Inspection on 08/08/06 for Lilac House Care Home

This inspection was carried out on 8th August 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

Lilac House Care Home 21/01/09

Lilac House Care Home 10/09/08

Lilac House Care Home 26/09/07

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Lilac House Care Home 2 Lilac Grove Beeston Nottingham NG9 1PA Lead Inspector Susan Lewis Key Unannounced Inspection 8th August 2006 09:45 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.V301982.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.V301982.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 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.V301982.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). 25th October 2005 Date of last inspection Brief Description of the Service: The fees for 2006 are £277 -£319 per week. The last inspection report for the home carried out in October 2005 can be found in the office. 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.V301982.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views of the service provided. The primary method of Inspection used was ‘case tracking’ which involves selecting clients and tracking the care they received through looking at their records, talking with them where possible, and looking at their accommodation. The inspection was unannounced and took place over 6 hours one Tuesday in August 2006, and was conducted by one inspector as part of the annual inspection process. A tour of the building took place and a selection of residents’ bedrooms was inspected. Residents’ records were inspected and Four residents and staff on duty were spoken with. What the service does well: What has improved since the last inspection? There were two requirements set at the last inspection and evidence was seen that the requirement relating to window restrictors was now met and all windows viewed as part of the tour had restrictors fitted. The second requirement relating to risk assessing safe working practices is partially completed, however enough work has been done for any further remarks to be recommendations. Lilac House Care Home DS0000008708.V301982.R01.S.doc Version 5.2 Page 6 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.V301982.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 Lilac House Care Home DS0000008708.V301982.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 6 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have contracts but they are not signed, placing them at potential risk. Residents do not move into the home without having their needs assessed and assured that they will be met. EVIDENCE: Intermediate care is not provided in this service. Although residents’ files had copies of the statement of purpose and contract the residents or their representative did not sign the contracts. It is strongly recommended that the Registered Person have these documents signed by the appropriate person. Three care plans were looked at for the purpose of this inspection and showed that residents were assessed prior to coming to the home. It is comprehensive and covers all aspects of a persons daily living providing information that will inform the care plan. Lilac House Care Home DS0000008708.V301982.R01.S.doc Version 5.2 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 and 10 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ health, personal and social care needs are set out in individual plans but do not involve the individual in their creation or review. It is not always clear from evidence that residents’ health needs are fully met. Residents are protected by the home’s policy and procedure for dealing with medicines and residents feel their privacy and dignity are protected. EVIDENCE: Although the care plan is created from the assessment, each plan viewed was a replica of each other; they did not provide evidence of individual responses to residents’ individual needs. Care plans provided evidence that appropriate risk assessments were taking place following guidelines produced by relevant bodies for the prevention of falls. Although evidence in plans showed that they were reviewed at least monthly there was no evidence that the resident of their representative were involved in this review. Residents spoken with were not aware that they had care plans and could not recollect being involved in their creation. Lilac House Care Home DS0000008708.V301982.R01.S.doc Version 5.2 Page 10 A visitor spoken with said that when their relative moved to the home the family had been involved in the creation of the plan but not subsequent reviews. The Registered Person must ensure that residents or their representatives are involved where possible in the creation and review of care plans. Diary notes provided evidence that where necessary district nurses were involved with residents who had pressure care needs, it was also seen during the tour of the building that resident with pressure needs had pressure relieving mattresses. Where residents had continence needs these were also well documented in the diary notes where district nurses were visiting and what action staff were taking to work with residents to support them. Care plans provided evidence that residents’ mental health was being monitored, with action taken such as contacting a GP where concerns were highlighted. It was however noted in diary notes that on occasions staff would raise a concern regarding a resident’s physical health and there appeared to be no follow up. The Registered Person must ensure that where diary notes highlight concerns that follow up has been taken and that this is recorded. Relatives spoken with said that they were aware that residents could get involved in exercise activities if they wanted to and that they were informed if their loved one fell or had needed to see a health care worker. There was no evidence that nutritional screening was taking place and residents’ weights have not been monitored for a year. The Registered Person must carry out appropriate monitoring to ensure residents remain at a healthy weight and that other health concerns or not overlooked as a result of lack of this monitoring. Medication is stored in a locked area with controlled drugs stored correctly and recorded appropriately with two signatures. The member of staff on duty who administered the medication