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

This inspection was carried out on 7th August 2006.

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.

Other inspections for this house

Lilac Lodge And Lavender Cottage 06/08/07

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 7th August 2006 3:00 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.V305542.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.V305542.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 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.V305542.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. 5th December 2005 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 £470 to £525; all new rooms are £485, with the exception of a very large room new room which is £525. Hairdressing, chiropody, and personal toiletries are not included in this fee. Lilac Lodge And Lavender Cottage DS0000024434.V305542.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on one Monday in August 2006. The home had provided a completed Pre-Inspection Questionnaire prior to the inspection. The Registered Manager facilitated the inspection which took five and a half hours during an afternoon and early evening and took five and a half hours. The inspection focused on Lilac lodge where a group of five residents were spoken with, and one resident was spoken with individually in their room. Four resident’s records and care were tracked. A visit was made to Lavender cottage after tea-time, all residents were observed participating in their early evening routine. Ten relatives’ comments cards and 16 residents “ Have your Say” surveys were returned to the CSCI prior to the inspection. There were two vacancies at the time of the inspection, one in Lilac Lodge and one in Lavender cottage. What the service does well: What has improved since the last inspection? Bedrooms were free from odour and the home has its own carpet cleaning equipment. The home was free of inappropriately stored items awaiting repair. Residents General Practitioners are providing annual medical reviews and are reviewing medications for residents who are on more than 3 medications on a six monthly basis. Care notes include advice given by General Practitioners. Meal times were considered by residents to be relaxed and comfortable. Lilac Lodge And Lavender Cottage DS0000024434.V305542.R01.S.doc Version 5.2 Page 6 Care plan formats had been reviewed, however the new formats which were amended and stored on computer did not include goals for the care provided. Although the home had commissioned a fire risk assessment from an independent consultant, and provided the CSCI with a copy, this was not adequate. The stair gate at the top of a back flight of stairs was secure and there was a risk assessment in place, but routine maintenance checks on it were not scheduled. 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.V305542.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lilac Lodge And Lavender Cottage DS0000024434.V305542.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,6 The quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. Whilst service users can expect to be assessed prior to being admitted to the home, they cannot be assured that all of their needs have been fully considered. EVIDENCE: All service users are given a copy of terms and conditions prior to admission. Two residents who had been admitted over a month ago, but within the last three months did not have a contract on file, two others tracked did. The Registered Manager advised that the four most recently admitted residents awaited contracts, which are normally signed by the resident or social care services after the six weekly review to confirm the placement. The organisation’s own quality assurance (QA) exercise undertaken in February 2006 states that local authority needs assessments had been received by the home for all residents. The Registered Manager clarified that this was for residents who received social care funding. The QA exercise also stated that most residents were also visited in their own home or in hospital prior to Lilac Lodge And Lavender Cottage DS0000024434.V305542.R01.S.doc Version 5.2 Page 9 admission. The Registered Manager advised that the home’s own assessments were sometimes done when prospective residents visit the home for a day, as they are invited to, prior to admission. The files of two residents admitted within the last three months both included pre admission assessments. These were quite brief, and in one case did not clearly show why a resident needed care. The Registered Manager advised that this was because of a recent bereavement and subsequent self-harm attempt. This was not indicated anywhere on the pre admission assessment, or care plan. The Registered Manager advised that the home did not provide intermediate care. Lilac Lodge And Lavender Cottage DS0000024434.V305542.R01.S.doc Version 5.2 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 the following standard(s): 7,8,9,10 The quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. Whilst service users can expect to have a care plan and for staff to understand their needs, they cannot be assured that their wider goals will be addressed within their plan, or that their needs will be reviewed sufficiently frequently. EVIDENCE: The home has reported, through Regulation 26, that care plans have been changed and resident information had been inputted onto a computerised system. All four residents tracked had care plans. These were not user friendly and did not identify clear goals for specific areas of care, which the previous style of plans did identify. A consent agreement was seen to be in place for a resident with bed rails. The Regulation 26 report for July 2006 stated that a sample of six care plans seen were all being reviewed on a monthly basis, and that reviews included reviews of medication. The method of conducting