Inspection on 01/02/06 for 6 Lilac Grove

This inspection was carried out on 1st February 2006.

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

6 Lilac Grove 24/04/07

6 Lilac Grove 17/05/05

6 Lilac Grove 06/10/04

6 Lilac Grove 07/04/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Lilac Grove 6 Lilac Grove Trowbridge Wiltshire BA14 0HB Lead Inspector Ms Sally Walker Unannounced Inspection 9:15 1 February 2006 st Lilac Grove DS0000028252.V261548.R01.S.doc Version 5.0 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 Lilac Grove DS0000028252.V261548.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 Adults 18-65. 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. Lilac Grove DS0000028252.V261548.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Lilac Grove Address 6 Lilac Grove Trowbridge Wiltshire BA14 0HB 01225 766200 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) Sense Vacant Care Home 4 Category(ies) of Learning disability (4), Physical disability (4), registration, with number Sensory impairment (4) of places Lilac Grove DS0000028252.V261548.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. No more than 4 service users with a sensory impairment No more than 4 service users with a learning disability No more than 4 service users with a physical disability Date of last inspection 17th May 2005 Brief Description of the Service: 6 Lilac Grove provides care and support to 4 younger adults with learning disabilities, sensory impairment and physical disabilities. There is one single bedroom with an en-suite shower and toilet to the first floor and three single bedrooms on the ground floor, one of which has an ensuite toilet and washbasin. There is a large wheelchair accessible bathroom with shower, bath and toilet to the ground floor. Also on the ground floor are a sitting room, adjacent dining room, kitchen, laundry room, separate toilet and conservatory, divided into offices. All the exits have level access or ramps. There is a reasonably large enclosed garden to the rear of the property. The front garden has been covered with asphalt to alleviate the local parking problem. The interior has been decorated to take into account the needs of people with a visual impairment with dark doors, frames and light walls. The home promotes a Deaf environment with all staff signing as well as speaking. All staff are expected to obtain British Sign Language qualifications. The staffing rota provides for a minimum of 3 care staff during the waking day and 1 waking night staff with 1 staff sleeping in. Staff carry out domestic tasks as well as care and support. Lilac Grove DS0000028252.V261548.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 9.15am and 1.00pm. Carole Fitzwalter, support worker, assisted with access to records. The care records and staff rota were examined. The new ensuite facility in one of the bedrooms was also examined. Two residents and 2 staff were spoken with. Since this inspection Mrs Vicky James’s application to register as manager has been approved and she is now registered. There were no requirements or recommendations made at the last inspection. 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 contacting your local CSCI office. Lilac Grove DS0000028252.V261548.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lilac Grove DS0000028252.V261548.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&4 Much preparation goes into ensuring that any new residents will have a successful placement. EVIDENCE: Referrals and admission were organised through the organisation. Full preadmission assessments were carried out with prospective residents to ensure that the placement was suitable for them. Current residents were taken into consideration. Much preparation goes into ensuring the placement will succeed with regular visits to view the accommodation offered, meet with the other residents and staff and in gathering as much information as possible about the potential resident. Lilac Grove DS0000028252.V261548.R01.S.doc Version 5.0 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Care plans directed the care and residents were encouraged to retain their independence with staff support. Residents were consulted on all aspects of their lives. Risk assessment did not prevent residents from having a full and active lifestyle. EVIDENCE: Each resident had a detailed care plan which was kept in their bedrooms. The files contained individual profiles, any diagnosis and medical history, communication needs, preferences and daily living skills. Most of the information was in large print and it was clear from the records that residents were regularly consulted about their care in regular ‘circle of support’ meetings. These meetings also enabled residents to discuss and develop strategies for dealing with difficult situations with staff support. There was clear guidance on residents preferences with personal care giving, daily routines, managing behaviours, communication and objects of reference, individual moving routines for residents with a visual impairment, use of equipment, giving of medication, identified risks and nutrition. The care plans directed the care. Risk assessment did not stop residents from experiencing new situations or activities. All of the care plans and risk assessments were regularly reviewed and revised each month or as care needs changed or events occurred. Reviews were also carried out with family. Staff were required to Lilac Grove DS0000028252.V261548.R01.S.doc Version 5.0 Page 9 sign up to each care plan and assessment of risk. Signs and finger spelling used by one resident had been collated on a card for agency staff to use. Each resident had a daily report book, which were written with good detail and related to all aspects of the care plans. Staff reported on what residents have achieved each day together with food and fluid intake, mood or behaviours, sleep patterns, communication, unusual events, activities and what residents were wearing. Some events were colour coded; times of administration of medication, mood or special monitoring. As a matter of good practice, staff were using proper recording methods, no spaces in the report so they could not be altered or added to. All records were signed dated and timed. Lilac Grove DS0000028252.V261548.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12 & 14 Residents have a range of activities and the programme provided for leisure activities and quiet time. Staffing levels support one to one time. EVIDENCE: Each resident had a weekly programme of activities and staff hours were made available during the week to support residents with certain projects of one to one time. Two residents attend the local college which is reported to have good facilities for people with learning disabilities and in particular, signed support for Deaf people. Other activities included walking, going to the gym, swimming, going to the pub and local theatre, and household tasks. The home had its own accessible transport. The programmes also provided for some quiet time for relaxing or watching television. The home has a range of subtitled videos. The home had access to the Internet and a computer was available for residents to send and receive emails. Residents were planning their holidays for this year. Sense makes a contribution to the price and pays for staff support. Residents were looking at 2 activity centres and a holiday with the college. Residents also took holidays with parents and made regular weekend trips to the family home. Lilac Grove DS0000028252.V261548.