Inspection on 26/02/06 for Lound Hall Nursing Home

This inspection was carried out on 26th February 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 15/10/08

Lound Hall Nursing Home 15/10/07

Lound Hall Nursing Home 02/10/06

Lound Hall Nursing Home 11/08/05

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Lound Hall Nursing Home Town Street Lound Retford Nottinghamshire DN22 8RS Lead Inspector Jayne Hilton Unannounced Inspection 26th February 2006 11:10 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.V279679.R01.S.doc Version 5.1 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.V279679.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Lound Hall Nursing Home Address Town Street Lound Retford Nottinghamshire DN22 8RS 01777 818082 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 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.V279679.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Provider will: (a) Provide external support from within the organisation to the home (b) Review the current management arrangements within the home within three months of purchase to determine the employment of a manager for registration Service users shall be within categories OP or PD (over 50 Years) 2. Date of last inspection 11th August 2005 Brief Description of the Service: Lound Hall Care Home is situated in the village of Lound close to Retford.The home provides Nursing and Residential Care for up to 29 older people. The categories of registration include 2 beds for people with a Terminal Illness and 6 beds for people with a physical disability. The provider was registered with the Commission in May 2005.There are single and double rooms, all ensuite. The home is suitable for people with mobility problems, provides a passenger lift and level access. The gardens are accessible to wheelchairs and provide a range of seating within a mature well-maintained garden. Lound Hall Nursing Home DS0000063130.V279679.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Regulation Inspector Jayne Hilton undertook the inspection on Sunday 26th February 2006 for four and a half hours. The focus of the inspection was to assess the remaining key standards not previously inspected in this inspection year. The methodology used included speaking with staff members, service users and relatives; a part tour of the environment and examination of a sample of care plans and associated records. As it was a weekend the Registered Manager was not on duty and therefore some records were understandably not available for inspection. It was reported that the Registered provider has plans to undertake some refurbishment to the home, including the provision of office facilities for the manager and to store file sand documentation. Some files are stored in the entrance area and others were locked away. What the service does well: Service users live in a generally well managed home, a statement of purpose and service user guide has been produced and displayed in the home. Service users financial interests are safeguarded. The service users health, personal and social care needs are set out in an individual plan of care. The systems in place for the management of medication require review to ensure they are fully safe. Service users feel they are treated with respect and their right to privacy is upheld. Service users and their relatives state they felt confident to complain and service users are protected from abuse. Service users live in a clean, comfortable and well-maintained environment. Staff appear to receive training for their role and responsibilities, however more evidence is needed to confirm this fully. Service users and staff spoke well of the manager and service users spoke highly of the staff team overall. Service users were well presented, appeared relaxed and happy in the home overall. Staff was observed to interact with service users and treat them sensitively, respecting privacy and dignity. Service users scored the overall services provided as between 6/10 and 8/10. Lound Hall Nursing Home DS0000063130.V279679.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lound Hall Nursing Home DS0000063130.V279679.R01.S.doc Version 5.1 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 DS0000063130.V279679.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 A statement of purpose and service user guide has been produced and displayed in the home. More evidence is needed to be confident that service users have the information they need about the facilities and service in the home and that it has been confirmed to them that the home can meet their individual needs. EVIDENCE: A statement of purpose and service users guide and a copy of the last inspection report were seen posted above the visitor’s book. The documents were not assessed at this visit, as these would have been presented to CSCI in the last twelve- month period for the transfer of registration. Service users and relatives spoken with were not however aware of the documents when asked and there was no evidence in place that each service user or representative had been given their own individual copy. There were no contracts/or terms and conditions documentation within the care plans, neither was there any written evidence that the service user or their representative had been informed in writing that the home could meet Lound Hall Nursing Home DS0000063130.V279679.R01.S.doc Version 5.1 Page 9 the needs of the service user. [Although this is a requirement by regulation 14, a recommendation for this was set at the previous visit] The inspector was unable to assess if this had been met at this visit and therefore the recommendation is carried forward to be assessed at the next visit. Should evidence not be provided at the next visit the inspector may set a requirement for this to be put into place. Intermediate care is not provided by the home. Lound Hall Nursing Home DS0000063130.V279679.