Inspection on 15/12/05 for Lavender House

This inspection was carried out on 15th December 2005.

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.

Other inspections for this house

Lavender House 15/02/07

Lavender House 21/06/05

Lavender House 11/01/05

Lavender House 24/08/04

Lavender House 02/03/04

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 Lavender House 205 Broadway Peterborough PE1 4DS Lead Inspector Janie Buchanan Unannounced Inspection 14th December 2005 09:15 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 Lavender House DS0000015123.V261539.R01.S.doc Version 5.0 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. Lavender House DS0000015123.V261539.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Lavender House Address 205 Broadway Peterborough PE1 4DS 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) 01733 564986 01733 555841 Mr Baldev (David) Marjara Mr A Kachra Ms Eirlys Williams Care Home 33 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (33) of places Lavender House DS0000015123.V261539.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st June 2005 Brief Description of the Service: Lavender House is situated in a residential area, close to Peterborough city centre and provides accommodation and personal care for 33 older people. The home has 29 bedrooms, two of which are shared. An extension has already been added to the original building and the proprietors have recently built a second extension to create two further bedrooms. The home is on two floors, with the first floor being accessed by a stair lift. Attractive grounds surround the property. Lavender House DS0000015123.V261539.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s second inspection for the year 2005/6 and was unannounced. The inspector spent four and half hours at the home and talked with five residents, three relatives, three members of staff and the administrator. A tour of the home was undertaken and a number of documents, including residents’ financial records, were viewed. What the service does well: 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 Lavender House DS0000015123.V261539.R01.S.doc Version 5.0 Page 6 contacting your local CSCI office. Lavender House DS0000015123.V261539.R01.S.doc Version 5.0 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 Lavender House DS0000015123.V261539.R01.S.doc Version 5.0 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): 1,3,5 Information available about the home is good and helps prospective residents decide whether or not the home is where they want to live. Residents’ needs are thoroughly assessed before they move in, so they can be assured they will be met at the home. EVIDENCE: The home has a Statement of Purpose and Service User Guide that give good information about the home and the facilities it offers. There is also information available on the internet (www.peterboroughcare.co.uk). The manager and administrator assess all prospective residents before they move in, and detailed pre-admission assessments were viewed on all the files checked by the inspector. Prospective residents and their families are always invited to visit the home and three residents told the inspector that they had looked round the home, and had been shown their bedroom, before moving in. Lavender House DS0000015123.V261539.R01.S.doc Version 5.0 Page 9 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): 8,10,11 Residents’ health care needs are well met and monitored, and staff treat them respectfully. However, some practices at the home compromise their dignity. EVIDENCE: Residents’ health care needs were clearly recorded in the care plans viewed by the inspector and residents confirmed that they regularly see a range of health care professionals. Staff treat residents respectfully and one resident commented: ‘the staff are so polite, caring and respectful, I can’t fault them at all’. Screening is provided in shared bedrooms to ensure that residents’ privacy is not compromised when personal care is being given. However, there is no separate hairdressing facility for residents and they have to sit in a busy main corridor whilst having their hair done. The inspector also noted that every armchair in the main sitting room had a continence cover placed on top of the seat cushion. These must be removed because, as well as being undignified for residents, they give the home an institutional feel. These covers should only be used for particular residents with specific continence management difficulties, and not universally for all residents, regardless of their continence needs. Lavender House DS0000015123.V261539.R01.S.doc Version 5.0 Page 10 The home has suitable policies and procedures in place for handling death and dying and these have been updated since the last inspection to include information about retaining medicines for a period of seven days after death. Residents’ terminal care wishes are recorded but more could be done to give residents the opportunity to discuss (if they want) how they wish to live the end of their lives. This would ensure that a dying resident’s physical, emotional and spiritual needs are honoured. Lavender House DS0000015123.V261539.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,14 Activities in the home provide entertainment, stimulation and variety for residents and they are able to choose how they spend their day. EVIDENCE: The variety and frequency of activities in the home continues to be excellent. There is a scheduled activity each afternoon as well as many additional events. The home had a busy Christmas events program in place. On 8 December the local Rotary Club visited to sing carols, on the 9 December a number of residents visited the Queensgate centre to watch the Christmas lights being switched on, on 13 December residents visited St Mary’s Church and on 14 December the Sally Army visited the home. A pantomime is scheduled for the 20 December and ‘Shades’ tap dancers are due to visit on the 21 December. Residents clearly enjoyed these events and one commented: ‘ the Christmas lights were so beautiful, they really cheered me up’. Routines of daily living are flexible and residents can choose how to spend their day. Residents comments included: ‘ I prefer to spend the afternoon in my bedroom, If I go downstairs I get a bit bewildered’ and ‘ If I’m’ not feeling well I like to have a lie in’ I and ‘I live my own life here’. Lavender House DS0000015123.V261539.R01.S.doc Version 5.0 Page 12 Lavender House DS0000015123.V261539.R01.S.doc Version 5.0 Page 13 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 Residents complaints are listened to, and