was observed and correct procedures were followed. Care plans show where residents do not want to remain in control of their medication, identifying that they want staff to administer their medication in the future. Medication was appropriately recorded when it was returned to the pharmacy and when it entered the home creating a clear audit trail. It was noted on the Medication Administration Record sheet that a number of entries were hand written; where this needs to happen it is strongly recommended that the Registered Person ensure that they are signed and countersigned to ensure that they are entered correctly. Staff were observed with residents interacting in a positive manner, and staff spoken with said that they knew the residents they could have a laugh and a joke with and those they couldn’t. Residents confirmed that staff treated them with respect and dignity. Residents confirmed that they wore their own clothes and staff knocked on their door prior to entering their bedroom. Lilac House Care Home DS0000008708.V301982.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents find the lifestyle matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. Residents are able to maintain contact with their family and friends. Although residents are able to exercise control over their lives limited recording does not always provide clear evidence that this is taking place. Residents receive appetising meals in pleasant surroundings but need more information regarding choices available to them. EVIDENCE: Residents spoken with said that they were able to spend the day how they wanted to and were able to get up and go to bed when they wanted to. Staff were seen interacting with residents and ensuring that they had drinks through out the day. There is no information available on what activities take place, however from the diary notes it was evident that residents were involved in various things such as sing a longs, quizzes, reminiscence and going out for walks supported by staff. Residents spoken with said that they were able to see visitors when they wanted to and visitors spoken with said that they were able to visit whenever Lilac House Care Home DS0000008708.V301982.R01.S.doc Version 5.2 Page 12 they wanted. A relative spoken with said that the family had been given information about the home and felt informed about what was going on. Care plans detailed who dealt with residents finances if the resident was no longer able and residents were supported to maintain control for as long as possible. The manager reported getting advocates involved with residents to support in making decisions, however this was not always recorded. It is strongly recommended that all activities that involve residents well being are recorded to evidence where good practice is taking place and show that every effort is made to ensure residents are represented to maintain their independence and rights. Although there is a board up to display the menu it was not displayed on the day of the inspection. There is a four week rotating menu and the cook reported that when it has been very hot this has been varied to include more seasonally appropriate food such as salads. Residents spoken with confirmed this. There was evidence that fresh fruit and vegetables were available for residents and the cook advised that fresh vegetables are obtained on a daily basis to maintain their freshness. Evidence was seen of fresh vegetables being cooked for lunch and arrangements being made for more to be bought for the following day. Records were maintained of the temperature of the fridge and freezer as well as temperature of cooked food to be served to residents to ensure good food hygiene was observed. The cook was aware of the needs of those residents who had special dietary requirements such as diabetes and appropriate meals were provided. Residents were able to choose where they ate and staff were observed moving between the two dining areas and the lounge to provide any support that was needed. Residents spoken with said that they thought the food was ‘good’ or ‘ very nice’. However none of the residents spoken with were aware that they could have a choice if they did not like the meal served. In discussion with the manager and from evidence in diary notes it was evident that alternatives were provided. It is recommended that information be placed on the notice board regarding what choices are available at meal times. Visitors spoken with said that on their observation the meals appeared very appetising and that there was plenty of it. Lilac House Care Home DS0000008708.V301982.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The quality in this outcome area is good. Residents feel confident to complain and that it will be dealt with, residents are also protected from abuse. EVIDENCE: Staff spoken with were aware of the need to ensure residents could raise concerns and residents and visitors spoken with were aware of the complaints procedure, one visitor confirmed that information had been given to the family regarding how to complain on their relatives admission to the home. Residents said ‘I would speak to ……… if I had a problem’. When asked if they felt confident it would be sorted out all said that when they have raised any little problem it has been dealt with quickly. Although not recorded the inspector is aware from discussion with residents and staff that the registered provider visits the home weekly and talks to residents about any concerns they have. It is recommended that this practice be recorded to ensure that it can be used for future good practice evidence. Where there are issues of concern the manager records them and shows what has been done to resolve them. Staff spoken with understood the importance of ensuring residents are protected from abuse and know what to do if they suspected anything. Evidence was seen that the manager is due to attend Adult Protection training in November 2006. Residents spoken with said that they felt safe and that staff were ‘kind and helpful’. Visitors spoken with said that they felt confident that their loved ones were being well care for and were safe in the care of the staff. Lilac House Care Home DS0000008708.V301982.R01.S.doc Version 5.2 Page 14 The inspector has evidence from contact with the manager over the past year that he takes the protection of residents from financial abuse very seriously and care records show that the manager and staff work closely with solicitors and social workers in the maintaining of residents financial safety. Lilac House Care Home DS0000008708.V301982.