 28 of the national minimum standards (NMS) for care homes for older people. Lound Hall Nursing Home DS0000024439.V349274.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, 38. Quality in this outcome area is good. People who use this service can expect to be consulted and have their welfare protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The new manager has been in post at Lound Hall since March 2007 and registered with CSCI since July 2007. They are a registered nurse with twenty-seven years experience in a variety of posts in the public and private sector of health care. They hold a Diploma in Management and have a particular interest in moving and handling training. Staff spoken with said the manager is making changes that will improve the care of residents such as making a case for new manual handling equipment. Lound Hall Nursing Home DS0000024439.V349274.R01.S.doc Version 5.2 Page 21 The home holds residents’ and relatives’ meetings to discuss anything they wish to raise and give information about changes taking place in the home. The minutes are available to residents unable to attend. Recent minutes seen showed that suggestions for activities and outings were made and the proposed upgrade to the kitchen discussed as arrangements will be made to have meals brought into the home during the two days of work. An annual quality assurance survey has been commenced and covers areas of care such as medication, complaints, meals, healthcare and staffing. One comment was, ‘The care staff are lovely’, and another, ‘ Staff are kind, always cheerful, they go the extra mile for the comfort of residents’. The administrator manages personal finances for some residents. The system used was explained and records checked. The wallets inspected at random tallied with the records and with receipts kept there was a clear audit trail. The administrator prints a statement for each resident every three months that is either kept by the resident of filed in their personal records. There are written and computerised records and the manager also has access to the finances. A number of service sheets and certificates were inspected. The boiler was serviced in July 2007 and there was a gas pipe inspection the same month. The passenger lift was serviced in April 2007. External consultants checked fire equipment in May 2007. Hoists and special baths were inspected in June 2007. Lound Hall Nursing Home DS0000024439.V349274.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 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 3 X 3 X 3 X X 3 Lound Hall Nursing Home DS0000024439.V349274.R01.S.doc Version 5.2 Page 23 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 OP9 Regulation 13 (2) Requirement A system must be devised to ensure that residents receive topical medication as prescribed and the applications are recorded to ensure correct compliance with the instructions and that residents are treated as the health professional has prescribed. The storage of oxygen cylinders must comply with Health and Safety regulations and warning signs applied to doors of rooms containing cylinders to protect residents and staff from harm. All prepared food stored in refrigerators must be identified and dated to ensure food that has deteriorated is not served to residents. Timescale for action 21/08/07 2. OP9 13 (2) 21/08/07 3. OP15 13 (3) (4) (c) 21/08/07 Lound Hall Nursing Home DS0000024439.V349274.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Lound Hall Nursing Home DS0000024439.V349274.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. 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