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

This inspection was carried out on 5th December 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.

Other inspections for this house

Lilac Lodge And Lavender Cottage 06/08/07

Lilac Lodge And Lavender Cottage 07/08/06

Lilac Lodge And Lavender Cottage 12/05/05

Lilac Lodge And Lavender Cottage 11/11/04

Lilac Lodge And Lavender Cottage 23/06/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Lilac Lodge And Lavender Cottage 11 And 44 Gorleston Road Lowestoft Suffolk NR32 3AA Lead Inspector Alan Clare Unannounced Inspection 5th December 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 Lodge And Lavender Cottage DS0000024434.V271345.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 Lodge And Lavender Cottage DS0000024434.V271345.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Lilac Lodge And Lavender Cottage Address 11 And 44 Gorleston Road Lowestoft Suffolk NR32 3AA 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) 01502 581920 01502 581920 Country Retirement and Nursing Homes Limited Cheryl Abel Care Home 32 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (5), Old age, not falling within any other of places category (26) Lilac Lodge And Lavender Cottage DS0000024434.V271345.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 Lilac Lodge may accommodate persons of either sex, aged over 65 years, who require care by reason of old age (not to exceed 26 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 persons). 3 Lavender Cottage may care for one named service user, as named in the application for 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 32. 12th May 2005 2. 3. 4. Date of last inspection Brief Description of the Service: Accommodation at Lilac Lodge is comprised of a detached property that has been considerably enlarged and adapted to provide bedroom accommodation for service users on both 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. Lavender Cottage is a single storey building situated on the opposite side of the road and provides four residential places and fourday care places to older people who have dementia. Both properties are situated on a busy main road in Oulton Broad, however the buildings are set well back off the road and the front door to Lavender Cottage remains locked, access to the large enclosed garden is gained via the back door. Lilac Lodge has a large enclosed rear garden with car parking. Shops and local facilities are a short distance away. Lilac Lodge And Lavender Cottage DS0000024434.V271345.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 on Monday 5 December 2005 starting at 12.20pm, just as arrangements were beginning for lunch. The registered manager and Operations Director assisted the inspector throughout the inspection. The inspector’s time was spent talking with 5 residents, 3 staff and 3 visitors to the home. One other resident and relative was spoken with separately. A tour of the premises was made and a number of records were examined including those relating to resident’s care, staff, food orders and invoices and a selection of policies and procedures. Prior to the unannounced inspection The Commission For Social Care Inspection (CSCI) had received an anonymous complaint of which the relevant matters raised were included in the inspection and are addressed in this report. This was explained to the registered manager at the beginning of the visit. What the service does well: Both homes offer a good standard of individual accommodation which residents have been encouraged to personalise with their own items. Since the last inspection, staffing levels at lunchtime have been increased and the home is now able to offer attentive individual assistance to residents with meals. The home offers a high standard in well pre-pared ‘home cooked’ food. Throughout the communal areas of the home there was a pleasant fragrance. Residents commented on having had “ a marvellous Christmas party” the day before the visit adding that “ the staff did us proud”. One resident remarked that she might not be able to eat her lunch having “ had so much to eat at the party”. Lilac Lodge And Lavender Cottage DS0000024434.V271345.R01.S.doc Version 5.0 Page 6 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 Lodge And Lavender Cottage DS0000024434.V271345.R01.S.doc Version 5.0 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 Lodge And Lavender Cottage DS0000024434.V271345.R01.S.doc Version 5.0 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): 1,5 Perspective residents and their relatives can expect that they will be offered an opportunity to visit the home and be provided with the information they need to make an informed choice about whether to live at the home. EVIDENCE: During the visit the inspector took time to speak with two relatives and one companion of a prospective resident. Both persons informed the inspector that on making contact with the home they were invited to visit “ at a convenient time for residents” and that during the visit they had found staff of the home to be “ very friendly and helpful and able to answer questions”. The inspector noted that the visitors had been given a copy of the home’s information pack and that previous inspection reports were available on display for the visitors to view. Lilac Lodge And Lavender Cottage DS0000024434.V271345.