Inspection on 06/08/07 for Lilac Lodge And Lavender Cottage

This inspection was carried out on 6th August 2007.

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 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 07/08/06

Lilac Lodge And Lavender Cottage 05/12/05

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 Mary Jeffries Unannounced Inspection 6th August 2007 14:15 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.V348113.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 Lodge And Lavender Cottage DS0000024434.V348113.R01.S.doc Version 5.2 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 581922 cheryl@kingsleycarehomes.com 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.V348113.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 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). 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). 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. The total number of service users at Lilac Lodge and Lavender Cottage must not exceed 32. 7th August 2006 4. Date of last inspection 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 residents 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-six 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 six residents. 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. The home’s fees range from £341 to £550. Hairdressing, chiropody, and personal toiletries are not included in this fee. Lilac Lodge And Lavender Cottage DS0000024434.V348113.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, which focused on the core standards relating to older people. The report has been written using accumulated evidence gathered prior to and during the inspection. An Annual Quality Assurance Assessment (AQAA) was provided by the home prior to the inspection. The inspection was facilitated by the Registered Manager. A number of other members of staff were spoken with and gave assistance. The inspection occurred on an afternoon and early evening in July 2007 and took five and a half hours. The process included a tour of both Lilac Lodge and Lavender Cottage. Three residents were tracked. Observations of staff and resident interaction took place and, and a number of documents were examined including residents care plans, medication records, the staff rota, recruitment, training records and records relating to health and safety. What the service does well: What has improved since the last inspection? Lilac Lodge And Lavender Cottage DS0000024434.V348113.R01.S.doc Version 5.2 Page 6 Full pre admission assessments were on file for recently admitted residents. Incontinence pads were discreetly stored. All residents have a contract and receive a statement of terms and conditions at the point of moving into the home. An induction programme based on Skills for Care common induction standards had been put in place since October 2006 when these standards came on line. Regular supervision was occurring. The home had met the recommendations of the fire service. The home had met the requirements of the environmental health department. As found at the last inspection the stair gate at the top of a back flight of stairs was secure and there was a risk assessment in place; routine maintenance checks on it had been scheduled on a weekly basis. 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. The summary of this inspection report can Lilac Lodge And Lavender Cottage DS0000024434.V348113.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. Lilac Lodge And Lavender Cottage DS0000024434.V348113.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lilac Lodge And Lavender Cottage DS0000024434.V348113.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to be assessed before they are offered a place in the home and to have the opportunity to visit he home before deciding if it is for them. They can expect to be made fully aware of the terms and conditions of residence on admission, and to receive a contract once their place is confirmed at the first review. EVIDENCE: All three residents tracked had pre admission assessments on file. All had contracts, one was awaiting their first review before this was signed, but a copy of the contact was in the Service Users Guide provided to all residents. A recently admitted resident advised that they had visited the home from hospital the day before they were admitted. Lilac Lodge And Lavender Cottage DS0000024434.V348113.R01.S.doc Version 5.2 Page 10 The Registered Manager confirmed that the home does not provide intermediate care. Lilac Lodge And Lavender Cottage DS0000024434.V348113.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to have a care plan that is regularly reviewed and for their health and care needs to be met. EVIDENCE: All three residents tracked had care plans; two had been regularly reviewed, the third was awaiting their first main review. The files contained a life story, which the manager advised they were now doing for all new admissions into the home. One of the residents tracked had made such good progress in the first six weeks at the home that it was decided at review that a move into sheltered accommodation could be considered by the social worker. Their file contained a Waterlow tissue viability assessment and an Aston Care Nutritional assessment. The resident had some difficulties swallowing, and the dietician and speech therapist had been involved in their care. A medical appointment sheet in their records detailed this. A carer was spoken with about this Lilac Lodge And Lavender Cottage DS0000024434.V348113.R01.S.doc Version 5.2 Page 12 resident’s care. They advised that the home had set targets to get them eating and drinking, and that they had promoted family support as this was identified as a key factor in the resident’s progress. Daily notes on Lilac Lodge were less detailed than those on the dementia unit, Lavender Cottage. This resident had had gaps of two and three days, and an entry one day just stated, “ had lunch with (their spouse).” This level of recording does not fully support the review process. Another resident tracked had a pressure area on their heel; this was dressed by the district nurse, who also attended to provide bladder wash outs for the resident who had a catheter. A general