Inspection on 21/01/09 for Lilac House Care Home

This inspection was carried out on 21st January 2009.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Lilac House Care Home 10/09/08

Lilac House Care Home 26/09/07

Lilac House Care Home 08/08/06

Lilac House Care Home 25/10/05

Lilac House Care Home 19/04/05

Lilac House Care Home 09/11/04

Lilac House Care Home 14/04/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

CARE HOMES FOR OLDER PEOPLE Lilac House Care Home 2 Lilac Grove Beeston Nottingham NG9 1PA Lead Inspector Mary O`Loughlin Unannounced Inspection 21st January 2009 09:30 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 Lilac House Care Home DS0000008708.V373965.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. Lilac House Care Home DS0000008708.V373965.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lilac House Care Home Address 2 Lilac Grove Beeston Nottingham NG9 1PA 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) 0115 925 2319 MANAGER@LILACHOUSE.CO.UK Mr Bashir Ahmed Mrs Sakina Ahmed Mr Imran Ahmed Care Home 19 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (19) of places Lilac House Care Home DS0000008708.V373965.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Out of the total number of beds 2 beds can be used for the 2 named service users in the category DE(E). 10th September 2008 Date of last inspection Brief Description of the Service: Lilac House Care Home is situated close to Beeston town centre and can be easily accessed by car. Beeston has a wide range of shops and other community facilities. The Home provides long term care for up to nineteen older people. The facilities at the home include a lounge, a dining room, and a second room, which is also used as a dining room. The accommodation is on two floors and is served by a passenger lift. There is a small paved garden at the rear with potted plants and flowers. The fees for this service are currently £294.00 to £348.00 per week. Additional expenditure is charged for hairdressing and chiropody. Further details can be found in the providers ‘Service User Guide’, which is available at Lilac House. Lilac House Care Home DS0000008708.V373965.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. A review of all the information we have received about the home was considered in planning this visit including the improvement plan we received following the last inspection, and this helped decide what areas were looked at. 2 Inspectors completed this unannounced inspection over 2 days. The main method of inspection used was called ‘case tracking’ which involved selecting the care plans of 3 people and looking at the quality of the care they receive by speaking to them, observation, reading their records and asking staff about their needs. Members of staff, people who use the service and an external health care professional were spoken with as part of this visit. A partial tour was undertaken by the regulation inspector, which included looking at people’s bedrooms and communal areas of the home. Fire and Environmental Health issues that were evident during this inspection were referred to the local Fire and Environmental Health Agencies to ensure the safety of people at the home. The quality rating for this service is 0 star this means that people who use the service experience poor quality outcomes. What the service does well: Lilac House is a residential care home situated in a residential area, close to a local shop and near the main roads into the centre of town. People living at Lilac House experience a calm, quiet environment. Lilac House Care Home DS0000008708.V373965.R01.S.doc Version 5.2 Page 6 The staff team have worked at Lilac House for a number of years. Staff have a good relationship with the people living at the Home. Some of the comments received from people living at Lilac House told us that people were happy with the care provided and felt safe. What has improved since the last inspection? What they could do better: The registered manager must access training and supervision to ensure he is fully able to meet the obligations of his role. There must be improved measures in place to maintain the home safely, ensuring that there are safe systems of work that control hazards and that people who use the service are adequately protected. Staff must have sufficient and regular updated training to enable them to work safely and maintain the health and wellbeing and understand the needs of people living at the home. The policies and procedures of the home must be reviewed and amended with changes in legislation to ensure staff have access to up to date information. Lilac House Care Home DS0000008708.V373965.R01.S.doc Version 5.2 Page 7 Before agreeing admission the manager must carefully consider the needs assessment for each individual prospective person and the capacity of the home to meet their needs. The assessment must focus on achieving positive outcomes for people and this includes ensuring that the facilities, staffing and specialist services provided by the home meet the ethnic and diversity needs of the individual. There must be improved quality assurance in place with the registered provider completing regular reports on the quality of the services provided to people and their satisfaction with the care delivered. 