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,9,10 The service users health, personal and social care needs are set out in an individual plan of care. The systems in place for the management of medication require review to ensure they are fully safe. Service users feel they are treated with respect and their right to privacy is upheld. EVIDENCE: Care plans are currently stored in a lockable cabinet in the main entrance, however on the day of the inspection the keys were left in the lock, so they were not stored securely on this day. A random sample of care plans was examined and on the whole the format and contents were assessed as detailed and satisfactory. The care plans were noted to have been reviewed regularly but not all had been reviewed monthly and this is recommended. Diet and nutritional screening was however noted to be up to date. There was a lack of evidence in relation to the involvement of service users and relatives within the documentation examined and all service users and relatives spoken with were not aware of their care plans. The care plans do contain a section for service users and relatives to complete to document what input they require, however Lound Hall Nursing Home DS0000063130.V279679.R01.S.doc Version 5.1 Page 11 this was not completed for two out of three plans. It is also recommended that authorisation for the service user if able or the service users relative or representative also sign use of bedrails and safety gates. Standard 7 was assessed as exceeding the standard at the last inspection, this score cannot be repeated at this visit due to the gaps in completion of all plans and the lack of evidence of service user knowledge and input into their plans. Medicines management was partly assessed, as a routine medication round was observed and was assessed as satisfactory. The medicines trolley is kept in the dining room, but was not secured to the wall. The deputy manager reported that the medicines trolley was previously kept on the opposite side of the room but a radiator cover had been fitted and therefore the space reduced. A security chain was seen in this area. The medicines trolley must be secured to the wall, when not in use. The storage temperatures of the medication are not being monitored and therefore a requirement is set for this to be implemented. The home was observed to have a copy of the Royal Pharmaceutical Guidance for safe handling of medicines in Care Homes and the medication protocols should be reviewed to meet the guidance and Medicines Act, including for example an appropriate and accessible drug error protocol, secure storage for medicines that need to be stored in the fridge, provision of sample signatures of those staff authorised to administer medication. Service users confirmed that staff treated them with respect and maintained their dignity and service users were observed to be treated respectfully by staff during the inspection. Service users spoke of how good the staff were and that they were very considerate. A pay phone is accessible for use . Lound Hall Nursing Home DS0000063130.V279679.R01.S.doc Version 5.1 Page 12 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): 15 Service users and relatives are not totally satisfied with the meal provision and the practices and record keeping in relation to food safety and food eaten by service users needs to be improved. EVIDENCE: A menu is provided and devised over a four- week cycle. The menu appeared varied and offered a choice of two options most days. It was reported that sometimes the menu was changed. There was no records to support the reason for this and there were no records kept to evidence that service users had been offered a choice or what dietary option they had taken. Service users and staff spoken with confirmed that service users did have a choice. Regulation 17[2] Records to be kept- Schedule 4 [14] states: “Records of the food provided for service users is sufficient in detail to enable any person inspecting the record to determine whether the diet is satisfactory in relation to nutrition and otherwise and of any special diets prepared for individual service users” The inspector suggested page a day diary to be used for this purpose and which fridge and freezer temperatures and food probing records can be kept routinely on a daily basis. Lound Hall Nursing Home DS0000063130.V279679.R01.S.doc Version 5.1 Page 13 The fridge and freezer temperatures and food probing temperatures were not being routinely documented. It transpired that the cook on duty on the day of the inspection was actually a carer and that the home had been having recruitment difficulties for a second cook since Christmas. Care staff are covering