reviews was discussed with the Registered Manager. They advised that they review the care plan on the Lilac Lodge And Lavender Cottage DS0000024434.V305542.R01.S.doc Version 5.2 Page 11 computer based on information given to them by staff, and then printed copies were made available for any section of the plan where there had been a change. Scheduled reviews had been completed on a regular basis for the four residents tracked, but these had been administrative exercises, rather than meetings. On one of them there was a gap of seven weeks between the last two reviews. The Registered manager advised they reviewed care plans on a monthly to bi-monthly basis. Residents in Lilac and Lavender were all clean and comfortably but smartly attired. A requirement was made at the last inspection that in the event of any changes in resident’s health the home must inform the resident’s GP. The home must maintain an accurate record of such occurrences. This is completed by senior carers on the care plans by hand; the Registered Manager advised that she checks these to ensure it has been done. Carers spoken with demonstrated a good knowledge of residents’ needs. The pre inspection questionnaire indicated that residents use a range of different general practitioners. The manager advised that they have been requesting annual medical reviews for all residents; that initially the home received a mixed response from G.P’s, but that subsequently they are providing this service. They are also reviewing medications for residents who are on more than 3 medications on a six monthly basis. The senior who gave out medicines on the evening of the inspection advised that the four seniors were the only staff who administer medication, and that all had recently had Boots refresher training. Teatime medications in Lilac Lodge were observed. A monitored dose system (MDS) is used for administration of medicine. The carer administering medication followed correct procedure. Residents were offered drink with their medication, and when being given regular tablets were asked if they needed any medications that they been prescribed to take if and when they were required. The carer was unhurried, and took time with each residents. The medicine cabinet was locked every time it was left. One resident was still eating their tea-time meal (sandwiches) when their medication was taken to them in their room. This was discussed with the carer administering medicines; she advised that sometimes this resident ate slowly, at other times, more quickly so it was difficult to judge whether they had finished. The controlled drug storage was seen, and drugs counted were found to match the record in the controlled drug book. The controlled drug cabinet was a locked soft wood cabinet within a small locked wooden cupboard/room. A recommendation had been made following the CSCI inspection in December 2005 that the home should take necessary action to ensure that the amount of Lilac Lodge And Lavender Cottage DS0000024434.V305542.R01.S.doc Version 5.2 Page 12 prescribed medication which is stored in the home is not excessive. A report from the pharmacist of a visit made in February 2006 was seen. This recommended that a larger cupboard may be needed, but that otherwise no problems were identified. The Registered Manager advised that this was because of the amount of stock, but that since then a large return had been made, including supplies for three deceased residents. Records showed a large return in March 2006, the previous return had been made 5 months prior to that. Medicine administration records (MAR) sheets all had a photograph of the resident. Records for the last two weeks for 26 residents were inspected. One gap, only, was found. Interactions between staff and residents were seen to be polite and respectful, and the group of residents spoken with confirmed that this was always the case. One resident said, “ the girls are lovely here, they’ve got a nice manner about them.” Residents confirmed that carers would always knock before entering their rooms. The storage of incontinence pads was not satisfactory, a pack was visible in the corner of a shared room; in another room a new pad was out ready to use on a pillow. Lilac Lodge And Lavender Cottage DS0000024434.V305542.R01.S.doc Version 5.2 Page 13 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 The quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Service users can expect to enjoy a pleasant atmosphere in comfortable surroundings, and for there to be a range of organised activities they can take part in. EVIDENCE: The home’s family survey undertaken in January 2006 focused on this area of provision, and outcomes were predominantly very positive or positive. A member of staff was asked what they thought the home did well; they advised that they thought the choices offered in terms of meals and activities were particularly good. A notice board in the home advertised scheduled activities for the next three weeks which included games, crosswords, quizzes and reminiscence sessions. Additionally, aromatherapy was available on Mondays, armchair exercises on Tuesdays and pleasant pastimes on Wednesdays. The Regulation 26 report for July 2006 stated that some residents were to attend a tea dance on 19th July at the Masonic Hall. Photographs of this occasion and of a recent river trip Lilac Lodge And Lavender Cottage DS0000024434.V305542.R01.S.doc Version 5.2 Page 14 were displayed in the home. The board advertised a singer who was coming to the home to entertain in August. During the late afternoon, before teatime, two relatives were seen visiting residents; the TV was on, but there was a lively atmosphere in the main lounge on Lilac Lodge, with an interplay of conversation. Residents spoken to said that visitors were welcome at any time. The contract stated that this was so, but that if they intend to visit after 9pm, the home asks that