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. Lilac House Care Home DS0000008708.V373965.R01.S.doc Version 5.2 Page 8 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 Lilac House Care Home DS0000008708.V373965.R01.S.doc Version 5.2 Page 9 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): 1-2-3-4-6 Quality in this outcome area is Poor. This judgement has been made using available evidence including a visit to this service. The manager ensures that people are assessed before they are admitted to the home but does not fully consider whether the service is suitable to provide the care that people need or give people enough accurate information on the services that the home is registered or able to provide. Intermediate care is not provided. EVIDENCE: We examined the records of a recently admitted person and saw that the manager had completed an assessment of the person’s needs before they were admitted to the home but he had not considered the homes statement of purpose to ensure that the service was able to meet the person’s needs. Lilac House Care Home DS0000008708.V373965.R01.S.doc Version 5.2 Page 10 The manager had obtained a copy of the social services assessment and a discharge letter from the hospital, however each one stated that the person required a home that was registered to admit people with Dementia, the home does not have this category within their registration except for 2 named individuals. The manager told us that 7 staff received a half-day Dementia awareness training in June 2008 and of 3 staff files we examined 1 person had a training certificate that reflected they had attended this training. When we spoke to staff they told us that they found it hard to do activities with people who had Dementia and due to the number of people with this illness they don’t bother with arranging entertainment. We spoke to 2 staff who told us they were not able to care for people when they become immobile because the hoist was not working and they were not trained to use it, this was confirmed when we spoke to an external health care professional and the Manager, however the statement of purpose does not inform people that they must be mobile to live at the home. We looked at the homes statement of purpose and saw that it was not reflecting the homes true registered categories or the actual training and experience of the staff team and could be misleading for anyone considering admission to the home. We recommended at the last inspection that people sign their individual contracts with the home, this inspection found no evidence that indicates the manager has made sure that all people living in or thinking about moving into the care home sign as necessary to indicate acceptance of the contract terms, or are properly represented in considering and agreeing to contracts. Lilac House Care Home DS0000008708.V373965.R01.S.doc Version 5.2 Page 11 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 adequate. This judgement has been made using available evidence including a visit to this service. Further improvements are needed in care planning, risk assessment, reviews and medicine management to ensure that each person has their care delivered in accordance with their needs and wishes and to ensure their safety. EVIDENCE: At this inspection we examined 3 care plans, 2 of the plans had been signed indicating that people had seen them and agreed to the content. 2 people we spoke with said they were very happy with how their care is delivered. We examined the care plans for details of how people had their health monitored and found that risks to their health had not been reviewed and planned for on a regular basis. Lilac House Care Home DS0000008708.V373965.R01.S.doc Version 5.2 Page 12 Some people living in the home were being weighed but this was not being done on a regular basis and staff said that if a person’s mobility were poor, their ability to weigh them would be restricted as the scales were of a domestic nature. There are no assessments surrounding nutrition in peoples care plans, but staff were able to tell us about how people were supported with their diets. We read the pre-admission assessment document of a recently admitted person which informed staff that the person was at a high risk of falling but the home’s care plan did not reflect this or the effect that the person’s medicine may have on their mobility, which means that staff cannot plan to reduce the possibility of falls and injuries. Staff did not have access to any lifting equipment for people who fall. One person who was confused had lost his hearing aid but staff had not done anything about getting this replaced which meant the person would be more impaired due to the fact that he could not hear people. At the last inspection we had also required that the manager ensure that staff were suitably trained and competent to undertake medicine administration. During this inspection the manager arranged training for staff through the supplying pharmacist to ensure staff received regular updates in medicine administration to protect the health and safety of people at the home. We examined the way medicines were recorded into the home and found good recording practices. Most medicines were safely stored and any medicines returned were recorded to provide a suitable audit trail. Some medicines were being stored within a filing cabinet, which is not sufficiently safe to protect people. All 3 people case tracked were taking medicines that caused drowsiness and their care plans did not inform staff of the required monitoring and risks associated with this type of medicine or when to prompt a review to ensure their health and wellbeing. Controlled medicines were stored safely but the controlled medicine record book was not compliant with the