Practitioner had visited this resident on the day of the inspection. There were some days where there was no daily notes were made for this resident, including one where there were no notes for four consecutive days. This resident maintained their own daily diary and was able to give a full account of their care and life in the home. During the afternoon a resident in Lilac lodge was observed being transferred into their wheel chair to go to the toilet, using a frame. The resident was smiling throughout, and clearly confident and comfortable. Footplates were put down on the wheel chair when the resident was moved. On Lavender there was good daily recording, with three entries for each resident in a twenty-four hour period. Care plans on the dementia unit included an assessment of the individuals contact and activity, which included whether the resident had the opportunity to experience fun, whether they were involved in giving and receiving, whether they kept in touch with others, and whether they had the opportunity for friendship, affection and contact. These important aspects of life were considered in terms of how frequently residents had these opportunities. The care plans also detailed how individuals expressed a need. The home’s own annual quality report showed that 55 of residents responding had indicated they thought the service received always matched what was written in their care plan, 45 had stated that they thought it usually did. The administration of teatime medication was observed in Lilac Lodge. The carer had a very good manner however, they gave out medication to three residents and then signed for them, which is not good practice and enhances the risk of error. It was evident that this is standard practice for this carer, at teatime. They advised that when there are only a few medications to give out they do not take the trolley around and it would be difficult to carry the book. Records inspected were complete. One resident’s medication had been changed and this was written onto the Mars Chart, it was supported by an entry in the care notes detailing that the GP had given this instruction. Where residents had refused medication this was properly indicated. An audit of Lilac Lodge And Lavender Cottage DS0000024434.V348113.R01.S.doc Version 5.2 Page 13 controlled drugs was undertaken and found to be correct. Controlled drugs were kept in a locked cupboard with a locked cupboard. The Registered Manager agreed that they would review the teatime medications practice in order to ensure that medications are signed for individually as they are given. The Registered Manager also confirmed that residents’ General Practitioners are providing medical reviews and reviewing medications for residents, but that this is now being done on an ongoing basis rather than periodic reviews being arranged. Medication administration is checked daily by senior carers or the manager, and by the Director of Nursing in regulation 26 monthly visits. The home’s quality report showed that 75 of residents responding to their questionnaire had indicated that the home always understands their needs and treats them as a person, 25 had stated that it usually does. 83 indicated that they were always treated with dignity, 17 that they usually were. The Registered Manager advised that one of the residents with dementia had been reluctant to have a bath when they first came to the home. The carers had been able to establish that this was a modesty issue, and had found the resident was willing to bath if they could get in still wearing their nightdress, and remove it once in the water. Another resident spoken with advised that staff always knock on their room door before entering. Lilac Lodge And Lavender Cottage DS0000024434.V348113.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to enjoy a good quality of daily life, good food and a good programme of activities for them to participate in if they wish to do so. EVIDENCE: On approaching the home the inspector met a resident sitting on a bench in the back garden. They advised that they had returned from a walk with their relative, and liked sitting there when it was fine as they liked the outdoors and they could see the comings and goings. The resident spoke about their military background, and the Registered Manager advised that they were working with the family to establish whether an activity could be arranged for the resident to recapture this. A resident spoken with advised that they could see their relatives in private, either in their own room or in the small interview room. A resident who was tracked spent the afternoon sitting with their spouse in the veranda; staff advised that the partner visits regularly and has a very positive impact on the residents’ well being. After the relative had left, the resident was seen asking Lilac Lodge And Lavender Cottage DS0000024434.V348113.R01.S.doc Version 5.2 Page 15 staff, “What shall I do?” Staff advised that when the resident was admitted they could not speak. During the afternoon a number of relatives were seen visiting residents and sitting with them in the large main lounge in Lilac Lodge, which is light and airy. There was a mainly relaxed atmosphere in the main lounge on Lilac Lodge, with interplay of conversation. One resident however was in an angry mood, and more or less threw a footstool over to another resident to “help”. One resident said that this had frightened them, but that they had not seen it before. The manager and a carer advised that they were aware that this resident could sometimes dominate others and that they monitored the situation. Menu sheets were provided. These showed a good range of home cooked meals and fresh vegetables, with a choice available to residents. The fridge and larder were seen to be well stocked. Another resident spoken with advised; “The food is very good, my only tiny criticism is that they could be more patient when dishing it up; I don’t like to be rushed.” This resident pointed out that staff were starting to come round and ask what they wanted to eat the next day, and advised that they did this every day. The carer who enquired about this resident’s choice, showed that they were aware of their likes and dislikes. The carer commented that they