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Inspection on 07/11/07 for Lilliput House Rest Home

Also see our care home review for Lilliput House Rest Home for more information

This is the latest available inspection report for this service, carried out on 7th November 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The Registered Manager ensures that residents are only admitted to the home following a full assessment of their needs and having confirmed that the home can meet those needs. Residents are treated with the utmost care, consideration and respect for their privacy and dignity. The activities arranged within the home meet the expectations of the residents living there. Residents are encouraged to maintain their links with friends and family and all visitors are made very welcome. Residents are helped to exercise choice and control over their lives as far as possible. A varied, individual and balanced diet is enjoyed by people living at the home, which caters for the varied needs of the residents.The complaints procedure can reassure residents that their views are important to the home and that any complaints they raise will be properly investigated. The home continues to protect those living there from abuse by ensuring the robust policies and procedures are in place and staff are aware of them. Sufficient numbers of staff are on duty throughout the day and night, who are well trained to be able to meet the needs of the residents. The Registered Manager runs the home well together with a competent and committed staff team and supportive providers, whose main aim is to give a good level of care and support to all the residents. Financial procedures within the home also ensure that residents` interests are protected. The health and safety of the residents and staff are protected by the policies and procedures that the staff follow at the home.

What has improved since the last inspection?

Nutritional and pressure sore risk assessments have been developed to ensure that residents` healthcare needs are accurately assessed. The home now has a policy in respect of the promotion of continence. All handwritten entries to the MAR charts are now countersigned and the General Practitioner is consulted to ensure that all medicines prescribed are reviewed and MAR charts amended accordingly. The timing of mealtimes provide flexibility according to residents` choices. Progress is being made in ensuring that a minimum of 50% of staff must be trained to NVQ level 2 or equivalent in care to ensure that staff are suitably qualified and competent. Recruitment procedures have improved and all documentation and checks needed prior to an employee starting work are now thoroughly completed. Sufficient numbers of waking care staff are now working in the home, and an appropriate skill mix of staff, ensure that residents` needs are fully met. Hazardous substances are now securely stored at all times. Additional rails, providing an aid to residents safely mobilising, have been installed following a review of fixed handrails around the home.

What the care home could do better:

Individual risk assessments for residents who self medicate should be implemented and signed by the resident. A record of meals that all residents have eaten within the home should be kept as good health and safety practice. Improved feedback from residents should be gained from holding regular resident meetings.

CARE HOMES FOR OLDER PEOPLE Lilliput House Rest Home 299 Sandbanks Road Poole Dorset BH14 8LH Lead Inspector Jo Pasker Key Unannounced Inspection 7th & 22nd November 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 Lilliput House Rest Home DS0000051239.V354315.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. Lilliput House Rest Home DS0000051239.V354315.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lilliput House Rest Home Address 299 Sandbanks Road Poole Dorset BH14 8LH 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) 01202 709245 info@lilliputhouse.co.uk Mr Mark Edney Mrs Louise Edney Katie Marina Jackson Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Lilliput House Rest Home DS0000051239.V354315.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 20. 21st August 2006 Date of last inspection Brief Description of the Service: Lilliput House was originally two detached residential properties, which have been linked on the ground floor. It is set in a residential area of Poole and close to local shops and facilities as well as transport links. The registered providers, Mr and Mrs Edney, are frequent visitors to the home and the registered, day-to-day manager is Ms Katie Jackson. The home is registered to provide care and accommodation to a maximum of 20 residents in the category of OP (older people) but is currently under going major building work to increase the occupancy capacity to 39 bedrooms. Accommodation is offered on both the ground and first floors of the home. All bedrooms are for single occupancy and have ensuite facilities. There is a passenger lift on each side of the home therefore making all areas of the home fully accessible. The home has a comfortable main lounge and a separate dining room that also has some comfortable seating. Both of these areas are on the ground floor at the rear of the property and have views of the garden that is due to be fully landscaped. There are also communal bathrooms on both floors in addition to ensuite facilities. A new parking area at the front of the property is also due to be completed. The home’s fees range from £555 to £580 per week. There are charges for extras including hairdressing, chiropody, newspapers, toiletries and outings. See the following website for further guidance on fees and contracts Lilliput House Rest Home DS0000051239.V354315.R01.S.doc Version 5.2 Page 5 www.oft.gov.uk (Value for Money and Fair Terms in Contracts). The home holds a copy of the most recent inspection report, which is available, on request. Lilliput House Rest Home DS0000051239.V354315.