law. Cold storage medicines were held within a medicine fridge, this was left unlocked and potentially a risk to people in the home. The care plans did not inform staff of people’s wishes regarding going to bed and getting up times, we spoke to people using the service and they told us that they can get up or go to bed when they wish, some saying they choose to go to bed quite early and wake early the next day. Lilac House Care Home DS0000008708.V373965.R01.S.doc Version 5.2 Page 13 People told us that they felt safe and well cared for by the staff at the home but we found that their lack of up to date training means they may not always deliver best practice when caring for people. Staff were seen to undertake unsafe moving and handling practices, and leaving their own medicine within reach of the people who may be confused and not aware of the dangers. Lilac House Care Home DS0000008708.V373965.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 adequate. This judgement has been made using available evidence including a visit to this service. There are limited opportunities for people to be involved in activities of their choice and staff are not trained to provide activities for people with Dementia. The food in the home is of satisfactory quality, well presented and meets the dietary and cultural needs of people who use the service. EVIDENCE: At the last inspection we required the manager to consult with people about their hobbies and interests and develop a programme of activities that would suit their individual needs. At this inspection we found some progress in that people who were newly admitted to the home were asked about their interests, however there was not a programme of activities developed. We spoke to staff about the provision of activities and found that they provide some things such as board games and sing a long for people. Staff told us that there had been a visiting entertainer but it had been expensive and very few people had attended. They also felt unable to occupy Lilac House Care Home DS0000008708.V373965.R01.S.doc Version 5.2 Page 15 people due to their deteriorating health having no knowledge of how to develop recreational activities for people with Dementia. People living at the home who were able to communicate their views told us they were happy and said they were able to do what they wanted each day. From speaking to people at the home and looking at food stocks we found that suitable quantities of food were being provided. Lunch was observed and the meal was well presented and appeared to be nutritional with good sized portions served. Staff were in attendance to assist people who needed encouragement and support to eat and they did this in a respectful manner. There were drinks available on the tables, which were set nicely with condiments for people to use. The meal was a relaxed and positive experience for the people living in the home. Lilac House Care Home DS0000008708.V373965.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 adequate. This judgement has been made using available evidence including a visit to this service. People are listened to and taken seriously. Further training in safeguarding adults is required to ensure staff can fully protect people. EVIDENCE: The manager obtained a copy of the local safeguarding adults procedures during this inspection and told us that he had arranged to attend a study day with the Local Authority on safeguarding adults, which would provide him with more up to date information on how to protect people from abuse and respond appropriately. The manager told us that he intends to teach his staff team about the safeguarding adults procedures to ensure that they know how to respond and protect people. People using the service told us they felt safe and cared for and knew what to do if they had any concerns or complaints. The home received 1 complaint since our last inspection, which was referred under the safeguarding of adults procedures to the social services. The investigation is not completed at the time of this report. Lilac House Care Home DS0000008708.V373965.R01.S.doc Version 5.2 Page 17 The complaint procedure is available in the home but does require review, as some information is out of date. Lilac House Care Home DS0000008708.V373965.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): 19-25-26 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The management of hot water and the control of infection present a high risk for people using the service. EVIDENCE: We looked at the bedrooms of people we case tracked and found them to be clean and warm. People were able to lock their door if able and had a call bell for assistance. The manager told us that there were no cleaning schedules for the home. The communal areas and high traffic areas of the home were not clean. There was dust on high and low surfaces and carpets showed a build up of dust around the edges. Lilac House Care Home DS0000008708.V373965.R01.S.doc Version 5.2 Page 19 We saw 2 bathrooms and found them to be dusty and the toilets dirty. The hot water thermostatic control valves on the baths were not working and people were at risk of excessively hot water. The manager told us that water temperatures are checked but they did not have a suitable thermometer and no written records of checks were available. The manager was not able to tell us the temperature of hot water storage and distribution to prevent Legionella developing. There was a policy on the control of legionella but the manager was not aware of its contents and had no evidence that he was undertaking any of the required checks. There was no infection control policy in place and clinical waste was not stored safely to prevent any spread of infection. There have been no reported outbreaks of infection. The environmental health department have inspected the home in January 2009 and have identified that there are no written food hygiene systems in place, some cupboard doors are broken or missing and the general kitchen area was dirty in places. We saw fire doors wedged open that would not be closed automatically in the event of fire. The environmental health department was contacted as a result of our inspection and made an immediate visit to the premises to secure the safety of people accommodated. Lilac House Care Home DS0000008708.V373965.