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Inspection on 12/05/05 for Lilac Lodge And Lavender Cottage

Also see our care home review for Lilac Lodge And Lavender Cottage for more information

This inspection was carried out on 12th May 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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 service obtained pre-admission assessments on all service users tracked during this inspection. This standard has been inspected on three occasions over two years, and has been found to be met on each occasion. The administration of medication was found to be in very good order. A good standard of individual accommodation is provided.

What has improved since the last inspection?

The home had met all of the eight requirements and one recommendation made at the previous inspection. A number of the requirements that were met from the last inspection were in respect of repairs to the communal areas of the home.

What the care home could do better:

Care plans need to be developed, to have clear goals and to have all aspects dated, and any risk assessments relating to restraints must be signed. The other requirements made relate to a wide number of standards, where the general provision was quite good, but specific shortfalls were found. For example, supervision was found to fall very short of the standard, for one worker only. Staffing was generally at a good level, but lunch-time arrangements on Lilac lodge were not adequately supported. This supports a view that the home needs to develop consistent and comprehensive monitoring of systems and processes. The Manager had been registered fairly recently, and taking on responsibilities for the new build at the same time as developing their role may account for this.

CARE HOMES FOR OLDER PEOPLE Lilac Lodge & Lavender Cottage 11 & 14 Gorleston Road Lowestoft Suffolk NR32 3AA Lead Inspector Mary Jeffries Announced 12 May 2005 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 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 Lodge & Lavender Cottage I54-I04 S24434 Lilac Lodge V218615 050512 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Lilac Lodge & Lavender Cottage Address 11 & 14 Gorleston Road Lowestoft Suffolk NR32 3AA 01502 581920 01502 581920 Lilac.lodge@btconnect.com Country Retirement & Nursing Homes Ltd Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Cheryl Abel-Madgwick Care Home 27 Category(ies) of Dementia, Dementia-over 65 years of age, Old registration, with number age, not falling within any other category of places Lilac Lodge & Lavender Cottage I54-I04 S24434 Lilac Lodge V218615 050512 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1.Lilac Lodge may accommodate persons of either sex, aged over 65 years, who require care by reason of old age (not to exceed 21 persons). 2. Lavender Cottage may accommodate persons of either sex, aged over 65 years, who require care by reason of a diagnosis of dementia (not to exceed 5) 3.Lavender Cottage may care for one named service user, as named in the application of variation dated 17th December 2004, who requires care by reason of a diagnosis of dementia and who is under the age of 65 years. 4. The total number of service users at Lilac Lodge and Lavender Cottage must not exceed 27. Date of last inspection 11/11/04 Brief Description of the Service: Accommodation at Lilac Lodge comprises of a detached property that has been considerably enlarged and adapted to provide bedroom accommodation for service users both on the ground and first floors. Upper floors of the building are accessed by a stairway and shaft lift. Lilac Lodge is able to accommodate twenty-one older people. A single storey building on the opposite side of the road, called Lavender Cottage is a residential unit for older people with dementia care needs. Lavender Cottage is able to accommodate four service users. An additional day care service for four older people with special needs is also available on this site. Both properties are situated on a busy main road in Oulton Broad, however the buildings are set well back from the roadway and the front door to Lavender Cottage remains locked, although access to outside areas can be gained via the back door. Lavender Cottage has a large enclosed rear garden with secure boundaries. Shops and local facilities are a short distance away. Lilac Lodge & Lavender Cottage I54-I04 S24434 Lilac Lodge V218615 050512 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place on one day in June 2005. The home’s registered manager took part in the inspection. An interim site visit was conducted on the same day as the inspection, in respect of a long-standing application for an extension at Lilac Lodge, to accommodate an additional 4 frail elderly service users. All places were occupied on the day of the inspection. None of the service users were in hospital. Ten visitors who responded to pre inspection surveys indicated that they were satisfied with the overall care provided. Two were not. A friend visiting a service user on the dementia unit was spoken with on the day of the inspection. What the service does well: What has improved since the last inspection? The home had met all of the eight requirements and one recommendation made at the previous inspection. A number of the requirements that were met from the last inspection were in respect of repairs to the communal areas of the home. Lilac Lodge & Lavender Cottage I54-I04 S24434 Lilac Lodge V218615 050512 Stage 4.doc Version 