they tell the home to expect them. Tea was served between 5 and 5.30. The Inspector was advised one resident likes to have it in their room, some like to have it in the lounge. Menus provided showed a good range of meals, with a choice of two cooked main meals and two puddings every day. Records were kept of the choices each resident had made. One resident said, “All the food is lovely, all the cooks are good.” Others in the group strongly agreed with this. They described lunchtime as a nice occasion that they looked forward to. One resident explained, “Some need some help or encouragement, they get it,” The residents advised that at a monthly residents’ meeting food and choices were often discussed. Residents spoken to said that they could have a cup of tea brought to them in the morning if they wanted one, one explained that they could call for this in the morning if they “fancied one”. The Registered manager advised that residents are asked if they want one, but that they would not take one round as a matter of course as not all residents like to get up at the same time. After tea, residents in Lavender Cottage were seen enjoying a relaxed time. A number of them were in dressing gowns watching the television, some had had a bath. Residents were moving around freely and there was no sign of anyone being in any distress. The carers reported that they had had a good day. The French window to the back patio was open, and the atmosphere was relaxed. Lilac Lodge And Lavender Cottage DS0000024434.V305542.R01.S.doc Version 5.2 Page 15 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): 16,18 The quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Residents can expect to felt able to raise concerns and complaints and for them to be appropriately responded to. EVIDENCE: The organisation’s own quality assurance exercise undertaken in February 2006 states that every resident has a Service Users’ Guide in their own room. Residents spoken with confirmed this to be the case. The Service Users’ Guide contains a copy of the complaint procedure. The home’s complaints log contained two complaints received since the last inspection in December 2005. Both were informal and had been responded to. Residents spoken with said that they felt comfortable to raise any concerns and described the manager as very approachable. A copy of the home’s policy on the protection of vulnerable adults, dated May 2006, was provided. The policy is comprehensive, and states that the home’s manager will immediately report any allegation of abuse to Customer First. It does not, however, state clearly that Social Care Services will, in conjunction with the police if appropriate, determine who will carry out any investigation. No referrals had been made in respect of the protection of vulnerable adults. Lilac Lodge And Lavender Cottage DS0000024434.V305542.R01.S.doc Version 5.2 Page 16 A carer spoken with was aware of the policy and knew what action to take if they suspected abuse. Awareness of abuse was included in the home’s induction training. The home’s whistle – blowing policy had also been reviewed in May 2006. This was acceptable. Lilac Lodge And Lavender Cottage DS0000024434.V305542.R01.S.doc Version 5.2 Page 17 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): 19,23,25,26 The quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. Whilst residents can expect that the home to be generally maintained in a good state of repair and cleanliness, the deficiencies in the fire protection measures mean that the home is not as safe as it should be. EVIDENCE: The Regulation 26 report for July 2006 stated that all areas of the home were decorated; maintained and clean to a satisfactory standard, although some minor maintenance matters were identified that were passed to the maintenance team for attention. The Registered Manager advised that any items requiring repair are now stored in her office. A tour of the environment was made and no other items awaiting repair were seen. The communal areas were on the whole adequately decorated, although a number of bedroom doors were seen to be are badly scuffed and need renovating. The home was clean and odour free throughout. A group of Lilac Lodge And Lavender Cottage DS0000024434.V305542.R01.S.doc Version 5.2 Page 18 residents spoken with all said that the home was always kept to a good standard of cleanliness. The home has four shared rooms, one of which is occupied by a married couple. All of these rooms have 2 commodes in them. The manager advised that carpets are regularly shampooed in these rooms, and all have an air freshener. These four rooms were inspected; none had unpleasant odours. all were clean and personalised, and had modesty curtains in place. The manager advised that night staff are emptying the commodes now throughout the night, as used. The home now has its own carpet shampooer, which is available at all times. A risk assessment was in place for a stair gate at the top of a flight of stairs that leads from the first floor to a hallway. This route is not normally used. The manager advised that the maintenance team attend weekly and go through a checklist; this was seen and the need to ensure that this stair gate was firmly fixed was not contained within the checklist. The stair gate was checked and found to be firmly in place. One resident tracked had an air mattress on their bed. None had bedsides in place. The maintenance book was seen; this contained a record that all bed sides had been reviewed by maintenance. The Registered Manager advised that they also do a weekly check on bedsides. A number of fire protection measures were not in place. See standard 38. Lilac Lodge And Lavender Cottage DS0000024434.V305542.