cooking duties on the days the cook does not work and possibly the lack of record keeping was because of this. The cook was wearing an apron but this was folded in half and did not cover all personal clothing. Nursing and care staff were observed to enter the kitchen without personal protective clothing for food safety. Staff were also observed to be assisting service users with eating without aprons. The staff member on cooking duty confirmed she had undertaken appropriate food hygiene training. Service users and relatives spoken with had mixed views about the quality of the food provided, and it seemed that it did depend on who was cooking as to the quality and presentation of the meals. Service users reported that the meat on the day of the inspection was tough. Carrots cauliflower and potatoes and gravy accompanied the beef served. Chocolate pudding and custard was served as a sweet. One service user commented that the vegetables tasted reheated and another who eats in their room, stated that as the sweet is brought on a tray at the same time as the main course, when it is a hot pudding, it is cold by the time the service user has finished eating the main course. Relatives commented that staff did not always ensure meals were placed within service users comfortable reach when serving in bedrooms and that some meals were observed not to be very appetising. Service users and relatives reported that they had not complained about the meals to the home. Service users confirmed that drinks can be accessed at any time and are served frequently throughout the day. Juice was observed in two bedrooms examined and all service users were offered juice ant lunchtime. Supper was reported to be served at around 8pm and was usually biscuits or sandwiches if requested. Cooked breakfasts are provided for and fruit is also an option. Contrasting views were also obtained in relation to dining arrangements. The provision of a napkin was important to one service user who said that serviettes were not always provided and that these had to be asked for on occasions. Another who likes a pot of butter on the table, said staff ensure this was always provided. They also commented that saucers were not always provided with cups. The dining arrangements appeared well organised as two sittings are in place. One sitting ensures that those service users who require assistance have the necessary time and attention to meet their individual needs. Staff were observed to be seated and speaking appropriately with service users during the meal. The practice of reheating and temperatures of food is a food safety issue Lound Hall Nursing Home DS0000063130.V279679.R01.S.doc Version 5.1 Page 14 and it is therefore paramount that appropriate procedures and record keeping is maintained. The deputy manager reported that the ethos of the home was to provide a homely environment and this was supported by observations made on the day of the inspection. It is important that a balance of homely and safe practices, required by the legislation for food-handling services are in place. The use of care staff for catering obviously leaves the care team short staffed and cannot be sustained long term. The Registered Provider should look at alternative catering arrangements, for example use of agency staff. The Registered Provider is therefore required to review all food safety practices to ensure service users health, welfare and safety is protected and promoted. There are clearly many issues highlighted around food provision and it is also recommended that a service user survey is undertaken for all aspects of food provision and mealtimes to determine the best way forward. Lound Hall Nursing Home DS0000063130.V279679.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16.18 Service users and their relatives state they felt confident to complain and service users are protected from abuse. EVIDENCE: The complaints records were not accessible on the day of the inspection and arrangements should be made that the deputy or other nurses in charges have access to these, when the manager is not on duty. The deputy manager was not aware of any complaints being recorded. A blank formal complaint document was seen and this assessed as an n appropriated document. The complaints procedure was displayed with the statement of purpose and service users guide, but it was hidden behind these documents. The complaints procedure should be clearly accessible by service users and consideration should be made to placing a copy in each bedroom and posting it in a more visible position. Service users and relatives spoken with did state that they would tell the manager if they had any complaints and felt confident to do so, all said however that although staff had tried to assist with any problems or requests that they had not made any formal complaints yet, there was clearly expressed dissatisfaction with food/meals provision. From speaking with staff members it was clear that they were aware of what constitutes abuse and that training was in hand and that they would respond promptly to any incident to safeguard the individual. It was reported that the manager had attended training on Safeguarding Adults and the Nottinghamshire Committee for the Protection of Vulnerable Adults Guidance Lound Hall Nursing Home DS0000063130.V279679.R01.S.doc