1.30 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 Lodge & Lavender Cottage I54-I04 S24434 Lilac Lodge V218615 050512 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Lilac Lodge & Lavender Cottage I54-I04 S24434 Lilac Lodge V218615 050512 Stage 4.doc Version 1.30 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 standard(s) 1,2,3, Service Users can expect to have their needs assessed and to have the opportunity to visit the home prior to admission. EVIDENCE: The Statement of Purpose and service user’s guide were the same document, entitled ‘Information Pack’. The document had been updated since the last inspection, was well presented and informative and contained all information required, as well as the specific room sizes within the home. The Service Users Guide should include service users views. Service users had been provided with a copy of the updated Statement of Purpose. The home states that it offers trial visits to prospective residents in it’s Statement of Purpose. Three service users were asked whether they did so. One said that they had visited for a day before deciding to apply, another said they had previously attended the day centre for lunch and tea and the third said that their relative had, as they had moved from some distance. Lilac Lodge & Lavender Cottage I54-I04 S24434 Lilac Lodge V218615 050512 Stage 4.doc Version 1.30 Page 9 A single assessment was on the file of a service use admitted this year, and it had been undertaken prior to admission. Another four service users files had assessments completed by the home. Lilac Lodge & Lavender Cottage I54-I04 S24434 Lilac Lodge V218615 050512 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 Service users can expect that their medication will be safely administered by well trained staff. Service users care plans need further development and attention paid to signing and dating documents that form part of them. EVIDENCE: Four service users care plans all were in place, but a number of parts of the documentation on several of the files inspected were not dated. They had a space to enter date of first review which was not routinely either so it was not possible to check when these had been done. Care plans did not have clear goals stated for all the service users identified needs. One relative noted on their pre inspection questionnaire that “ a more accessible and informative care plan would be useful”. One service user who had bedsides in place, also had a risk assessment for these on their file, but this had not been signed by a GP or a relative. Lilac Lodge & Lavender Cottage I54-I04 S24434 Lilac Lodge V218615 050512 Stage 4.doc Version 1.30 Page 11 All six files inspected had been reviewed on a regular monthly basis, and indicated how the service user’s needs had changed over time. Existing risk assessments had been updated and new risk assessments had been undertaken in view of these changes. Staff members had made regular and informative entries in the care notes describing the moods, actions and general well-being of the service user. The home’s policy on the custody and administration of medicines dated February 2005 was provided. A copy of a pharmacist’s inspection report undertaken on 31/03/05 was provided. All aspects of the checklist had been checked on both of the homes buildings, and no requirements were identified. A care manager advised that administration of medication is only done by care managers. She advised that she has received Boots training, and also that she had recently finished a 12 week course on medication provided by Lowestoft College, which most of the care managers had also undertaken. This was confirmed by information provided on the pre- inspection questionnaire. The medication system had recently changed to the NOMAD dosset box system, as the pharmacy providing the medication had changed to this system. Medication records of the six service users on lavender cottage were checked and found to have no errors. The home’s manager advised that service users were not regularly reviewed by their G.P.’s unless a need to do so was identified. One service user confirmed that “ if I want something they get him (the G.P) to call in, no problem at all.” All thirteen service users who returned the pre inspection survey indicated that they liked living at the home and felt well cared for. All replied positively to an enquiry as to whether they felt well cared for, and also as to whether their privacy was respected. Eleven of twelve visitors responding indicated that they could see their relative or friend in private. A Service users spoken with said that any mail that they received was brought to them unopened. Lilac Lodge & Lavender Cottage I54-I04 S24434 Lilac Lodge V218615 050512 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 Service users can expect to enjoy most of the meals provided by the home, but may have to wait until others have finished if they require assistance. The home’s social and activities programme, could be developed to better meet service users social and emotional needs. Relatives can expect to feel welcomed by the home. EVIDENCE: Twelve relatives or friends responded to the pre inspection survey. Eleven replied to positively to an enquiry as to whether staff and owners welcomed them into the home at any time, one said they only visited on a regular basis but they were aware some relatives visited at meal times. One commented “we visit…weekly and are always welcomed at Lilac Lodge” A visitor spoken