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a safe well maintained environment internally, externally some improvement could be made. The home is clean, pleasant and hygienic. EVIDENCE: There was evidence of ongoing maintenance to the home, again the manager reported that the registered provider visits weekly to tour the building to look at maintenance issues, however this is not recorded anywhere. This issue will be dealt with under standard 33 relating to Quality Assurance. The home’s layout is suitable for the needs of the residents enabling residents to be as independent as possible; there is a passenger lift to the first floor. The exterior of the building is beginning to look tired and in need of attention and a number of the window frames appeared to be rotten and although not yet creating a risk to the residents they will need attention promptly to prevent further deterioration. Lilac House Care Home DS0000008708.V301982.R01.S.doc Version 5.2 Page 16 There is a small rear garden, which is in need of some attention it is overgrown and although is accessible to some residents is of limited use to those residents who may have a tendency to wander as it is not secure. The Registered Person must ensure that the external grounds are suitable for, and safe for use by, residents. The home was clean and free from odour, during the course of the inspection a cleaner was seen cleaning residents’ bedrooms and communal areas. The laundry area is small but is able to handle residents laundry needs. The floor is impermeable ensuring it is readily cleanable. The window ledge in the laundry is tiled however these are loose and appropriate measures need to be taken to ensure that they are fixed to the window ledge. The laundry is sited so that soiled articles are not carried through areas where food is prepared, stored, cooked or eaten. There are hand washing facilities in the laundry room itself but are located in such a way as not to be easily accessible to staff, the Registered Person should consider the location of this sink to ensure that good infection control is maintained. There are clear policies and procedures in the home for infection control and staff were aware of maintaining good hygiene to ensure residents well being. Lilac House Care Home DS0000008708.V301982.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are met by the numbers and skills mix of staff they are in safe hands and their safety is supported by the home’s recruitment policies and practices, however the manager must regularly update himself on practices. Staff are trained and competent to do their job. EVIDENCE: Residents spoken with said that staff were available to assist them when they needed help and observation during the morning showed that extra staff were available during the busy period to ensure residents needs are met appropriately. The manager is aware of the changing needs of residents and is vigilant in letting social services know if residents need to be reassessed with the view of moving residents on to have nursing needs met, this was evidenced through diary notes. Staff spoken with were also aware of the importance of ensuring that residents needs could be met safely with staffing levels. Sufficient domestic staff are employed to ensure that the standards relating to food and hygiene can be met. Visitors spoken with confirmed that there always appeared to be enough staff on duty and that their loved ones were always clean and tidy. Staff are able to access training and staff spoken with said that the manager supported them to access training. Lilac House Care Home DS0000008708.V301982.R01.S.doc Version 5.2 Page 18 The manager reported that 7 out of 12 staff had NVQ level 2 ensuring residents were supported by competent staff. This was not immediately evident from staff files. (See recommendation below for training records). Three staff files were looked at during the inspection and had application forms and information relating to the interview that documented equal opportunity issues, there was evidence that two references were obtained prior to staff starting work and that Criminal Records Bureau certificates were also obtained. However in discussion with manager it appeared that PoVA First clearance was not being asked for at the same time Criminal Records Bureau checks were being done. It is strongly recommended that these are carried out as this information is returned to the employer quicker that the Criminal Records Bureau check and so enables the manager to start the member of staff at work with supervision whilst waiting the full check to come through. It is also recommended that the manager read the new guidance on storage of Criminal Records Bureau checks to ensure that appropriate records are maintained. Evidence was seen on staff files that staff received induction training when starting work and staff confirmed that they had induction training that covered different aspects of care in the home ensuring residents received appropriate care. However although there were some certificates kept on staff files regarding what training staff had completed it was not always clear what training had been done if certificates had not yet been received. It is recommended that the manager create a training record that provides clear information of all training carried out by staff with dates of any needing to be renewed. Lilac House Care Home DS0000008708.V301982.