taken seriously. EVIDENCE: Details of how to complain are contained in the home’s Statement of Purpose, the Service Users’ Guide (a copy of which is in each resident’s bedroom) and the procedure is also displayed in the main entrance hall. All residents interviewed by the inspector felt confident about complaining if they needed to. One resident told the inspector of recent concerns about the quality of food raised by residents and commented ‘ You can complain and they really listen’. The Commission for Social Care Inspection has not received any complaints about Lavender House in the last year. All care staff have received recent training in protecting vulnerable adults and the manager has completed the 3-day advanced practitioner course. Lavender House DS0000015123.V261539.R01.S.doc Version 5.0 Page 14 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): 19,20, 26 Residents live in a comfortable and well-maintained environment. However, poor hygiene practices in the kitchen potentially put residents at risk. EVIDENCE: The home is comfortable, well maintained and furnishings and fittings are of good quality. The home offers a variety of communal areas for its residents: there is a spacious sitting room to the rear of the property and a smaller brighter one at the front, as well as two dining rooms. Appropriate aids and adaptations have been provided throughout the home including handrails, grab rails, toilet frames, raised toilet seats and assisted baths. A mobile hoist is available on each floor. The home is fully accessible to residents: access to the grounds outside is available by ramp and there is a chair lift for the stairway. A call system is available in all bedrooms and communal rooms, as are lockable cabinets for residents to safely store valuable items or medication. New carpeting has been laid along the main corridors and the corridor walls have been recently wallpapered. Lavender House DS0000015123.V261539.R01.S.doc Version 5.0 Page 15 The cleanliness of the home’s kitchen, however, was poor. The floor was dirty and stained; walls were marked; shelves in the dry food storage area were sticky and dusty; and skirting boards were thick with dust. One freezer was so frosted up that ice prevented the lid closing and sealing properly. Temperature gauges on two of the freezers did not work. The inspector was also concerned by the number of care staff who wandered in and out the home’s kitchen, without protective clothing on. It was not clear if these staff washed their hands prior to entering the kitchen and could risk spreading infection by touching kitchen surfaces after having given personal care to residents. These issues were discussed at length with the administrator who agreed to remedy them immediately. Lavender House DS0000015123.V261539.R01.S.doc Version 5.0 Page 16 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): 29, 30 The home’s recruitment and selections procedures are robust and ensure that service users are adequately protected. Training is good and caring and competent staff look after service users. EVIDENCE: Staff recruitment and selection is good. Personnel files for the two most recently employed care staff were checked and each contained appropriate references, and CRB and POVA checks. Staff training is good too and 50 of staff have achieved their NVQ level 2 in care. In addition to all mandatory training, staff also receive training specific to the needs of the people they look after including dementia care, nutrition and the elderly, and MRSA. The inspector received many positive comments about the quality of the staff from the both the residents and visiting relatives she interviewed. Comments included ‘we are well looked after here’ and ‘mum seems very happy here and there are always plenty staff around’. Lavender House DS0000015123.V261539.R01.S.doc Version 5.0 Page 17 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): 32,33,34,36,38 Leadership in this home is good and ensures both residents and staff are supported and listened to. Records required by regulation for the protection of residents were up to date and accurate. EVIDENCE: The processes of managing and running the home are open and transparent and there are strategies in place for enabling staff and residents to affect the way the service is delivered. Staff are regularly supervised and have their working practices appraised every six months. They reported that the management team was approachable and supportive. A number of records in relation to health and safety (fire, gas, hoist servicing, portable appliance testing) were viewed by the inspector and found to be in good order. Staff interviewed by the inspector confirmed that they had received training in fire safety, food hygiene, moving and handling, and first aid. The inspector viewed no major health and safety hazards in the home, Lavender House DS0000015123.V261539.R01.S.doc Version 5.0 Page 18 apart from those already referred to in standards 19-26 of this report. Paperwork in relation to residents’ monies and fee payments were also checked, and satisfactory accounting records and receipts were maintained. However, the inspector suggested that someone in addition to home’s secretary, checks residents’ cash sheets regularly. Lavender House DS0000015123.V261539.R01.S.doc Version 5.0 Page 19 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 3 x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 3 9 x 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 x 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 x x x x x 1 STAFFING Standard No Score 27 x 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x 3 3 3 x 3 x 3 Lavender House DS0000015123.V261539.R01.S.doc Version 5.0 Page 20 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 OP26 Regulation 23(2)(d) Requirement The home’s kitchen and food storage areas must be kept clean and hygienic. Timescale for action 14/12/05 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 OP11 OP26 OP35 Good Practice Recommendations Residents should be given the opportunity to discuss their wishes in relation to the end of their lives. Ways of reducing the number of staff who access the main kitchen must be introduced so as to minimise the risk of spreading infection Residents’ cash sheets should be checked more thoroughly. Lavender House DS0000015123.V261539.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE 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. Extracts may not be used or reproduced without the express permission of CSCI Lavender House DS0000015123.V261539.R01.S.doc Version 5.0 Page 22 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!