with at the inspection said that they were always given a cup of tea without having to be asked. One of the twelve visitor’s comments cards received, drew attention to the quality of the food at times. Thirteen service users responded that they liked the food, two commented that they only sometimes liked it. Menus were provided, which indicated that a choice of nourishing meals were available, and records were maintained of the meals taken by each service user. Lilac Lodge & Lavender Cottage I54-I04 S24434 Lilac Lodge V218615 050512 Stage 4.doc Version 1.30 Page 13 Day care service users were present at lunch time on Lavender Cottage. Staff said that the maximum number attending for day care was 4, and that there were 2 on Saturday and Sunday. Lunch menus were available on the tables in Lavender cottage on the day of the inspection. Two service users said that they knew what was on the menu, and that staff tell them what the main meal. A second choice of cooked main meal was available on the day. Three service users and a relative of one who attended for day care were spoken with at lunch time. One said that the food was “ generally good”. Another said that “it’s pretty good usually”. Another service user described the food as very good. Two service users were encouraged to eat, another two were seen being assisted with eating, and the carers doing this had a good manner. Another service user, however, who needed assistance with eating had to wait 15 minutes before she could be assisted. The carers advised that they could heat the food up with a microwave. This service users care plan review had noted that they “do not always want to feed them self”. A service user advised that a hot drink was provided at 11 am, at 3 pm And at 8 pm. They advised that breakfast time was flexible, but that breakfast “ wasn’t all that special”. Another service user said they usually came down at twenty to nine. They said they were not offered tea in their bedroom. Service users confirmed that they could go to bed when they liked. Seven of the 13 service users replying to the pre inspection survey indicated that the home provided suitable activities, six said that the home sometimes did: two of these noted that they would like more. The manager advised that activities routinely provided, and open to all service users were a weekly exercise session, pastimes such as quizzes twice a week, aromatherapy once a month (at no extra cost) and occasional events. A service user spoken with commented “ I find they are very able to do everything necessary to keep to a certain standard, ….by such standards they are helping a way of life that is important. ….The people (carers) are very pleasant, very concerned to keep you well and healthy… …They regard it as a way of life that you do such things as make people feel worth living even if we are rather old and not as active as we used to be.” Another service user said that they had “never been in a place before where you spend so much time sitting down chatting to your next neighbour.” But that they had “ tried to make it more interesting but couldn’t see how.” They said that ideally they would like the opportunity for more self expression, rather than more activities. Lilac Lodge & Lavender Cottage I54-I04 S24434 Lilac Lodge V218615 050512 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 The home has an open atmosphere where service users feel able to bring up concerns and get a response. Employment practices did not fully protect service users. EVIDENCE: All thirteen of the service users responding to the pre inspection questionnaire stated that they felt safe living in the home, eleven indicated that if they were unhappy with their care they would know who to speak to, two did not know. Seven visitors confirmed in the survey that they were aware of the home’s complaints procedure: five indicated they were not. The home’s pre inspection documentation stated that they had 12 complaints in the previous 12 months, and all had been responded to within 28 days and all had been substantiated. None of these involved adult protection investigations. A complaints log showing clearly date received and responded to and outcome was not maintained by the home, so it was not possible to review these in more detail in the time available. One service user spoken with said “ if I have any issues, I go and see the manager. She is quite happy that I will go to her, she says, “ I’d be the same Lilac Lodge & Lavender Cottage I54-I04 S24434 Lilac Lodge V218615 050512 Stage 4.doc Version 1.30 Page 15 as you.” A visitor spoken with also said that they felt that they could make a complaint, and that matters seemed to be dealt with as they come up, and gave the example of the wrong clothes very occasionally being given to the service user, which is immediately dealt with when they have pointed it out. Another service user advised, “ I complain if I want to, I do it nicely so no one is upset, and I just ask if anything can be done. … It usually can be.” One service user said “ you can speak your mind, and know you are not going to be jumped on, unless you are a deliberate trouble maker.” The homes Protection of Vulnerable Adults Policy was dated July 2004. It did not incorporate changes to the local PoVA agreement, for example it referred to the CSCI as the lead agency to be informed, rather than Social Care Services. Details of employment practices which did not fully protect service users are detailed under standard 27. Lilac Lodge & Lavender