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 poor. This judgement has been made using available evidence including a visit to this service. There are gaps in staff training which does not ensure people are in safe hands at all times and the number of staff employed to clean the home is insufficient to ensure the health and safety of people living there. EVIDENCE: We examined 3 staff files which showed us there is a good recruitment procedure that is followed in practice and recognising the importance of effective recruitment procedures in the delivery of good quality services and for the protection of individuals. We looked at records of induction training and found that they did not reflect the national standards and inexperienced staff could be placed in situations they cannot manage. The manager did not have any individual records of training plans for staff, we saw some training certificates on people’s files but these were incomplete. We saw staff using poor moving and handling techniques and found that although some staff have attended a mobility day in the last year the Lilac House Care Home DS0000008708.V373965.R01.S.doc Version 5.2 Page 21 mandatory training areas such as moving and handling training has not been arranged annually as required. Staff spoken to had received some training in Dementia awareness but they told us they did not know how to provide activities for people who were confused. People told us they felt there was enough staff on duty to care for them but one person felt they were worried with only 1 carer at night. The manager said that there is always 1 carer who sleeps over to support the waking night staff and other staff confirmed this. We saw as described in the environmental group of standards that the home is not maintained in a clean and hygienic state, which means there are insufficient cleaning hours to maintain the home effectively. Lilac House Care Home DS0000008708.V373965.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): 31-32-33-35-36-38 Quality in this outcome area is Poor This judgement has been made using available evidence including a visit to this service. The service is not run in the best interests of people living there and the management of health and safety presents a risk to their health and wellbeing. EVIDENCE: The manager sent us an improvement plan after we requested it following our last inspection. He told us that he would make the required improvements within the timescales that were set. Some improvements were found to have taken place at this inspection but there was slippage with others. Lilac House Care Home DS0000008708.V373965.R01.S.doc Version 5.2 Page 23 The information provided by the home to people wishing to use the service is misleading. The manager has not considered the homes registration category or the skills of the staff team before providing care for people. The manager does not arrange training for staff that would ensure they have the up to date skills necessary to meet the needs of the people they care for. There is little importance being placed on ensuring that people have access to the equipment they need to support them. We saw records of a review of the needs of 1 person who had needed more support with their mobility but there was no working hoist or suitable weighing scales, and staff were not able to move and handle them safely. The manager holds meetings with staff 6 times a year and records of these meetings are held, however this is not sufficient to ensure that staff are appropriately supervised and have their training and development needs identified and planned for. The policies and procedures of the home are not kept up to date and the manager was not adhering to the homes policy on the control of Legionella. The management of health and safety is not safe with excessively hot water and inadequate first aid supplies. The manager does not have an infection control policy and the disposal of clinical waste does not safeguard people from harm. We saw automatic closure doors wedged open which renders them ineffective in the event of fire and presents a serious risk to people. The main entrance door was only accessible with a key, which is not held by everyone and restricts exit in the event of fire. The environmental health department conducted an inspection of the food hygiene practices in January 2009 and found that there was no written system in place around food hygiene systems, some areas were dirty and cupboard doors were broken or missing. The AQAA was returned but it contains very little information on the service and claims made within it about the training of staff cannot be evidenced at inspection. Lilac House Care Home DS0000008708.V373965.