had seen the resident’s family at the home’s Strawberry Tea event, held the day before in the grounds of Lavender Cottage. Another resident spoken with was asked about the food in the home, they replied, “Oh, that’s lovely”. Their relative who was sitting with them advised, “I knew (they) would say that, (they) always says so.” This resident also said that the entertainment and activities were good, adding that they get something every day. Details of the activities programme for the week were displayed on the notice board in Lilac loge, these included Aromatherapy, Rex the pat dog, musical entertainment and Pleasant Pastimes. Details of religious services were also posted. Several residents received hand massages during the afternoon of the inspection, one resident said that they enjoyed this and found it very relaxing. A resident in Lavender Cottage had retired to their room by 7.30 pm. They were reposing on their bed, and advised that they liked to retire early. They appeared very well and comfortable, and were dressed in their dressing gown. Lilac Lodge And Lavender Cottage DS0000024434.V348113.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to be able to make a complaint and for it to be thoroughly responded to in a timely way. EVIDENCE: The home’s own annual quality report showed that 82 of residents had indicated that they always found it easy to raise a concern, 18 had stated that they usually did. A resident spoken with said, “I would have no problem complaining, the manager’s a very nice person.” All residents had a Service User Guide which contained a complaints policy. The complaint’s policy gives the name of the Responsible Individual as the person to whom complaints must be made, however, the Registered Manager had responded to complaints logged in the complaints book and forward a copy to the Responsible person. Whilst the complaints policy did not appear to have been followed strictly, complaints seen had been addressed. The Director of Quality and Compliance has subsequently advised that the policy had been revised but had not been filed in the operational folder at the time of the inspection. The home maintained a complaints book, which evidenced timely responses and appropriate action having been taken. A relative spoken with advised that Lilac Lodge And Lavender Cottage DS0000024434.V348113.R01.S.doc Version 5.2 Page 17 they had made a complaint and that the home had taken appropriate action and kept them informed. Following the last inspection the home had advised that it’s policy on the protection of vulnerable adults, had been amended to show clearly that Social Care Services will, in conjunction with the police if appropriate, determine who will carry out any investigation. This was also stated as done in the home’s quality assurance report, however the policy available in the home pre-dated the last inspection and this point had not been clarified. Staff had been trained in the Protection of Vulnerable adults. A carer spoken with showed an awareness of the signs of abuse and knew that any such concerns should be reported immediately to the manager. No referrals had been made in respect of the protection of vulnerable adults. Lilac Lodge And Lavender Cottage DS0000024434.V348113.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to live in a clean and attractive home. EVIDENCE: Residents in Lilac Lodge have a choice of areas where they can sit. The dining room is adjacent to the main lounge, and has an open wall through to the main sitting area. One resident said of the main lounge, “It’s a lovely room, its cheerful.” There is also seating in the reception area that is like a veranda area; it was being used by a resident and their relative on the day of the inspection. At the last inspection it was noted that a number of doors were badly scuffed. There was still some scuffing on doors; the Registered Manager advised that these had been sanded and painted since the last inspection and the marks now apparent were new. They advised that consideration was being given to Lilac Lodge And Lavender Cottage DS0000024434.V348113.R01.S.doc Version 5.2 Page 19 putting guards on doors to help prevent scuffing. The stair gate at the top of a back flight of stairs was secure and there was a risk assessment in place; routine maintenance checks on it had been scheduled on a weekly basis. Prior to the last inspection a number of requirements had been made in respect of Lilac Lodge by the environmental health department. The home advised the CSCI that these had been met. The requirements made and actions taken were checked at this inspection. A food safety management system was already in place, a damaged lid to a chest freezer had been repaired, however, the repair was showing further signs of wear. The accumulation of rubbish behind a chest freezer noted by the environmental health officer had been removed prior to the last inspection and the cleanliness of this area was maintained. Lavender Cottage was also seen to be clean and attractive. During the early evening the patio doors were open onto the garden, all of the residents were ambulant and able to go outside as they wished. Although there are only six bedrooms in Lavender Cottage, they would benefit from having symbolic notices on room doors to help residents identify their rooms. The home’s laundry was seen to be clean and orderly, apart from to mops which were stored head down in buckets in this room. The heads of the mop were damp. A bar of soap was found in a bathroom upstairs and a downstairs bathroom in Lilac Lodge. Both of these practices increase the risk of the spread of infection. Vinyl gloves and aprons were available at strategic points around the home. Lilac Lodge And Lavender Cottage DS0000024434.V348113.