Inspection on 15/02/07 for Lavender House

This inspection was carried out on 15th February 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.

Other inspections for this house

Lavender House 15/12/05

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 Key Unannounced Inspection 15th February 2007 08:30 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.V329635.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. Lavender House DS0000015123.V329635.R01.S.doc Version 5.2 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 info@peterboroughcare.co.uk Mr Baldev (David) Marjara 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.V329635.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th December 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. 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. Fees vary between £372 and £453 depending upon residents’ needs. A copy of the most recent inspection report is available in the entrance hallway of the home. Lavender House DS0000015123.V329635.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s key inspection for the year 2006/7 and was unannounced. The inspector spent four hours at the home and talked with four residents, three members of staff and two of the owners. The inspector also received 18 completed comment cards from both residents and their relatives. The overwhelming majority of respondents’ expressed a high degree of satisfaction with the quality of care, staffing and activities. 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: Lavender House DS0000015123.V329635.R01.S.doc Version 5.2 Page 6 Overseas references received for prospective employees should be more thoroughly checked to ensure their current applicability and authenticity. The timings of meals should be reviewed to ensure that there is not too long a gap between when food is available for residents. 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. Lavender House DS0000015123.V329635.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lavender House DS0000015123.V329635.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5 Quality in this outcome area is good. Information available about the home is good ensuring prospective residents have details of the services the home provides and enabling them to make an informed decision about moving in. Residents’ needs are assessed before they move in, so they can be assured they will be met at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a Statement of Purpose and Service User Guide that give good information about the home and the facilities it offers. A copy of the service user guide was viewed in each resident’s bedroom. There is also information available on the internet (www.peterboroughcare.com). The manager and administrator assess all prospective residents before they move in, and pre-admission assessments were viewed on the files checked, in addition to assessments completed by the local primary care partnership. Prospective residents and their families are always invited to visit the home and residents confirmed that either they, or their families, had visited to Lavender House DS0000015123.V329635.R01.S.doc Version 5.2 Page 9 assess its suitability. One resident stated that the owners visited her in hospital and then she viewed the home before moving in. Two residents told the inspector they chose the home based on its excellent reputation. Each resident is issued with a contract that clearly sets out the fees payable, the room to be occupied, the services included and the home’s insurance details. All contracts viewed had been signed either by the resident themselves, or their representative. Lavender House DS0000015123.V329635.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is excellent. Residents’ needs are clearly recorded in the care plans, and their health is monitored closely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans were excellent. Information in them was detailed, easy to find and had been reviewed regularly with changes in residents’ needs being well documented. The plans also contained comprehensive risk assessments for residents. For example one confused resident likes to smoke: a risk assessment had been drawn up for her that covered her access to cigarettes, the use of ashtrays, the lighting of her cigarette and how many she should have. This is excellent and means that the resident can continue to enjoy smoking in a safe way and supervised way. Another plan contained clear guidance for staff of how to manage the sometimes difficult and aggressive behaviour of particular resident. Residents’ plans contained good information about their health needs and contained evidence that they see a wide range of health professionals regularly. Residents’ weight, blood pressure and pulse are monitored monthly and there were nutrition and falls assessments in place. One relative Lavender House DS0000015123.V329635.R01.S.doc Version 5.2 Page 11 commented: ‘ I am extremely impressed with Lavender House. Since being accepted into the home my mother’s health has gone from strength to strength’. The home’s has satisfactory policies and procedures in place for medication. Medication storage and administration records were checked and found to be in good order, with hand written additions to MAR sheets clearly signed and dated, and residents’ refusal of medication documented. The temperature of the drug’s storage fridge was taken daily. All residents interviewed spoke highly about the staff and how they treated them. One resident commented: ‘staff make time to talk to you, and they do listen’. Residents’ terminal care needs were documented in their care plans and staff have been implementing elements of the Liverpool Care Pathway (guidance on how to support people when they are dying) to improve care for residents in the final stages of their life. The manager has recently attended a number of lectures in death and dying to update her knowledge in current practices. Lavender House DS0000015123.V329635.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is excellent. Activities in the home provide entertainment, stimulation and variety for residents and they are able to choose how they spend their day. Mealtimes are relaxed and enjoyable. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The variety and frequency of activities in the home continues to be excellent. There is a scheduled activity each day (clearly advertised on the notice board) as well as many additional events. Residents had just been to see the Wizard of Oz the day before the inspection and one resident told the inspector she had particularly enjoyed the ice cream at the interval. One staff member has recently completed the ‘Full of Beans’ course and there is a weekly exercise class for residents. One relative commented: ‘ we have been very pleased with the addition to the staff team of the person who organises activities. This has served to keep the residents both entertained and alert’. Family and visitors are made to feel welcome at the home and one resident particularly appreciated having her own telephone in her room so that she can ring her son and daughter daily. Lavender House DS0000015123.V329635.R01.S.doc Version 5.2 Page 13 Residents reported that they choose how to spend their day. One commented: ‘there’s always lots to do but the best thing is, no one ever dragoons you into doing them’. Lunch on the day of inspection consisted of vegetable soup, pork casserole with carrots, cabbage and potatoes, followed by sponge and custard. One resident was having fish instead as he preferred this. The food looked tasty and plentiful and the cook showed a good understanding of differing nutritional needs. A full feature about the home’s excellent nutritional practices for older people appeared in the Guardian newspaper last year. The timing of meals was discussed with the owners of the home, as the inspector was concerned that the teatime meal was served very early at 4pm, not long after lunch. Although snacks are available after this meal, there is along wait until breakfast the following morning. The owners agreed to investigate and consult with residents on this matter further. Lavender House DS0000015123.V329635.R01.S.doc Version 5.2 Page 14 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. Residents’ complaints are listened to, and taken seriously. This judgement has been made using available evidence including a visit to this service. 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. Concerns and complaints made by residents were clearly recorded in the home’s ‘Small Complaints’ Book, as was the action taken to resolve them. Residents and relatives felt confident about raising concerns. One relative commented ‘my one complaint regarding a staff member was dealt with quickly and efficiently.’ Another reported: ‘the complaint I made was addressed swiftly and no reoccurrences have happened.’ Residents spoken to identified the manager as someone who they would to talk if unhappy and felt she would handle their concerns sensitively. Records viewed showed that staff had received training in protecting vulnerable adults. Lavender House DS0000015123.V329635.R01.S.doc Version 5.2 Page 15 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): 19,20,22 26 Quality in this outcome area is good. Residents live in a pleasant, comfortable, safe and well-maintained environment with sufficient aids and adaptations in place to maximise their independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is comfortable, well maintained and furnishings and fittings are of good quality. It smelt fresh and clean on the day of inspection. One relative commented ‘Lavender House is the ONLY home I’ve been to where I have rarely smelt urine’. 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 Lavender House DS0000015123.V329635.R01.S.doc Version 5.2 Page 16 system is available in all bedrooms and communal rooms, as are lockable cabinets for residents to safely store valuable items or medication. All double bed rooms have now been converted to single ones to maintain residents’ privacy and dignity. Lavender House DS0000015123.V329635.R01.S.doc Version 5.2 Page 17 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): 27,29,30 Quality in this outcome area is good. Residents are looked after by competent and trained staff, in sufficient numbers to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels at the home are adequate. There are four staff on duty between 7am and 1pm, and a minimum of 3 staff on duty between 1pm and 9pm to support 33 residents. Two members of ‘waking’ staff are on duty at night. Although this is quite a high ratio of residents to staff, residents reported that they didn’t wait too long for help and staff stated that they were never too rushed. The home employs a number of overseas staff whose first language is not English. Residents reported however that they could communicate easily with these staff, and understand them. Comments received from relatives and residents at the home indicate that staff are caring and competent in their role. Comments included: ‘extremely supportive, caring staff’ and ‘nothing is too much trouble for the managers and staff’. The personnel files for two recently recruited members of staff were checked. Each contained appropriate CRB and POVA checks, and two references. However the references for one worker were obtained from overseas employers via a recruitment agency, and one was undated. The difficulty of verifying these references was discussed with the owners Lavender House DS0000015123.V329635.R01.S.doc Version 5.2 Page 18 Training records viewed showed that staff had received training in all mandatory areas as well as training in dementia care, challenging behaviour and nutrition. Lavender House DS0000015123.V329635.R01.S.doc Version 5.2 Page 19 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, 32, 33,34, 38 Quality in this outcome area is excellent. The management administration of the home is based on openness and respect, and there is an effective quality assurance system in place to gather the views of residents This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has the required qualifications and experience to run a care home for older people and the inspector received many positive comments about her approachability, competence and style. The management approach of the home creates an open, positive and inclusive environment for both residents and staff. One resident told the inspector ‘I like the atmosphere here’. There are regular residents’ and staff meetings and staff reported they enjoyed their work and felt well supported. The home has recently achieved an ‘Investor’s in People Award’. Lavender House DS0000015123.V329635.R01.S.doc Version 5.2 Page 20 Three times a year a survey is sent to residents, their relatives, visiting professionals and staff. Comments concerning staff appearance, knowledge, the environment, cleanliness and admission procedures are requested. A detailed analysis is made of the results, which are then displayed in the main entrance to the home. Secure facilities are provided for the safekeeping of residents’ monies. A sample of residents’ cash sheets was checked: all financial transactions undertaken on behalf of residents’ were clearly recorded, and receipts were kept. Records in relation to a number of health and safety issues (fire, portable appliance testing, gas, fridge and freezer temperatures, stair lift and hoist serving) were checked and found to be of a good standard and routinely completed. Lavender House DS0000015123.V329635.R01.S.doc Version 5.2 Page 21 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 3 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 x 3 x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 4 3 x x x 3 Lavender House DS0000015123.V329635.R01.S.doc Version 5.2 Page 22 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. Refer to Standard OP15 OP29 Good Practice Recommendations The timings of meals should be reviewed to ensure that there is not too long a gap between when food is readily available for residents. References received for staff from overseas should be more thoroughly checked to ensure their authenticity. Lavender House DS0000015123.V329635.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 Lavender House DS0000015123.V329635.R01.S.doc Version 5.2 Page 24 - 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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