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): 7,8,9,11, Residents can expect that their health and social care needs be set out in an individual care plan. However, the system in which the records of their care are maintained is complicated and uses a number of recording sheets, this would benefit from simplifying. Residents can expect that the home will meet their health care needs but may not always record the advice given by their medical practitioners. Residents can expect that a trained member of staff safely administers their medicines but they cannot be assured that the amount of medicine ‘in stock’ is not in excess of resident’s requirements. Resident’s can expect that at the time of death that staff will care for them with sensitivity and in a dignified way. EVIDENCE: Lilac Lodge And Lavender Cottage DS0000024434.V271345.R01.S.doc Version 5.0 Page 10 A sampling of six resident’s records of care by the inspector showed that the information is recorded across a large number of forms which sometimes leads to duplication or omission of information in appropriate sections. The inspector looked at twelve residents care plans in relation to a complaint that the home had recently experienced but not reported an outbreak of diarrhoea and vomiting. Two records confirmed that at the time that the complaint referred to, two residents experienced a lesser condition for which appropriate care and attention was given. However, whilst the home sought to assure the inspector that the resident’s GP’s had been consulted on their behalf, the home was not able to provide evidence of this for inspection. Both residents were seen by the inspector to be well during the visit. The inspector took time to examine the care records of a recently deceased resident. The records gave an account of the sensitive and respectful attention that the resident had received at the time of death. Administration of lunchtime of resident’s medicines was seen to be correct and met with the home’s medicine policy. Recording was inspected and found to be correct on a number of Medication administration record recording sheets. Inspection of the medicine storage cupboard revealed a large quantity of prescribed medicines some of which were for administration for periods exceeding four weeks. Lilac Lodge And Lavender Cottage DS0000024434.V271345.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): 12, 13, 14, 15. Residents can expect that they will be provided experiences in the home, which matched their life style, and preferences in maintaining contact with relatives and friends. On occasions seating arrangements in the spacious lounge may not be organised in the most informal and social manner. Residents can expect to be served a nutritious and well cooked meal with which they can expect individual assistance to eat if they require it. However, the congestion created by the combined number of care and catering staff present at mealtime detracts from attempts to create a calm and personable ambience. EVIDENCE: Relatives who were present on the day talked about “ an open and friendly” attitude on the part of staff. One talked of “often being offered tea and biscuits”. One resident remarked about liking “ being able to have visitors in my room “. “ It is much more convenient for them since I moved here”. During the visit a resident returned from visiting her previous neighbours. Throughout the visit, residents talked very enthusiastically about their Christmas Party, which had been held the previous day. A lot of references were made to the food and “entertainments”, and “ hard work of the staff”. Lilac Lodge And Lavender Cottage DS0000024434.V271345.R01.S.doc Version 5.0 Page 12 The seating in the large and spacious lounge had not yet been re-arranged back in to smaller more intimate grouped seating arrangements. Resident’s choose their lunch earlier in the day; one resident remarked, “ Our cook takes a lot of pride in what she does”. The inspector noted that the food arrived well prepared and looked and smelt appetising, residents were invited or assisted by staff in to the dinning room. Those that chose to remained in their sitting or bedroom and those that needed help to eat were seen to be assisted by staff in a dignified manner. The inspector noted that meal portions were seen to be adequate to resident’s requirements. This was contrary to an anonymous complaint received by CSCI, which referred to reductions in portions of resident’s food. The number of staff involved in the serving, assisting and clearing away at lunchtime did created congestion around thoroughfares and the noise of staff talking and calling detracted from the mealtime being as calm and social for residents as it could have been. The inspector noted that more attention to the presentation of resident’s food on the plate would have been a further way of enhancing the resident’s dinning experience. Lilac Lodge And Lavender Cottage DS0000024434.V271345.R01.S.doc Version 5.0 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 Resident’s, relatives and visitors can expect that their complaints or concerns will be listened and responded to. EVIDENCE: This standard was met at the last inspection and throughout this visit the inspector took particular account of the informal, friendly interaction between staff, residents and visitors, which was conducive to an open atmosphere. One resident and relative remarked on the “open and friendly attitude” of the registered manager who is “ very kind” and “is willing to hear what you have to say”. During the visit the inspector received full co operation from the registered manager and Operations Director in investigating matters raised in an anonymous complaint. The registered manager stated that the complaints log is now maintained and that since the last inspection no complaints have been received. Lilac Lodge And Lavender Cottage DS0000024434.V271345.R01.S.doc Version 5.0 Page 14 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): 19,23,26 Residents can expect that the home is generally maintained in a good state of repair and cleanliness, but with some exceptions. EVIDENCE: Other than in the shared rooms the home was odour free. In all shared rooms with domestic style carpeting and where commodes are in use there was a build up of an unpleasant odour. On the day of the visit, the home was not due to be cleaned until 3pm, (see Standard 27). A Kitchen cupboard and drawer in Lilac Cottage requires repair. Items for storage where located outside the passenger lift. Lilac