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to be cared for by a well-trained and supported staff group who are able to meet their needs. EVIDENCE: The level of staffing is good. The home’s roster showed that on Lilac Lodge in addition to manager or deputy manager there were there were four carers plus a team leader on duty until 11am, two carers and a team leader until 6pm and three carers and a team leader until 10pm. There are two waking night staff. The shifts change over at three pm, and the team leader is involved with care on the floor of the home. In Lavender cottage there are 2 carers between 8am and 10 pm and 1 at night; none of the current residents required two carers for personal care or moving and handling, however assistance could be obtained form Lilac Lodge if required. Of the twenty-six residents living in Lilac Lodge, three required two carers to move and handle them, twenty required personal care. One member of staff spoken with advised that at times they felt they were very pushed, particularly in the mornings. They advised that getting up times were staggered. Lilac Lodge And Lavender Cottage DS0000024434.V348113.R01.S.doc Version 5.2 Page 21 The home’s own annual quality report showed that 25 of residents responding to their questionnaire had indicated that care workers always come to do things with them at a time that suits them, 75 had stated that they usually do. The files of two recently recruited staff were inspected and found to be in order. One was a carer, one a domestic worker. PoVA firsts had been obtained, and good supervision arrangements were in place for these staff for whom CRB checks had not yet been received. The in-house induction programme was inspected, and was seen to conform to Skills for Care common induction standards. It had been in place since October 2006 when these standards came on line. A member of staff spoken with advised that they had done a lot of training including first aid, Protection of Vulnerable Adults and fire training. They advised that their manual handling training was up to date. This carer advised that the home was trying to arrange infection control training through Otley College. The homes’ AQAA stated that 56 of care staff had NVQ 2 or above. Staff files selected at random supported this and also that other training as described by the carer had been undertaken. Lilac Lodge And Lavender Cottage DS0000024434.V348113.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to live in a well managed home, and for their views to be sought in order to make relevant changes and improvements. EVIDENCE: The Registered Manager advised that a deputy manager had been appointed since the last inspection, and was able to show that this post had a job description. Residents meetings are held regularly, minutes of the last meeting when residents considered day trips out that they wanted were seen. Staff meetings are also held regularly, and minutes of this meeting were available and seen. Lilac Lodge And Lavender Cottage DS0000024434.V348113.R01.S.doc Version 5.2 Page 23 The home had a number of good quality assurance procedures in place. Regular regulation 26 reports had been carried out and copies of the reports which are thorough documents had been forwarded to the CSCI. Kingsley homes have achieved re accreditation form Investors in People in 2007. The home had also produced an annual quality report for 2006/7, based on residents questionnaires distributed by the home; twelve were returned. The report gave examples of changes made in the home as a result of these findings, for example it stated that they put more maintenance time into the home as residents had reported delays with minor maintenance. This was discussed with the Registered Manager who advised that the home now receives a two day a week input form the company’s maintenance worker. The Registered Manager advised that no monies are looked after on behalf of residents. One resident had no relative who they thought could assist with handling their finances; they explained that the home’s manager had taken them to see a solicitor. Some items are purchased on behalf of residents and receipts are kept and sent to relatives for payment. Chiropody receipts were countersigned by the Registered Manager to evidence that the expenditure had been undertaken, smaller items, for example bubble bath were provided out of stock and a memo provided by the team leader against which invoices were raised. These were neither signed by the resident nor countersigned by the manager. They need to be countersigned to evidence the expenditure has been undertaken on behalf of the resident. Two carers spoken with individually advised that they received supervision about once a month. One of the carers spoke about the content of supervision, which covered all appropriate aspects of their work. Records showed that staff were receiving regular supervision. The home had advised the CSCI that it had met the requirements of the fire officer. Automatic closures, linked to the fire alarm were seen to have been had been fitted to doors as required. The home’s fire risk assessment had been updated by external fire consultants. Fire extinguishers seen to have been serviced in March 07. Lilac Lodge And Lavender Cottage DS0000024434.V348113.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 2 3 X X X X X X 2 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 3 Lilac Lodge And Lavender Cottage DS0000024434.V348113.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement Medicine administration records must be signed immediately after medicine being given to each individual resident. The home’s policy on the protection of vulnerable adults must be amended to reflect that Social Care Services will take a lead on determining who will carry out any investigation into an allegation into abuse, to ensure evidence is not contaminated by the home proceeding without agreement. This is a repeat requirement from the inspection of the 7th August 2006. Memos detailing expenditure undertaken by the residents on extras must be countersigned by the resident and / or another senior member of staff before being sent to relatives for payment to protect against abuse. Timescale for action 08/08/07 2. OP18 13(6) 14/09/07 3. OP18 17(2) 07/09/07 Lilac Lodge And Lavender Cottage DS0000024434.V348113.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP22 Good Practice Recommendations Doors to residents’ rooms In Lavender Cottage should have symbolic signage. Lilac Lodge And Lavender Cottage DS0000024434.V348113.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lilac Lodge And Lavender Cottage DS0000024434.V348113.R01.S.doc Version 5.2 Page 28 - 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!