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days the 7th and 22nd November 2007 and took approximately 6 hours. The purpose of the inspection was to assess all of the key standards and review the requirements and recommendations made in the last report. The registered manager, Katie Jackson and the providers, Mr and Mrs Edney were all present throughout the inspection process and were very helpful. At the time of the visit major building work was still taking place to add 19 new individual rooms to the service and additional communal and bathing facilities, to accommodate the increase in occupancy proposed. This will be subject to successful application for registration to the Commission for Social Care Inspection. Information for this report was obtained from discussion with the registered manager, registered providers, discussions with 5 residents and 2 members of staff on duty, a review of a variety of documentation including records provided to the Commission, care records, staff records, maintenance records, policies and procedures and a guided tour of the home. The annual quality assurance assessment (AQAA) sent before the inspection had also been completed and returned. A total of 23 comment cards from residents, relatives, representatives, staff, and other health professionals were also received. What the service does well: The Registered Manager ensures that residents are only admitted to the home following a full assessment of their needs and having confirmed that the home can meet those needs. Residents are treated with the utmost care, consideration and respect for their privacy and dignity. The activities arranged within the home meet the expectations of the residents living there. Residents are encouraged to maintain their links with friends and family and all visitors are made very welcome. Residents are helped to exercise choice and control over their lives as far as possible. A varied, individual and balanced diet is enjoyed by people living at the home, which caters for the varied needs of the residents. Lilliput House Rest Home DS0000051239.V354315.R01.S.doc Version 5.2 Page 7 The complaints procedure can reassure residents that their views are important to the home and that any complaints they raise will be properly investigated. The home continues to protect those living there from abuse by ensuring the robust policies and procedures are in place and staff are aware of them. Sufficient numbers of staff are on duty throughout the day and night, who are well trained to be able to meet the needs of the residents. The Registered Manager runs the home well together with a competent and committed staff team and supportive providers, whose main aim is to give a good level of care and support to all the residents. Financial procedures within the home also ensure that residents’ interests are protected. The health and safety of the residents and staff are protected by the policies and procedures that the staff follow at the home. What has improved since the last inspection? Nutritional and pressure sore risk assessments have been developed to ensure that residents’ healthcare needs are accurately assessed. The home now has a policy in respect of the promotion of continence. All handwritten entries to the MAR charts are now countersigned and the General Practitioner is consulted to ensure that all medicines prescribed are reviewed and MAR charts amended accordingly. The timing of mealtimes provide flexibility according to residents’ choices. Progress is being made in ensuring that a minimum of 50 of staff must be trained to NVQ level 2 or equivalent in care to ensure that staff are suitably qualified and competent. Recruitment procedures have improved and all documentation and checks needed prior to an employee starting work are now thoroughly completed. Sufficient numbers of waking care staff are now working in the home, and an appropriate skill mix of staff, ensure that residents’ needs are fully met. Hazardous substances are now securely stored at all times. Additional rails, providing an aid to residents safely mobilising, have been installed following a review of fixed handrails around the home. Lilliput House Rest Home DS0000051239.V354315.R01.S.doc Version 5.2 Page 8 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. Lilliput House Rest Home DS0000051239.V354315.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 Lilliput House Rest Home DS0000051239.V354315.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (The home does not provide intermediate care so Standard 6 does not apply). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Lilliput House ensures that prospective residents (or their representatives) are given sufficient information to make an informed choice about whether to move there and ensures that only residents whose needs can be met are offered a place. EVIDENCE: The pre admission assessment of one resident who had recently moved into the home was viewed. It contained detailed assessments and information regarding that person’s needs, wishes and preferences and included the name of the person completing the form. Information also included details of family and friends and the person’s daily routine. Of the 8 residents surveys received back, 6 said ‘yes’, they had received enough information about the home before they moved in, so that they could Lilliput House Rest Home DS0000051239.V354315.R01.S.doc Version 5.2 Page 11 decide if it was the right place for them. One said ‘no’ and the other said that their family had made this decision for them. Lilliput House Rest Home DS0000051239.V354315.