Lodge And Lavender Cottage DS0000024434.V271345.R01.S.doc Version 5.0 Page 15 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): 27,29,30 Residents can expect that the home will provide sufficient care staff with skill to meet their needs. However, the residents cannot be assured that arrangements for staff to clean the home will always meet their needs. EVIDENCE: Both Lilac Lodge and Lavender Cottage were on the day of the visit staffed appropriately in order to meet the care needs of residents. On the day of the inspection the home was not due to be cleaned until after 3pm. However, the inspector noted that for that afternoon, cleaning was allocated for food and kitchen cupboards only. This was seen to be the case. A specialist carpet-cleaning machine is only available to the home on rotation with other homes in the group. The staff files for two employees from abroad were seen to be complete and accurately held details of CRB and necessary checks. One file evidenced the progress of a staff member who is about to commence NVQ level three training in care. Lilac Lodge And Lavender Cottage DS0000024434.V271345.R01.S.doc Version 5.0 Page 16 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): 37, Residents can expect to benefit from the management and leadership approach of the registered manager but on occasions other tasks may detract the manager from always ensuring that their rights and best interests are safeguarded by the home’s record keeping and policies. The current method of recording resident’s information is cumbersome and in part is not updated or completed and on occasion’s duplicates information found elsewhere. EVIDENCE: Care plans were seen to contain a great deal of information about resident’s details. A sample looked at by the inspector duplicated information, omitted information or were not being updated frequently. The registered manager agreed that the system was in need of updating and informed the inspector that the home was planning to replace the current system, which “ had been around for a long time”. Lilac Lodge And Lavender Cottage DS0000024434.V271345.R01.S.doc Version 5.0 Page 17 Although the care plans of two residents recorded that they had recently experienced a short-term medical problem,the home was unable to provide evidence of their contacting the resident’s GP for advice. Rotas for the cleaning do not take in to account the need for the home to maintain a clean and odour free environment for residents, particularly in shared rooms where commodes are in use. A sample of the provisions ordering, invoicing and payment records showed that there has been no reduction in the quantities of foodstuffs ordered since the recent change to new suppliers for meat and vegetables. An inspection of the food stocks and comparison with menus demonstrated that the home keeps stocks of food sufficient to meet resident’s needs. A small stock of food purchased separately for the previous days party was suitably packaged and stored for later use. Lilac Lodge And Lavender Cottage DS0000024434.V271345.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 X X X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 X X X 2 X X 2 STAFFING Standard No Score 27 2 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X 2 X Lilac Lodge And Lavender Cottage DS0000024434.V271345.R01.S.doc Version 5.0 Page 19 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 8 Regulation Requirement Timescale for action 05/12/05 2 15 3 19 & 23 4 27 37 5 6 8 13,b,17,3, In the event any changes in a,b resident’s health the home must inform the resident’s GP. The home must maintain an accurate record of such occurrences. 12 (4) (a) The home must take steps to ensure that the presence and conduct of staff at resident’s mealtimes is not overbearing and does not affect the social ambience of the occasion. 16,2,k, The home must take steps to eliminate offensive odours in resident’s shared bedrooms. 18 (1) (c) The home must ensure that staff (i) have the necessary understanding and equipment to meet any specialist cleaning needs of the home 17,3,a,b, The registered manager must 14,2,a,b ensure that resident’s health care and advice from GP’s are kept up to date and available for inspection. 13(1(b) The Home should seek annual DS0000024434.V271345.R01.S.doc 31/01/06 05/12/05 05/12/05 05/12/05 31/01/06 Page 20 Lilac Lodge And Lavender Cottage Version 5.0 7 8 38,25 38,25 13(4) 13 (4) 9 19 23 (2) (l) medical reviews of those residents over 75 years of age. This is a outstanding requirement from the previous inspection. A Fire risk assessment must be undertaken and a report forwarded to CSCI. A risk assessment of the stair gate at the top of the flight must be undertaken and a copy of the report forwarede to CSCI. This is an outstanding requirement of the previous inspection. Items for repair must be attended to without delay. Items of equipment or furniture not in use must be stored away safely. 31/01/06 31/01/06 05/12/05 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 2 3 4 Refer to Standard 7 9 15 19 & 23 Good Practice Recommendations The current format of resident’s care plans would benefit from updating and changing to a more standard format. The home should take necessary action to ensure that the amount of resident’s prescribed medication which is stored in the home is not excessive. Resident’s food, which arrives in the dining area well prepared, would benefit being served in a more attractive manner on the resident’s plate. Particular attention to the cleaning of resident’s commodes in shared rooms may reduce a source of offensive odours. Lilac Lodge And Lavender Cottage DS0000024434.V271345.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk 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. Extracts may not be used or reproduced without the express permission of CSCI Lilac Lodge And Lavender Cottage DS0000024434.V271345.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!