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, and 38 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ benefit from the home being run by a manager who is fit to be in charge and of good character. Although the home is run in the best interests of the residents there is not always evidence provided to show this. Residents are financial interests are safeguarded. Staff are supervised as part of their normal working day but do not receive formal supervision. Although residents and staff health safety and welfare is taken seriously improved information on moving and handling for staff must be provided. EVIDENCE: The manager undergoes regular training to ensure he maintains his knowledge, skills and competence whilst managing the home. He is currently undergoing his NVQ level 4 Registered Manager’s Award. The manager has clear lines of accountability within the home and ensures residents benefit from a well run home. Lilac House Care Home DS0000008708.V301982.R01.S.doc Version 5.2 Page 20 Although the Registered Person usually ensures that requirements relating to residents safety are carried out promptly and visits the home regularly to ensure the home is maintained there is no formal quality assurance system that records these visits and provides evidence of what action is taking place. It is strongly recommended that a formal recording system be created to ensure that evidence can be provided to show how quality is being maintained within this service. Currently the Commission is not receiving monthly Regulation 26 visits from the provider and it is recommended that a the provider and manager use the weekly visits to evidence that the provider’s responsibilities under Regulation 26 are being met. Evidence was seen that records are kept of residents’ financial transactions and that two signatures are always required for each transaction, care plans detail who is appointee if required and the manager currently does not act in this capacity for any resident, ensuring residents financial interests are safeguarded. Staff spoken with said that the senior and the manager provides ‘on the job supervision’ but that formal supervision is not given. The manager confirmed that staff currently do not receive formal supervision at least 6 times a year the manager must ensure that staff receive formal supervision to ensure that areas such as career development and training needs are covered. Two requirements were made at the last inspection. The first was regarding window restrainers in residents’ bedrooms, during the tour of the building window restrainers were noted on several windows. This requirement is now met. The second requirement was regarding risk assessing safe working practices within the home. The manager has created a list of possible hazards within each working area of the home and sufficient work has been carried out to show that this requirement is met. However a recommendation has been made regarding good practice in this area asking that clear guidance is given on how risk is to be minimised. Staff spoken with said that they felt health and safety was taken seriously, residents confirmed that they felt safety was seen as important within the home. Records were seen to evidence that the manager maintains the health and safety of staff and residents, ensuring that electrical equipment is maintained, that radiators are covered in residents bedroom ensuring they are not at risk of burns. Accidents are recorded and showed that the manager audits them after each incident and provides information on what remedial action needs to be taken (if any) to minimise the risk of it happening again. This is seen as good practice. It was however noted in a number of diary entries that staff referred to ‘lifting’ a resident with mobility issues. The manager must ensure that correct moving and handling techniques are used to minimise risk of injury to residents and staff and if necessary ensure this resident can have their needs met within the home. Lilac House Care Home DS0000008708.V301982.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 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 Lilac House Care Home DS0000008708.V301982.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. 1 Standard OP7 Regulation 15(2)(c) Requirement Timescale for action 01/10/06 2 OP8 13(1)(b) 3 OP19 23(2)(o) 4 OP38 13(5) The Registered Person must ensure where appropriate and, unless it is impracticable to carry out such consultation, after consultation with the service user or a representative of his, revise the service users plan; and notify the service user of any such revision. The Registered Person shall 01/09/06 make arrangements for service users to receive where necessary, treatment, advice and other services from any healthcare professional. Where diary notes highlight concerns over service users health follow up action must be taken and documented. 01/10/06 The Registered Person shall having regard to the number and needs of the service users ensure that external grounds which are suitable for, and safe for use by, service users are provided and appropriately maintained; The Registered Person shall 01/09/06 make suitable arrangements to provide a safe system for moving and handling service users. DS0000008708.V301982.R01.S.doc Version 5.2 Lilac House Care Home Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Refer to Standard OP2 OP9 OP12 OP14 OP15 OP26 OP26 OP29 OP29 OP30 OP33 OP33 OP36 OP38 Good Practice Recommendations Either the resident or their representative signs contracts. Where Medication Administration Records are hand written they should be signed and countersigned. Provide information regarding activities that are available in the home in a format suited to the needs of the residents. Record where independent advice or advocate services have been used to maintain residents rights. Provide information to residents regarding choices available as an alternative to the meal provided. Assess whether the location of the hand wash basin in the laundry is appropriate to ensure that procedures on infection control can be adequately maintained. Arrange for loose to window ledge tiles to be mended. That PoVA First checks are carried out on all new staff. That the manager read and follows new Criminal Records Bureau guidance on the storage of CRB checks. The manager create a training record to show what training staff have attended with dates and qualifications. Create a system that records how quality is maintained in the home. Use the providers weekly visits to meet Regulation 26 obligations Staff receive supervision at least six times a year and it covers all aspects of practice, philosophy of the home and career development. Where risks are identified assessments for safe working practices should take place, identifying risk with action detailing ways to minimise risk. Lilac House Care Home DS0000008708.V301982.R01.S.doc Version 5.2 Page 24 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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