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed care plans and assessments are in place, which provide staff with the information they need to meet residents’ needs, ensure that their health needs are well met and treat them with respect and dignity. Medicine administration and handling is generally well managed with the home planning to improve their existing system to further protect residents. EVIDENCE: The home has reviewed its’ care planning documentation since the last inspection and improvements were evident in both assessments and care plans seen. The care records of two residents were viewed and found to be extremely individual and personalised, with a high level of detail about individual routines, needs, abilities and likes and dislikes. Relevant assessments were present for nutrition, pressure area care and falls with any risks and action needed being fully documented. All care plans seen were regularly reviewed and had been signed by the resident. Lilliput House Rest Home DS0000051239.V354315.R01.S.doc Version 5.2 Page 13 A comprehensive continence policy has been implemented since the last inspection and care plans regarding psychological and emotional well being were seen and clearly stated what the needs were and gave good directions to staff regarding the appropriate management of these. There was clear evidence of GPs’ and other healthcare professionals’ involvement in residents’ care, documented in the care records. Of the 4 GP’s and care managers that responded to surveys sent out prior to inspection, 3 said that individuals’ health care needs are ‘always’ met and 1 said ‘usually’. Medicines were seen to be properly stored, being locked away and records were kept of the receipt, administration and disposal of medication and examination of these showed that all was well recorded. All medicines were found to be in date apart from one box of test strips that were a week out of date. A homely remedies list was seen and patient information leaflets were available. All the medicine administration records seen for each resident clearly stated whether there were any known allergies to medicines and all medicines prescribed ‘as required’, had why and when they should be given written clearly in the care plans. Some residents administer their own medicines and reference to this was made on the general risk assessment form in each resident’s care file. However this does not provide sufficient detail and the manager confirmed that a specific self-medication administration form is being implemented, which the resident will also sign. The residents spoken with said they were very well cared for and observation of staff working in the home showed they were caring and respectful. When asked ‘Do you receive the care and support you need?’ in the survey, 5 residents responded ‘always’, 2 ‘usually’ and 1 ‘sometimes’. Comments from all people surveyed regarding the care received and ‘what the home does well’, included: • • • • • “Excellent caring staff” “They are respectful of the people in the home” “I think the staff are very caring, always polite and make me feel welcome” “Have a very caring attitude if needed” “Treating the residents with due respect and dignity”. Lilliput House Rest Home DS0000051239.V354315.R01.S.doc Version 5.2 Page 14 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. This judgement has been made using available evidence including a visit to this service. There is a range of activities and social events planned by the home, which meet the residents’ social, recreational and religious needs and visits by their friends and relatives are welcomed by the home. Residents are able to make their own choices about their daily lives and meals offered are varied and individual. EVIDENCE: Lilliput House employs an activity organiser for 5 afternoons a week and also has a dedicated mini bus, which enables the residents to go out on day trips. This has been particularly welcome during the building work, which has been underway since last year. At the time of the visit, people were getting ready to play a game in the lounge. Activities within the home include: • Skittles • Bingo • Word games • Quizzes • Exercise classes Lilliput House Rest Home DS0000051239.V354315.R01.S.doc Version 5.2 Page 15 Residents are free to choose whether or not they join in activities and when asked in the survey ‘Are there activities arranged by the home you can choose to take part in?’ 2 responded ‘always’ and 6 ‘usually’. Comments received from residents, included “excellent activities” and also described how they are free to stay in their room and do their own thing. Others said that they would like more opportunities to visit the beach or countryside to get the ‘fresh air’ but that staffing numbers restricted this at times. Local singers and entertainers are also regularly booked and residents spoken with confirmed that they especially enjoyed these visits. A hearing loop system is also in place in the communal lounge now to support residents with hearing difficulties to join in. At the time of the visit just a small area of the garden was able to be used by residents but the provider, Mrs Edney discussed the plans for garden which include it being completed re landscaped and the plans were seen for this. Residents who enjoy gardening will be encouraged to have their own plot of ground, which they can plant and tend to. Visitors are welcome at any time and the visitor book showed evidence of regular visits from friends and family. The differing needs of residents’ faiths are also well met through visits to the home on a monthly basis. A varied menu is offered with the provider, Mrs Edney choosing different meal choices each week based on what the residents enjoy. Residents were seen arriving at the dining room for lunch during the visit but were unsure what the meal would be. It was discussed with the manager and provider