Cottage I54-I04 S24434 Lilac Lodge V218615 050512 Stage 4.doc Version 1.30 Page 16 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 standard(s) 19,21,22,23, 24 ,25, 26 The home was generally in a very good state of repair and cleanliness, but there were one or two exceptions. EVIDENCE: The home provided a maintenance programme that had works completed in the month prior to the inspection, and included carpet cleaning, redecoration and replacement of some furniture. A number of repairs and renewals required at the previous inspection had been made good. The carpet in Lavender Cottage in bedroom 3 which extended out into the hallway had been replaced. The door to bedroom 14 of Lilac Lodge which was seen at the previous inspection to have come slightly away from its hinges had been repaired, and could be closed properly. The lock had been repaired in the communal assisted lavatory in Lilac Lodge. Radiator guards had been fitted to all radiators within the home, including one initially overlooked when these were installed. Lilac Lodge & Lavender Cottage I54-I04 S24434 Lilac Lodge V218615 050512 Stage 4.doc Version 1.30 Page 17 A fully operational call bell system was in place in all service users’ bedrooms, bathrooms and toilets. Call bell ropes reached the floor so they would be accessible to a service user who had fallen. The upstairs bathroom door in Lilac Lodge was damaged and required repair. A fire exit, down a flight of stairs had a stair gate at the top of the flight, next to room 16. It was not bolted and did not appear sturdy. The home had 19 single bedrooms and four double bedrooms. The four doubles are all within Lilac lodge. Service users’ bedrooms were nicely personalised and this was clearly encouraged by the home. They were attractively decorated, and had all appropriate furnishings. Locks were fitted to all service users’ bedroom doors and these were able to be overridden in the case of emergency. Lockable storage facilities were provided in all bedrooms. Stained wooden furniture in service user’s bedroom had been covered with runners. A visitor to the dementia unit, lavender cottage, said that the home was always clean and tidy, including the service user’s room and bathroom. Staff were seen to wear plastic aprons and gloves at appropriate times. Two flannels were seen in shared bathrooms in Lilac Lodge. A lingering odour of urine was noticed in one of the double rooms, despite the windows in that room being open. All single rooms available in Lilac Lodge had en suite facilities. The four shared bedrooms did not have this facility but were equipped with wash-hand basins. At the time of inspection Lilac Lodge had three communal bathrooms, one situated on the first floor and two on the ground floor. One of the bathrooms had assisted baths. There were previously has 2 assisted bathrooms in Lilac Lodge. Lavender Cottage did not have any bathing facilities but had one assisted shower room. Three single bedrooms had en suite facilities, including assisted showers. The kitchen was clean and modern. A food storage area was rather warm, with a temperature of 25 degrees Celsius. A nutritional supplement stored in this area read, store in a cool dry place. Staff training certificates were displayed on a corridor wall in the home. Lilac Lodge & Lavender Cottage I54-I04 S24434 Lilac Lodge V218615 050512 Stage 4.doc Version 1.30 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 The number of staff hours provided is good, but staffing at lunch time in Lavender cottage did not meet the assessed needs of the service users. Employment practices did not safeguard service users. EVIDENCE: Lavender Cottage routinely has 2 carers between 8 am and 10 pm, and 1 waking night carer. Scrutiny of staffing rosters confirmed that the usual morning staffing levels at Lilac Lodge were five care staff for the busiest period of 8am to 10.30am, then four care staff until after lunch, three in the afternoon and two during the night. These care staff included the shift leader who was termed as ‘care manager’. Ancillary staff were employed in addition and the acting manager was supernumerary to the care roster. Ten visitors out of twelve indicated on their pre-inspection surveys that they thought there were always enough staff on duty. Another stated that there were enough staff most of the time. At lunch time on Lavender cottage, two staff were on duty to asst service users and say care users. 2 Service users needed encouragement to eat, and four needed assistance. One service user waiting 15 minutes to be assisted to eat their meal. The home’s Pre- inspection questionnaire stated that 805 hours of care were provided, which is in excess of the hours indicated to be required by the Lilac Lodge & Lavender Cottage I54-I04 S24434 Lilac Lodge V218615 050512 Stage 4.doc Version 1.30 Page 19 staffing guidance tool, however that calculation does not include those attending for day care, which is up to 4 a day. Two workers who had come to the UK to work, and, the manager advised, had immediately commenced work at Lilac Lodge, had a CRB checks, but the copies of their police check from their country of origin was not available on file to check. One worker had no references on file. Lilac Lodge & Lavender Cottage I54-I04 S24434 Lilac Lodge V218615 050512 Stage 4.doc Version 1.30 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 35, 37, 38 The homes manager, having been recently registered has been involved with development work at the home, and needs to focus