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Inspection on 25/10/05 for Lilac House Care Home

Also see our care home review for Lilac House Care Home for more information

This inspection was carried out on 25th October 2005.

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.

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

What the care home does well

The staff group at the home remains stable and motivated to provide individual care. Residents spoken with all felt the care staff were caring and you could `have a laugh`. Staff were seen to interact well with residents providing `singalong` and quizzes. The home actively encourages visitors and were seen throughout the day being welcomed by staff. The home provides a quiet stable and safe environment for residents.

What has improved since the last inspection?

Some redecoration has taken place in the dining room and some bedrooms. New beds and some furniture have been purchased for residents` bedrooms. Four staff have started a Dementia Awareness training course. The majority of requirements set at the last inspection have been met.

What the care home could do better:

The registered manager must ensure that risk assessments are carried out in areas that have the potential for placing residents at risk. The windows identified at the last inspection that may need window restrictors have not been assessed.

CARE HOMES FOR OLDER PEOPLE Lilac House Care Home 2 Lilac Grove Beeston Nottingham NG9 1PA Lead Inspector Susan Lewis Unannounced Inspection 25th October 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lilac House Care Home DS0000008708.V250466.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lilac House Care Home DS0000008708.V250466.R01.S.doc Version 5.0 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 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.V250466.R01.S.doc Version 5.0 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). 19th May 2005 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. There is currently a variation for two service users who have dementia. 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 lift. There is a small rear garden, which can be accessed by the lounge. Lilac House Care Home DS0000008708.V250466.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 over 5 hours and was carried as part of the annual inspection process and carried out by one inspector. A partial tour of the building took place and a number of staff and care records were inspected. Four of the fifteen residents were spoken with. As the staff on duty had been spoken with recently no staff were spoken with. 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 House Care Home DS0000008708.V250466.R01.S.doc Version 5.0 Page 6 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.V250466.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 and 5 Progress has been made on the admission procedures ensuring residents have proper assessments prior to moving in. EVIDENCE: Three care plans were looked at for the purpose of this inspection, two of which were for new residents. All were found to have full assessments and care plans enabling staff to provide appropriate care. A requirement had been set at the last inspection when a new resident was found not to have a care plan. This is now met. The staff demonstrate that they are able to meet the needs of the residents who have dementia and four staff including the manager are currently undergoing dementia care training. A requirement was set at the last inspection to improve care plans where residents had dementia and identify risk this had been done with an improved pre- admission assessment. There was also evidence that care plans were being kept under regular review this was a requirement at the last inspection and is now met. A requirement had also been made at the last inspection to involve residents or relatives where possible in the creation of the care plan; residents’ signatures were seen on most plans. This requirement is now met. Lilac House Care Home DS0000008708.V250466.R01.S.doc Version 5.0 Page 8 There is a policy enabling residents to visit the home prior to admission and where this has not been possible residents spoken with said their relatives visited the home this enabled them to make an informed choice about where they wanted to live. All residents admitted recently have had a care plan created within the first few days of their admittance ensuring staff knew residents care needs, this had been a requirement at the last inspection and is now met. Lilac House Care Home DS0000008708.V250466.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Progress has been made on improving arrangements to ensure that residents’ personal and health care needs are identified and met. EVIDENCE: Evidence was seen that all residents had a care plan which provided information to cares enabling them to provide care, residents spoken with said that staff always asked talked to them about what they were doing and were kind and caring. Plans were reviewed regularly monitoring when residents care needs changed. Requirements set at the last inspection regarding care plans and their creation had been met. A requirement made at the last inspection regarding risk assessments has now been met with all plans looked at having risk assessments. Staff were able to identify where residents were at risk and what action needed to be taken to minimise that risk. Care plans also identified where residents were at risk of pressure sores identifying what action needed to be taken and by whom. This had also been a requirement at the last inspection and is met. Care plans now provide staff with a clear guide on how to meet residents needs and where their health may be at risk and what to do about it. Lilac House Care Home DS0000008708.V250466.R01.S.doc Version 5.0 Page 10 Residents are also risk assessed as to whether they are able to self medicate, providing a framework where residents are protected by the home’s policies and procedures, this was a requirement at the last inspection and is now met. Care plans identified residents’ wishes should their health deteriorate ensuring residents and family that they will be treated with dignity and respect. Lilac House Care Home DS0000008708.V250466.