that residents should be provided with a written copy of the menu and this was addressed immediately with a board being put up in the dining room. Weekly menus in advance should also be made available. Plenty of fresh fruit was seen in the dining room and residents are encouraged to help themselves and sherry and wine are also offered before and during mealtimes. It was seen that the home currently have a form which records what each resident has to eat for supper but this should be widened to also record other meals eaten, to support best health and safety practice. When asked on the survey ‘Do you like the meals at the home?’ 3 people responded ‘always’ and 5, ‘usually’ with one resident saying that the meals were “excellent”. Other comments from relatives and carers included: • “The menus are good and varied and exceptionally tasty” • “On the whole the food is excellent and if the resident doesn’t like some things they are offered an alternative” It was also suggested that a longer break between lunch and supper would be better. Lilliput House Rest Home DS0000051239.V354315.R01.S.doc Version 5.2 Page 16 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. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure. Protection from abuse is promoted through the home’s training, policy and procedure, in order to safeguard residents from potential abuse and harm. EVIDENCE: The home has an effective complaints policy in place and is available in several different formats such as Braille and audio tape/disc, for people who have sensory impairment. The home can also provide copies of this in different languages if needed for residents and their representatives. The home has received one complaint since the last inspection, which was seen to be dealt with appropriately and to the satisfaction of the complainant. When asked in the survey ‘Do you know how to make a complaint?’ 7 residents responded ‘yes’, with one stating that they would ask their family to manage this and 8 relatives replied ‘yes’ and 1 ‘no’ but added that this was not a problem as if they had reason to complain then they would. Another person commented that they would contact the funding authority for that resident if necessary. All staff have received adult protection training and were able to confirm in discussion what appropriate concerns would be regarding the care and Lilliput House Rest Home DS0000051239.V354315.R01.S.doc Version 5.2 Page 17 treatment of a resident and who to speak to. Most relatives and carers responding to the survey, stated that the home had ‘always’ responded appropriately if they or the resident themselves had raised concerns about their care. One person commented, “Yes, they have listened to me and acted on my concerns”. Lilliput House Rest Home DS0000051239.V354315.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The major building work taking place at the home does not provide a particularly homely or comfortable environment to live in at present, however the completed areas of the home provide an extremely high standard of living with excellent décor and facilities. EVIDENCE: The home is currently being extended and refurbished to provide a further 19 bedrooms and improved communal and bathing facilities, to increase the home’s potential capacity for residents (subject to registration by the Commission). There have been several issues however that have delayed this building work resulting in it taking much longer than originally planned. The owner and registered manager regularly let residents and their families know what is happening and consult with all residents about the project and ensure they are aware of progress. Residents spoken with during the visit were Lilliput House Rest Home DS0000051239.V354315.R01.S.doc Version 5.2 Page 19 exceptionally understanding and tolerant of the intrusion created by this work within the home. It is evident from areas that have already been completed that the home will provide an extremely comfortable environment in which to live with excellent facilities and a good garden area. However, despite the owners and builders efforts to ensure that this is carried out with the minimum of disruption, it is clear that the length of time it is taking is having a serious impact on the quality of living within and around the home. Comments received included: • “Finish the building work as soon as possible” • “We hope everything will settle down when the restoration is completed. It has taken much longer than we anticipated” • “When the building work is complete and the garden useable, everything will be perfect” • “Get the builders to take seriously the timescale of the building work at present.” • “Looking forward to completion of building works, everything that is finished looks wonderful”. This has resulted in the quality in this area receiving an ‘adequate’ rating at present. Since the last inspection the need for handrails around the home has been assessed and these have been fitted where required, following a previous recommendation made. Lilliput House Rest Home DS0000051239.V354315.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient levels of staff are employed to ensure that the needs of the residents are met and the home has a robust recruitment system to ensure that residents are properly protected from the risks of potentially unsuitable staff being employed. Staff are given comprehensive training and support so that they can give a good standard of care to the residents living at Lilliput House. EVIDENCE: Staffing levels have been reviewed following a requirement made at the last inspection and were seen to be sufficient given the current occupancy level of the home. 2 dedicated care staff and 2 housekeeping staff are now on duty in the mornings and 2 staff to cover both these roles work in the afternoons and evenings. At night, there are 2 members of staff on duty-1 waking and 1 sleep in. Surveys given to residents asked the question ‘Are the staff available when you need them?’ 1 replied ‘always’, 4 ‘usually’ and 1 ‘sometimes’. Staff surveys asked ‘Are there enough staff to meet the individual needs of all the people who use the service?’ and 1 said ‘always’ and 2 ‘usually’. The AQAA submitted prior to inspection showed that 4 care staff have completed their NVQ level 2 and 5 staff are currently undertaking it. The Lilliput House Rest Home DS0000051239.V354315.R01.S.doc Version 5.2 Page 21 registered manager is also an NVQ assessor. Copies of certificates were available in staff files. The home is working hard to ensure that more than 50 of it’s care staff hold this qualification. The files of 3 staff members were viewed and all relevant documentation was found to be present. It was evident that improvements had been made to the recruitment system and recording since the last inspection and requirement made. Evidence was seen of written verification of gaps in work employment history and additional statements requested from staff regarding any areas in their application and checks that needed further exploration. Training files demonstrated that staff were receiving training, including Skills for Care induction and this was confirmed with staff spoken with during the inspection. All mandatory training was up to date and other training completed included Mental Capacity Act briefing, care planning and record keeping, medication management and holistic hand massage. Further information on available training can be accessed through the following websites: www.picbdp.co.uk www.skillsforcare.org.uk Lilliput House Rest Home DS0000051239.V354315.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well organised and the daily management and running of the home centres round the care of residents, with a competent registered manager in post. Good quality assurance systems are in place, to ensure that the home is run in the best interests of residents, their finances are well protected and the welfare of residents and staff are well promoted, ensuring that risks to health and safety are minimised. EVIDENCE: The Registered Manager of the home is Katie Jackson who at the time of the inspection had been in post for 18 months and was previously the deputy manager of Lilliput House. She has completed an NVQ 4 in care and also the Registered Managers Award (RMA) and has worked hard to update all the care Lilliput House Rest Home DS0000051239.V354315.R01.S.doc Version 5.2 Page 23 planning records and implement several new policies and assessments since the previous inspection. She ensures that she speaks to all residents each morning and spoke to everyone during a tour of the premises and clearly had a good rapport with all people, including residents, staff and builders. The registered providers, Mr and Mrs Edney also have an active role in the daily running of the home and were on site during both visits. The registered manager and providers have a very good working relationship and ensuring that the home is run in the best interests of the residents. The home submitted its completed AQAA prior to inspection and sends out annual questionnaires to residents, relatives, care managers and health professionals. The home’s annual development plan is then based upon feedback received in these and this was viewed also. There is an information point within the home which provides leaflets and useful information for relatives and visitors, including a copy of the last inspection report. Comment cards are available around the home for people to pass on any concerns or comments they may have however there are currently no resident meetings held and this would be a further step in consulting with residents regarding the running of the home. Evidence was seen of audits which are carried of various areas, including training, care plans, call bell system and cleaning. The home does hold some small amounts of cash or personal money for residents and a sample of records and balance of monies held were seen and checked and demonstrated that the recording was accurate. Residents individual care files were found to be stored in an unlockable cabinet in the communal dining room, which could be accessed by anyone. It was discussed with the manager and provider that this was not appropriate storage and compromised confidentiality but the provider immediately addressed the issue and had locks fitted to the cabinets during the inspection. Fire safety records seen showed that all staff fire training, drills and fire checks were up to date and completed as required. All maintenance certificates sampled were seen to be up to date. Hazardous substances were stored appropriately, needing to be moved out of the locked storage cupboard once whilst some essential wiring was fitted in the cupboard. All accidents were seen to be well recorded in the accident book and outcomes documented. The home also have personal portable call pendants for residents using the grounds or who have increased needs. Lilliput House Rest Home DS0000051239.V354315.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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 4 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 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 2 X 3 X 2 3 Lilliput House Rest Home DS0000051239.V354315.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action 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. 3. Refer to Standard OP9 OP15 OP33 Good Practice Recommendations Lilliput House Rest Home DS0000051239.V354315.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lilliput House Rest Home DS0000051239.V354315.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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