Version 5.1 Page 16 was observed in the home. What was not clarified was that senior staff and management were fully aware of the current Safeguarding Adults reporting and referral protocols and that Social Services are the lead agency and contact should any incident arise. It is recommended that the Registered Person ensure that Safeguarding Adults protocols are up to date and that senior staff are trained in knowledge of this topic. Lound Hall Nursing Home DS0000063130.V279679.R01.S.doc Version 5.1 Page 17 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): 19,24,25,26 Service users live in a clean, comfortable and well-maintained environment. There are some areas to address in relation to the heating, water temperatures, laundry facilities, staff facilities and food hygiene practices. EVIDENCE: The home was clean, warm and well maintained. The internal facilities provide a safe environment. The gardens are accessible to wheelchairs although they are not enclosed and residents that may be at risk from wandering would require supervision outdoors. The bedrooms inspected appeared comfortable and clean, however on room did present mal odour despite a new carpet having recently been fitted. All rooms were fully carpeted, personalised and welcoming. Lound Hall Nursing Home DS0000063130.V279679.R01.S.doc Version 5.1 Page 18 Rooms are lockable and keys can be provided. [Reference to this should be included within the care plan with an appropriate risk assessment should a service user not be able to hold a keys to their room] There is also a lockable drawer space in each room for money or valuables. There was a range of good quality furnishings and some residents had brought their own furniture from home. All rooms are en-suite and there are toilets and assisted baths close by. The rooms are fitted with a nurse call bell. Service users reported that staff answer this in reasonable times but could have to wait a little longer when the home is short of staff. The equipment necessary to support each resident was in place. Radiators were covered to provide safe surface temperatures and prevent people from accidental burns. One room with a low temperature surface type was reported to not be in full working order and supplementary heating had been provided. [An electric oil filled radiator] The room temperature can only be controlled by turning off the radiators. The Registered Provider should explore having regulation valves fitted. A sample of water outlet temperatures were tested in two rooms and the hot water was tepid. Service users reported mixed views on the accessibility to hot water, some having to run the hot tap for a long period of time before getting warm water and another stating that if both taps are turned on together the water then becomes hot. Records were kept and showed that temperatures were within safe levels and the deputy reported that bath water temperatures are taken prior to anyone taking a bath for safety. Hot water is stored at the correct temperature to control Legionella. The laundry is sited on the first floor and houses five domestic type washing machines and a separate drying room. None of the washing machines in use had a sluicing and disinfecting facility. The laundry person explained how laundry was sluiced but the washing machines are not separated out for use in relation to soiled linen or kitchen/table linens. As the home provides nursing care, the Environmental Health officer must be consulted in relation to the laundry practices and the outcome of the consultation be communicated to the inspector. The laundry area was otherwise tidy and well organised with individual baskets for service users clothing to be stored. Gloves and aprons were seen to be provided around the home. Lound Hall Nursing Home DS0000063130.V279679.R01.S.doc Version 5.1 Page 19 Staff coats and bags were seen stored in the staff toilet and it is recommended that lockers be provided for staff to keep their valuables. The deputy manager reported that the provider has plans for refurbishment, which includes the provision of office facilities, which is clearly needed as the entrance area houses filing cabinets and shelves for the storage of some files. Lound Hall Nursing Home DS0000063130.V279679.R01.S.doc Version 5.1 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): 27,30 The numbers of staff provided on some days may not meet Service users needs and a staffing review is recommended. Staff appear to receive training for their role and responsibilities, however more evidence is needed to confirm this fully. EVIDENCE: On the day of the inspection one first level nurse and two carers were on duty. Another carer was on cooking duties and therefore could not be counted within the staffing numbers. A laundry assistant was also on duty. Twenty-five service users were in residence, fourteen of those being nursing and eleven requiring personal care only. For nights one nurse and one carer is rostered on duty. Whilst the staffing numbers provided on the day of the inspection were assessed as just meeting minimum standards, service users daily routines were being affected as one service user had been asked to wait until the following day due to staff shortage. The deputy manager explained that she and the manager work a joint day together super numery