Archived: Lansbury Court Nursing Home

Updated 1 October 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection took place on 8 and 12 September 2016. Day one of the inspection was unannounced.

The inspection team was made up of one adult social care inspector.

Before the inspection we reviewed the information we held about the service. This included the notifications we had received from the provider. Notifications are changes, events or incidents the provider is legally required to let us know about. We also contacted the local authority, commissioners of the service; the local authority safeguarding team; healthwatch and the local clinical commissioning group. No concerns were raised.

During the inspection we spoke with six people who lived at Lansbury Court Nursing Home. We also spoke with five visitors. We spoke with 11 members of staff, including two care staff, one senior care staff, one nursing staff, four ancillary staff and the administrative manager. We also spoke with the registered manager and the operations manager.

We used a Short Observation Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk to us.

We looked at five people’s care records and five people’s medicines records. We reviewed four staff files including recruitment processes. We reviewed the supervision and training reports as well as records relating to the management of the service. We looked around the building and spent time in the communal areas.

Updated 1 October 2016

This inspection took place on 9 September 2016 and was unannounced. This meant the provider did not know we would be visiting. A second day of inspection took place on 12 September 2016 and was announced.

Lansbury Court provides care for up to 56 people some of whom have nursing care needs. All bedrooms are on the ground floor. The service is in two units Lansbury and Castle Dene House which is specifically for people who are living with a dementia.

At the time of the inspection there were 52 people using the service.

We last inspected Lansbury Court Nursing Home on 16 June 2015 and found the provider had breached a number of regulations we inspected against. Specifically the provider had breached Regulations 11, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Staff were not always acting in accordance with the requirements of the Mental Capacity Act (2005) and associated code of practice. The provider had not ensured staff had received appropriate support, training, supervision and appraisal to enable them to carry out their duties. There was not always an accurate, complete and contemporaneous record of care and treatment provided to people.

During this inspection we found that the registered provider had implemented actions and improvements had been made.

A registered manager was registered with the Care Quality Commission at the time of the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People and their relatives said the staff were caring. We observed warm, compassionate relationships. There was lots of laughter and relationships were respectful. People told us they felt safe and staff understood how to safeguard people and report any concerns. Staff understood the principles of the mental capacity act and where people had authorised Deprivation of Liberty safeguards care plans were in place.

People said they had no complaints and were happy with the service they received. A complaints procedure was in place and included investigations and outcomes.

Two activities co-ordinators were in post and a programme of activities was on display. Some people and relatives felt there could be more to do but others said there were plenty of diverse activities available for people if they wanted to join in.

Health and safety checks were in place in relation to the safety of the premises. Personal emergency evacuation plans were in place and staff knew how to evacuate people if they needed to.

Risks to people and staff had been assessed and plans were in place to minimise the risk. All risk assessments had associated care plans which were personalised, detailed and supported people to maintain their independence. People were supported with their nutritional needs, and if needed, had access to healthcare professionals such as dieticians, speech and language therapy, consultants and GPs.

Medicines were managed safely. Risk assessments and care plans were in place, and there were specific protocols for people who were prescribed 'as and when' required medicines.

Staffing levels were assessed using a dependency tool and staff felt there were enough of them to meet people’s needs. Recruitment procedures were effective and included references and disclosure and barring service checks.

Staff had attended training relevant to their role; they also attended regular supervision and had an annual appraisal.

Quality assurance systems were in place and included surveys and audits. An overarching action plan had been developed which meant there was a plan in place for the continuous improvement and development of the service.