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 Meals are nutritious and well balanced and offer a healthy and varied diet for residents. EVIDENCE: Although the meal was not sampled during the inspection it appeared well presented and appetising. All the residents spoken with were very positive about the meals and choice they received. Care plans identified likes and dislikes as well as were residents had poor appetites. Staff were available to provide assistance. The kitchen was clean and well ordered. Plenty of fresh fruit and vegetables were available. The dining room has recently been redecorated and appeared fresh and bright making it a pleasant environment to eat in. However the second smaller dining room had a number of boxes of incontinence pads in due to a delivery the previous evening. As two resident choose to eat in this room the manager must ensure that it is kept free of such items and they are stored more appropriately. Lilac House Care Home DS0000008708.V250466.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The manager provides residents with confidence that their concerns will be listened to, taken seriously and acted upon. Residents are protected from abuse by the homes policies and procedures. EVIDENCE: All the residents spoken with were very positive about the staff and manager. One resident said ‘ you can have a laugh here’. All residents felt comfortable and safe to complain and felt that all staff would take it seriously and it would be dealt with. All residents said that they felt safe and had never seen or heard staff speak harshly or ill treat residents. The Commission has received no complaints regarding this home since the last inspection. The home has a copy of Nottinghamshire’s Vulnerable Adult Procedures ensuring should something happen the manager understands what procedure must be followed. Lilac House Care Home DS0000008708.V250466.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26 Some improvements have been made and a homely and comfortable environment is provided, with bedrooms that meet the residents’ needs. EVIDENCE: Evidence that some redecoration is taking place was seen a number of bedrooms and the dining room have already been decorated. Residents spoken with thought it looked ‘lovely’. Although a requirement was set at the last inspection regarding the garden maintenance, it was difficult to assess how much work had been done due to the wet weather conditions. A number of bedrooms were viewed and improvements had been made with new beds and getting rid of old and worn furniture, improving the environment for residents. The home was clean and free from odour; a requirement had been left at the last inspection regarding cleaning and is now met. Lilac House Care Home DS0000008708.V250466.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 The manager ensures that robust recruitment practices are in place to protect residents form potential abuse. EVIDENCE: At the last inspection staff files were not available for inspection and a requirement was left to ensure they were available for inspection at all times. The manager had the files available. Files contained information regarding the recruitment process and the manager was aware of the need to get PoVA First checks as well as Criminal Records Bureau checks prior to someone starting work at the home. Due to The Data Protection Act 1998 the manager had destroyed his copy of staffs Criminal Records Bureau checks it is recommended that a record is kept of the reference number to provide evidence that a Criminal Records Bureau has been completed. Lilac House Care Home DS0000008708.V250466.R01.S.doc Version 5.0 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38 Shortfalls in risk assessment places residents at potential risk. EVIDENCE: During the tour of bedrooms, windows were checked for restrictors. A requirement had been set at the last inspection to ensure that areas were free of avoidable risks for residents, including the fitting of window restrictors. This has yet to be done. The manager must ensure that risk assessments take place to identify where residents are at risk as result of windows being able to be opened wide. The manager must also contact the fire officer for advise regarding the propping open of residents doors at night, until this advise has been sought a risk assessment must take place to identify what the risk, if any, is and how to minimise it. Lilac House Care Home DS0000008708.V250466.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 2 Lilac House Care Home DS0000008708.V250466.R01.S.doc Version 5.0 Page 17 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 OP38 Regulation 13 Requirement The Registered Person shall ensure that all parts of the home to which service users have access are so far as reasonably practicable free from avoidable risks and window restrictors are fitted to all windows. (Outstanding requirement 01/06/05) The registered person shall ensure that unnecessary risks to the health and safety of service users are identified and so far as possible eliminated. Risk assessments for safe working practices must take place, identifying risk with action detailing ways to minimise risk. Timescale for action 01/12/05 2 OP38 13 01/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP29 Good Practice Recommendations A copy of the Criminal Records Bureau reference number be kept on staff files to evidence that checks have been carried out. DS0000008708.V250466.R01.S.doc Version 5.0 Page 18 Lilac House Care Home Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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. 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