to look at management issues. It is recommended that the manager work at least 90 of her time as super numery to undertake management tasks and meet with the expectation and function of responsibilities of the National Minimum Standards and Care Home Regulations 2001. Lound Hall Nursing Home DS0000063130.V279679.R01.S.doc Version 5.1 Page 21 It is accepted that attempts have been made to recruit a cook and that this has bee difficult, however the situation cannot be sustained long term and further action should be taken by the Registered Provider to ensure that care staff hours are not affected by them having to supplement catering duties. Staff reported that regular training is in place with new staff being inducted. There was not sufficient evidence to assess the training provision as the deputy did not have access to the annual training programme for the home, neither could the induction process be assessed as meeting with skills for work standards. It was reported that trained assessors will provide in house manual handling training for the future and that staff are not permitted to undertake manual handling duties until appropriately trained. The deputy manager reported that staff undertake mandatory training topics within the first six months of employment which includes, health and safety, infection control, food hygiene, fire safety. There is currently no training in place for first aid and this must be arranged. Staff also undertake safe Handling of medicines training. NVQs were in process but have been held up in progress due to the change of ownership. Two staff were reported to have achieved NVQ2 and the deputy and manager are NVQ assessors. It is requested that a training programme which encompasses the training details of all staff and any planned annual training provision for a period of twelve months be forwarded to the inspector as evidence of the training provided for staff. Lound Hall Nursing Home DS0000063130.V279679.R01.S.doc Version 5.1 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): 31.32, 33, 34, 35, 37 Service users live in a generally well managed home, however more evidence is needed in relation to consultation with service users to demonstrate the home is run in the best interests of service users. Service users financial interests are safeguarded. Improvement to record keeping is required. EVIDENCE: The manager was on a day off when the inspection took place. It was reported that the manager is not a first level nurse but that the deputy is a first level nurse. The manager was recently registered with the commission. The manager works as the nurse in charge on shifts on the rota, but works super numery with the deputy manager one day a week. Staff meetings take place and minutes of these are kept. It was confirmed that the manager supervises staff on a three monthly basis, but it was clear if all supervision meetings are documented. Staff and service users spoke positively about the Lound Hall Nursing Home DS0000063130.V279679.R01.S.doc Version 5.1 Page 23 manager and confirmed she was able to give the staff team leadership and direction. Staff are encouraged to offer ideas for discussion at staff meetings. It was suggested that the manager should delegate more. Quality monitoring is in place in relation to annual relatives questionnaire/surveys, but the inspector was unable to ascertain if the surveys are published/fed back to relatives. There is no newsletter or other forum for this to happen currently and it is recommended that service user and relative meetings/events are introduced. The Responsible Individual is reported to visit the home regularly, but there was no evidence of regulation 26 reports for this. It was reported that policies and procedures are reviewed regularly. Evidence of paperwork was seen in relation to potential audits being undertaken. More evidence is required of consultation with service users to meet the standard fully. It is recommended that surveys are topic based and which constructive evaluation and feedback can be used to inform and change practice within the home. One issue raised by service users is that one bath a week is normal practice and that this does not necessarily suit all individuals residing in the home. Service users must be consulted regarding their wishes for personal care and sign that they agree to the plan of care in the care plan. As the inspection took place on a Sunday, it was not possible to assess the financial and development plans for the home, however as the provider has only been in ownership of the home within the last twelve months it is acceptable that these plans will have been submitted as part of the registration. Suitable insurance cover was evidenced. Service users small cash amounts held in the home are recorded and audit trailed. Two signatures should be in place however. Valuables kept for safekeeping are not receipted for, but are documented on the inventory within the care plan. Ideally receipts should be kept with the appropriate transaction sheets for the individual. The manager and provider do not act as appointees or agents for any service users finances. Regulation 37, notifiable incidents were discussed. There was not a record of copies of these available. Notifiable incidents in relation to death of a service user are being sent to