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Residents care needs were delivered in the way that they preferred. Residents had good access to healthcare professionals and specialist workers or consultants. The arrangements for the control and administration of medication were satisfactory. Some residents administered some of their own medication. EVIDENCE: The detailed care plans identified how residents preferred to receive care and support. One of the male staff said they were never involved in giving of intimate personal care to female residents and worked mainly with male residents. Residents were registered with local GPs and had regularly input from specialist healthcare professionals who were monitoring progress. The records showed that staff were also monitoring residents healthcare needs with prompt referral to the relevant professional when necessary. Any guidance given was noted in care plans. Appointments with other healthcare professionals were made as necessary, for example, dentists, podiatrist or opticians. Records were kept of all medical appointments. Nutrition and weight were regularly monitored. Charts were in place for monitoring, menstruation, incidents or unexplained marks. Written guidance was in place for residents who may have a visual impairment and staff were using deafblind communication. It was clear that residents with a visual impairment had been supported to be orientated in their home environment and guidelines were in Lilac Grove DS0000028252.V261548.R01.S.doc Version 5.0 Page 12 place for orientation in the locality, particularly the supermarket. All of these guidelines had been discussed with the residents’ families. Medication was generally given by staff although residents did administer some of their own medication, for example, eye drops. All administrations of medication were witnessed signed and dated by 2 staff as a matter of good practice. Records were well kept with all medications received into the home or returned to the pharmacy were checked and signed by 2 staff. Regular checks were carried out of the temperature of the medication storage cupboard as recommended at an inspection by the Pharmacist Inspector. Allergies were highlighted in the records and the residents’ GPs had been requested to confirm whether certain homely remedies or over the counter medication could be taken with prescribed medication. It was noted that two prescribed topical creams identified in the medication administration record had no guidance in the care plan as to where they should be applied and when. Other medication to be administered when required was clearly documented. Lilac Grove DS0000028252.V261548.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Residents have opportunities to discuss their concerns and make formal complaints about all aspects of the service. Staff training ensures that staff are confident in using the vulnerable adults reporting of suspected abuse process. EVIDENCE: A complaints procedure was in place and all residents and their families had been given a copy. It was clear from residents’ records that they were encouraged to make formal complaints and discuss issues that they were not happy with. Staff were familiar with and confident in using the local vulnerable adults reporting process. All staff had received training in this area. Lilac Grove DS0000028252.V261548.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Care has been taken to ensure that the environment meets residents needs, particularly those people with a visual impairment. The home was well decorated and the accommodation was comfortable, clean and homely. EVIDENCE: All of the bedrooms are single accommodation; two with ensuite facilities. The accommodation was light, bright, clean and comfortable. The building was decorated in contrasting colours; light walls and dark architrave and doors, to aid people with a visual impairment to access the environment. A plumber was changing one of the hot water temperature regulators in one of the bedrooms. Mrs Fitzwalter showed the tests records of water temperature and Legionella that staff were required to carry out at regular intervals. A new kitchen was being considered and would be fitted whilst residents were on holiday to avoid any disruption. One of the bedrooms was being refurbished. Protective covers were on all door hinges to avoid injury. Health and safety notices in large print and BSL were noted in the kitchen, toilets and bathroom. One of the bedrooms had been fitted with an ensuite toilet and wash hand basin since the last inspection. It was also proposed that the loft space would be extended to provide office accommodation and return the conservatory to residents use. The home was cleaned to a high standard and protective clothing and gloves were available if necessary. Lilac Grove DS0000028252.V261548.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 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 & 35 Staffing levels support residents to achieve their identified aims and goals. Staff had good access to a range of ongoing training. Staff were well supported by management and the organisation. EVIDENCE: On the day of inspection there were 2 staff on duty during the morning and 3 during the afternoon and evening. Bank and agency staff were employed to cover some shifts. It was reported that the same agency staff were used as continuity for residents. Staff said they had very good access to training through the organisation. Staff could undertake NVQs to Level 3 and British Sign Language to Stage 2. There were also core subjects that staff were expected to be trained in; BSL Stage 1, values in to practice, first aid, moving and handling, health and safety, food hygiene, managing behaviours and non violent interventions, medication, person centred planning and adult protection. One of the staff showed their certificates of training. One of the senior staff had undertaken training in deafblind awareness and would cascade the training to the other staff. Lilac Grove DS0000028252.V261548.R01.S.doc Version 5.0 Page 16 Each member of staff had an area of responsibility, usually an administrative or management task. Staff knew most of the procedure as these tasks would be redistributed at different times. Staff said they had regular monthly supervision and regular staff meetings. Staff also had access to the Responsible Individual when they made their monthly unannounced visits as required by Regulation 26. Lilac Grove DS0000028252.V261548.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 42 The home is run in the best interests of the residents. Organisational policies and procedure were in place for the protection of residents. EVIDENCE: Since the inspection Mrs Victoria James has been approved and registered as manager. She had worked at the home for five years, 2 of which in a senior role. She was undertaking the Registered Managers Award. Organisational policies and procedures had been reviewed and re-organised. Staff showed the formats for regular checks and tests on the environment, fire safety and equipment. Lilac Grove DS0000028252.V261548.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X 3 3 X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 X 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X X 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Lilac Grove Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 X X X X 3 X DS0000028252.V261548.R01.S.doc Version 5.0 Page 19 No Are there any outstanding requirements from the last inspection? 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 Refer to Standard YA20 Good Practice Recommendations Care plans should identify details of prescribed topical creams, for example, where to apply, when and why. Lilac Grove DS0000028252.V261548.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Lilac Grove DS0000028252.V261548.R01.S.doc Version 5.0 Page 21 - 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. 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