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 1 2 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 X X X X X 1 1 STAFFING Standard No Score 27 1 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 1 2 X 3 2 3 1 Lilac House Care Home DS0000008708.V373965.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 OP1 Regulation 4 (1)(c) Requirement You must ensure that the statement of purpose includes accurate information on all the services provided as described in Schedule 1 of the Care Homes Regulations 2001. To make sure that people are given the correct information on which to base their decision to come into the home. You must ensure that people sign the contracts when moving into the home to show that they have agreed to the terms and conditions of residency or have a representative who acts for them sign on their behalf. To ensure that people are properly represented and aware of their rights and obligations. 3. OP3 14(1)(d) You must not provide accommodation to people in the care home unless you have confirmed in writing that following your assessment of need the home is suitable for the purpose of meeting those needs DS0000008708.V373965.R01.S.doc Timescale for action 01/04/09 2. OP2 5(b)(c) 01/04/09 01/04/09 Lilac House Care Home Version 5.2 Page 26 4. OP7 15 in respect of their health and welfare. You must ensure that each area of need including the social needs are included within a care plan and that the plans set out the individual preferences of each person in the way they wish their care to be delivered. This will ensure that staff are clear about the person’s wishes and expectations. 01/04/09 5. OP7 15(1) You must ensure that each person is assessed for the risk of them falling and write a care plan that describes the actions staff must take to reduce the identified risk. 01/04/09 6. OP8 12(1)(a)( b) To ensure any risk to their health is identified and they receive appropriate care or treatment. You must ensure that you review 01/04/09 the risk of people developing a pressure sore on a regular basis and use the information when you review their care plan each month or as their condition changes. To ensure any risk to their health is identified and they receive appropriate care or treatment. You must ensure that each 01/04/09 person is assessed on admission and each month for any nutritional risk including any weight gain or loss, and diet records or referral to external specialists is recorded in a care plan. To ensure that staff are aware of the needs of each person and provide the support and 7. OP8 14(2)(a)( b) Lilac House Care Home DS0000008708.V373965.R01.S.doc Version 5.2 Page 27 8. OP8 13(1)(b) treatment they require. You must make sure that people have access to hearing tests according to their needs. To make sure that people receive where necessary any health care service that their needs identify. Staff must receive regular training in or by other measures to safely administer medication and records available to verify that trained staff meets their needs. To ensure people’s health, safety and wellbeing. This requirement was partially met and the timescale of 10/11/08 has been extended. You must ensure suitable arrangements are in place for the recording and safekeeping of medicines in the home. 1. Obtain a suitable bound book for controlled medicines 2. Ensure that the medicine fridge is locked at all times. 3. Staff medicines must be locked away safely if required to be held on the premises. 4. Complete a signature list of all staff that administer medicines. 5. Provide suitable medicine storage arrangements. You must monitor the condition of people on medication that may cause drowsiness and record any required actions within the care plan. To ensure that staff are aware of any changes in the person’s 01/04/09 9. OP9 13(6)18(1 )(c)(i) 01/04/09 10. OP9 13(2) 01/04/09 11. OP9 14(2)(a) 01/04/09 Lilac House Care Home DS0000008708.V373965.R01.S.doc Version 5.2 Page 28 12. OP12 16(2)(m)( n) condition and promptly refer them for review of their medicines. You must consult with people about their social interests, daily living activities, and preferences and develop a regular programme of activities, recreation and engagement with the local community to stimulate people and ensure their health and wellbeing. This requirement was partially met and the timescale for completion of a written programme of activities has been extended. 01/04/09 13. OP18 13(6) You must ensure that staff are trained in the safeguarding adults procedures to protect people from being harmed, suffering abuse or being placed at risk of harm and abuse. To ensure people’ health, safety and wellbeing is protected. This requirement was partially met and the timescale for completion of staff training has been extended. 01/04/09 14. OP19 13(4) You must make suitable arrangements to ensure that the building complies with the local Fire service and environmental health departments. Automatic fire doors must not be wedged open. To ensure that all parts of the home are so far as possible free from hazards and any unnecessary risks to people’s 01/03/09 Lilac House Care Home DS0000008708.V373965.R01.S.doc Version 5.2 Page 29 15. OP25 13(4) health or safety is identified and as far as possible eliminated. You must ensure that water is stored at a temperature of at least 60ºC and distributed at 50ºC minimum, to prevent risks from Legionella. To prevent risks from scalding, pre-set valves of a type unaffected by changes in water pressure and which have fail-safe devices are fitted locally to provide water close to 43ºC. Hot water temperatures must be checked and recorded at regular intervals to ensure that thermostatic control valves are working safely. 