CSCI. The Deputy Manager was reminded that other notifications must be made to CSCI under this regulation, such as incidents of drug error and that the policies need to prompt staff in relation to this. Care plans were not secure on the day of the inspection and it is recommended that apart from staff personal files that senior staff have access to records that must be available 24/7 for inspection purposes. Lound Hall Nursing Home DS0000063130.V279679.R01.S.doc Version 5.1 Page 24 Some records were not available such as records of contracts/terms and conditions, training and complaints and some records did not meet standards such as the full completion of care plan documentation, Regulation 26 visits and kitchen records. Lound Hall Nursing Home DS0000063130.V279679.R01.S.doc Version 5.1 Page 25 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 2 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 2 2 STAFFING Standard No Score 27 2 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 X 2 X Lound Hall Nursing Home DS0000063130.V279679.R01.S.doc Version 5.1 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15,17 Requirement Timescale for action 26/03/06 2 OP9 13, Medicines Act Ensure care plans are fully completed and contain evidence of consultation and agreement of service users or their representative and for where mechanical restraint is used such as bedrails and safety gates Ensure safe systems are in place 26/03/06 for the storage, handling, administration and disposal of medication in relation to: Ensure the medicines trolley is secured to the wall when not in use. Ensure medication is stored at a safe temperature and records are kept of this monitoring. Ensure medicines protocols are reviewed and up to date in particular- a protocol for maladministration of medication need to be implemented and accessible to staff in an emergency. Ensure medication requiring cool, storage facilities are stored Lound Hall Nursing Home DS0000063130.V279679.R01.S.doc Version 5.1 Page 27 3 OP15 17[2] schedule 4[14] securely. Ensure records in relation to the food eaten by service users are kept. 26/04/06 4 OP15OP26 Ensure service users are consulted in relation to the issues raised in the inspection and that where necessary improvements are made to the quality of meals provided. 13,1 6, 17 Ensure appropriate and safe systems are in place for food safety: Records are to be consistent for food probing, fridge and freezer temperatures. Food that is reheated is appropriately tested and documented as at a safe temperature before serving. 26/03/06 5 OP26 12,1 3, 16, 23 6 7 OP30 OP33 18 25 Staff wear and promote others to follow food safety practices in relation to personal protective clothing. Seek advice from the 26/04/06 Environmental Health Officer in relation to the requirement for nursing homes to provide an appropriate sluicing disinfector. Ensure staff are trained in First 26/05/06 Aid Further develop the quality 26/05/06 monitoring systems to ensure consultation with service users and their relatives/representatives and provide evidence that regulation 26 visits are carried out and documented. Ensure consultation is evidenced in relation to service users personal care needs such as bathing frequency. Lound Hall Nursing Home DS0000063130.V279679.R01.S.doc Version 5.1 Page 28 8 OP37 17 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. 26/03/06 9 *RQN 16, [2][ii] Ensure care plans are stored securely. Ensure CSCI are provided with 26/03/06 evidence that a facsimile is provided in the home and the number of this machine supplied. 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. 2 Refer to Standard OP1 OP2OP3 Good Practice Recommendations Ensure all service users are issued with a personal copy of the service users guide and evidence this. 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. Terms and conditions should be kept in each individuals care plan. Ensure a sample list of staff signatures are provided with the medication records sheets. Provide a medicines fridge Ensure the complaints policy is visible and accessible to service users Review and ensure the protocols for Safeguarding Adults reporting and referral are promoted with all senior staff. Provide lockable facilities for staff valuables Eradicate the mal odour in the specified service users room 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. Lound Hall Nursing Home DS0000063130.V279679.R01.S.doc Version 5.1 Page 29 3 OP9 4 5 6 7 OP16 OP18 OP19 OP24 8 OP25 Ensure the radiator in the specified service users room is repaired and explore the fitting of regulating valves to individual radiators. Explore the reasons for the poor water outlet temperatures Undertake a staffing review and consider using agency staff for the deficits in staff. The manager should work 90 of her time as supernumery Provide evidence of a training plan for all staff to CSCI Undertake service users surveys for specific topics and arrange service user and relative meetings. Provide suitable facilities for the secure storage and accessibility of records and Keep a copy of regulation 37 notifications. 9 OP27 10 11 12 OP30 OP33 OP37 Lound Hall Nursing Home DS0000063130.V279679.R01.S.doc Version 5.1 Page 30 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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