now on getting areas of routine ongoing practice fully managed and supported. EVIDENCE: Regulation 26 visits had been regularly conducted and reports forwarded to the CSCI. The manager advised that she did not know when her manager was going to attend to conduct these visits. The home’s manager had been registered shortly before the inspection and met the criteria for registration. The homes Certificate of Registration was correctly displayed. The home received an Investors in People award in December 2004 which is therefore still valid. Lilac Lodge & Lavender Cottage I54-I04 S24434 Lilac Lodge V218615 050512 Stage 4.doc Version 1.30 Page 21 Two of four the pre-admission questionnaires inspected, and one of four care plans inspected were not dated. The manager advised that most of the staff formal supervision was up to date and meeting the schedule of every 8 weeks. One senior care spoken with stated that they had not had supervision for approximately a year, and that the manager had been trying to get this back onto line. This was confirmed by the manager. A carer spoken with advised that they had received supervision with the manager about two weeks ago. Two supervision files inspected were on line to meet the national minimum standard. The senior carer advised that a staff meeting had been held recently, the previous meeting having been approximately six months ago. The manager stated that the home does not keep any monies for service users. Service users have a locked drawer, and families or solicitor provide any assistance required. This confirmed information given on the pre inspection questionnaire. They also advised that the home does not keep any valuables on behalf of service users who are provided with a lock up drawer. Fire alarm tests were recorded as having been carried out at regular intervals. A fire drill was recorded as having been held in April 2005. Emergency lights were recorded as having been checked on a weekly basis. The home did not have a fire risk assessment. Lilac Lodge & Lavender Cottage I54-I04 S24434 Lilac Lodge V218615 050512 Stage 4.doc Version 1.30 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 x x x 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 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 x 2 2 3 3 2 2 STAFFING Standard No Score 27 2 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 3 x x x 3 x 2 2 Lilac Lodge & Lavender Cottage I54-I04 S24434 Lilac Lodge V218615 050512 Stage 4.doc Version 1.30 Page 23 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard 7 7 Regulation 15(1) 13(6)(7) Requirement Service users plans should have clear goals, and actions required to meet them set out Where a need for any form of restraint has been identified, for e.g. bedsides, these assessments should be signed by relatives or professionals involved. The home should seek annual medical reviews for everyone over 75 years old, or six-monthly reviews for those taking at least four regular medicines. Service Users care plans should be dated. The PoVA policy must be reviewed. An upstairs bathroom door in Lilac Lodge that is badly dameged must be repaired. A bathroom in Lilac Lodge that was previously assisted must be reinstated. Service users flannels must not remain in communal bathrooms. A lingering odour of urine in one of the double rooms in lilac lodge must be investigated and Timescale for action 30/09/05 Immediate and ongoing 3. 8 13(1(b) 30/09/05 4. 5. 6. 7. 8. 9. 17,37 18 19 21,22 26 26 171)(a0 13(6) 23(2)(b 23(2) (j)(n) 13(3) 13(3) Immediate and ongoing 30/09/05 30/09/05 30/09/05 Immediate and ongoing Immediate and ongoing Page 24 Lilac Lodge & Lavender Cottage I54-I04 S24434 Lilac Lodge V218615 050512 Stage 4.doc Version 1.30 removed. 10. 11. 12. 13. 14. 27,18 27, 15 38, 25 38,25 19 (1) schedule 2 1891) 13(4) 13(4) All staff files must have all information required under regulation 19 schedule 2 on file. Staffing levels for lunch times must be reveiwed. A fire risk assessment must be undertaken and a copy forwarded to the CSCI. The stair gate at the top of a flight leading to a fire exit must be risk assessed. Immediate and ongoing 31/08/05 Immediate 30/09/05 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. 2. Refer to Standard 1 12 Good Practice Recommendations The Service User Guide should include Service Users views The home should give thought to ways of developing service users opportunities for self expression and consult service users in the next questionnaire with a view to developing its ability to meet service users social and emotional needs. Service users should be offered a cup of tea in their bedrooms in the morning. A complaints log must be maintained, that contains all complaints recieved and outcomes of respeonses. Prior to commencement of employment , criminal Records checks should be sought from the country of origin for staff coming to the UK to work. The home should seek advice and review the suitablity of the ambient temperature in the food storage area. Service users should be consulted as to whether they consider the display of staffs training certificates on a corridor wall in the home detract from the homeliness of the environment. 3. 4. 5. 6. 7. 15 16 18, 29 25 19 8. 9. Lilac Lodge & Lavender Cottage I54-I04 S24434 Lilac Lodge V218615 050512 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection St Vincents House Cutlet Street Ipswich IP1 1UQ 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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