01/03/09 16. OP26 13(3) To ensure that all parts of the home are so far as possible free from hazards and any unnecessary risks to people’s health or safety is identified and as far as possible eliminated. You must ensure that you have a 01/04/09 suitable policy for the control of infection including the safe handling of clinical waste dealing with spillages; provision of protective clothing; hand washing. To ensure that people are protected from unnecessary risks to their health or safety. You must ensure that Domestic 01/04/09 staff are employed in sufficient numbers to ensure that standards relating to food, meals and nutrition are fully met, and that the home is maintained in a clean and hygienic state, free from dirt and unpleasant odours. To ensure that people are protected from unnecessary risks to their health or safety. 17. OP27 18(1)(a) Lilac House Care Home DS0000008708.V373965.R01.S.doc Version 5.2 Page 30 18. OP28 13(5) You must ensure staff receive 01/04/09 regular updated training in moving and handling and the use of hoisting equipment. To make proper provision for the health and welfare of people at the home. 19. OP30 18(1)(c) All members of staff must receive induction training within 6 weeks of appointment to their posts, including training on the principles of care, safe working practices, the organisation and worker role, the experiences and particular needs of the service user group, and the influences and particular requirements of the service setting. 01/06/09 20. OP32 10(1)(3) So that new workers know all they need to know to work safely and effectively. The registered manager must 01/06/09 access training and supervision as is appropriate to ensure that he has the skills necessary for carrying on the care home. To enable him to manage the care home with sufficient care, competence and skill. Policies, procedures and practices must be regularly reviewed. Action must be progressed within agreed timescales to implement requirements identified in CSCI inspection reports. 21. OP33 26 The registered person must carry 01/04/09 out the monthly visits to the Home and produce a report of the findings and action plan to address any issues. DS0000008708.V373965.R01.S.doc Version 5.2 Page 31 Lilac House Care Home To ensure the health, safety and wellbeing of the residents. This requirement had a timescale of 10/11/08, which has been extended. The provider must ensure that 01/04/09 staff receive regular supervision which is recorded, that ensures people receive care from staff that are competent that ensures people’s health and wellbeing. This requirement had a timescale of 10/11/08, which has not been met. Enforcement action is now being considered. 23. OP38 You must consult with the fire 23(4)(b)(c authority about the suitability of ) the main entrance door lock to make sure it complies with fire regulations. Provide each member of staff with an individual key to the door to ensure that at all times access and egress can be made from this door. Remove all objects that restrict automatic closure of fire doors. 24. OP38 13(5) You must ensure that suitable equipment is available to move and handle people safely and equipment must be regularly serviced and maintained properly. To make sure people have suitable equipment they need to support them safely. You must ensure that hot water is regulated to control the risk of DS0000008708.V373965.R01.S.doc 22. OP36 18(2) 01/03/09 01/04/09 25. OP38 13(4) 01/03/09 Lilac House Care Home Version 5.2 Page 32 scalding for people who are vulnerable. To make sure people are safe from excessively hot water. 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 OP1 Good Practice Recommendations It is recommended that the contact details of Advocacy services are included in the service user guide to enable people to seek independent support and guidance. Provide a photograph on each individual care file and Medicine Record sheet. Provide suitable equipment to weigh people Consult with people when any changes to their care plan are made. The carer’s competence to safely administer medicines should be formally tested and recorded. Make available written evidence that training in safe practice has been provided for all care staff who are involved in the handling of medicines Update the contact address for the Commission for Social Care Inspection within the complaint procedure. Staff should be trained to understand their responsibilities in the provision of services that offer equal access to people whatever their gender (including gender identity), age, sexual orientation, race, religion or belief, or disability. You should seek feedback from people using the service, family and friends and stakeholders in the community (e.g. GP’s, chiropodist about services provided. A risk assessment should be carried out to identify potential scalding risks from hot water temperatures and to assess the vulnerability of those who have access to bathing and washing facilities. Thermostatic mixer valves should be tested at regular intervals. 2. 3. 4. 5. 6. 7. 8. OP7 OP8 OP8 OP9 OP9 OP16 OP30 9. 10. OP33 OP38 Lilac House Care Home DS0000008708.V373965.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team 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 Lilac House Care Home DS0000008708.V373965.R01.S.doc Version 5.2 Page 34 - 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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