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Residents can expect that the home will provide sufficient care staff with appropriate skills to meet their needs. EVIDENCE: The vast majority of residents’ written feedback indicated that they considered the home always to be sufficiently well staffed, (12 out of 16 replies) and that staff were always available when needed. Three answered sometimes to these two questions, one stated that they thought the home needed more staff. Nine out of ten relatives who responded to the request for comments were generally satisfied, one commented that the home needed more staff in their opinion. Staffing rosters for the week of the inspection and the following two weeks were provided and were inspected. There were sufficient staff on duty to meet residents’ needs on the afternoon of the inspection. The call bell was heard on a couple of occasions only, and were promptly responded to. The organisation’s own quality assurance exercise undertaken in February 2006 stated that 66 of staff had achieved NVQ2 or above. This was confirmed in the pre inspection questionnaire. The Regulation 26 reports since the last inspection have stated that fire training had been arranged for staff on 22nd June 2006, that two staff have been on dementia awareness courses, two Lilac Lodge And Lavender Cottage DS0000024434.V305542.R01.S.doc Version 5.2 Page 20 had completed medication administration courses, and that one carer had achieved and one commenced, NVQ 3. Three staff files were inspected. All contained the required information for recruitment and employment purposes. All had enhanced Criminal Records Bureau checks; in two cases these had been achieved before employment commenced, in the third case a PoVA check had been made prior to employment commencing. In house induction was evidenced on all three files of the recently recruited staff, this included Manual handling and awareness of abuse. The Registered Manager advised that the course was provided by trainers from the company that owns the home, and that they were aware it had been recently reviewed but did not know if it met the standards of Skills for Care. Lilac Lodge And Lavender Cottage DS0000024434.V305542.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 The quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. Whilst there are some good quality assurance systems in place, residents cannot be assured that all shortfalls will be identified. The home’s fire risk assessment was not adequate. Service users cannot, therefore, be sure that the environment is as safe as it should be. EVIDENCE: The registered manager is currently undertaking their Registered Manager’s Award. They advised that they have completed six units and have four to go, and that they anticipate completing this in December. The home has provided regular Regulation 26 reports to the CSCI throughout the year. These are detailed and comprehensive documents. Lilac Lodge And Lavender Cottage DS0000024434.V305542.R01.S.doc Version 5.2 Page 22 The Regulation 26 reports stated that water temperature checks were being carried out and that on 27/06/06 all were found to be within range. The home provided a copy of a family survey undertaken in January 2006. The survey which forms part of the organisation’s quality assurance (QA) system focused on personal care, daily living and support. The written up account of the survey included details of the home’s action in any areas where a questionnaire indicated a relative was less than satisfied, and contained details of what the home was improving. For example it reported that one survey expressed that, sometimes, minor maintenance took too long to be rectified. The conclusion of the survey stated that a new system had been put in place to ensure that each repair reported to the head office maintenance team is signed off by the manager once completed. The company’s Operations Director had also undertaken a QA exercise on the first 11 minimum standards in February 2006, and copies of this were provided. The Registered Manager advised that no service monies are held by the home or the organisation for people in the home. The contract specifies that Residents who cannot handle their own financial affairs should arrange for their legal adviser, other representative, next of kin or friend to do this on their behalf, but that the manager and staff are allowed to handle monies with prior consent of the resident or representative with legal authority to give consent. The Regulation 26 reports stated that new supervision formats had been introduced into the home, that regular supervision was taking place, and that staff appraisals were due in August. This did not reflect the findings on the day of the inspection. A member of staff spoken with was asked about supervision. They advised that they usually had supervision every eight weeks, and the last supervision was about three weeks ago. Evidence of this was seen on file, however, there were no other recent records of this carer’s supervision. The Registered manager advised that they did not schedule supervision, and were not up to schedule on this. They advised that they left it to the carers to arrange it, and acknowledged that this can result in supervision not taking place if the carer wishes to avoid it. Following the previous inspection, the home had employed a consultant to produce a fire risk assessment and a copy was forwarded to the CSCI. Following this the CSCI wrote to the Registered Manager and advised that the response they had indicated to a point raised in the risk assessment was not adequate in respect of the arrangements for locking the front door, and that they must consult with the fire officer. The Fire Officer had visited the home on 12th July 2006. They had found a number of requirements that should have been identified in the fire risk assessment, and also required the home to change type of locks on main fire exits in both Lilac and Lavender, so that these could be opened from the inside without a key. Other requirements Lilac Lodge And Lavender Cottage DS0000024434.V305542.R01.S.doc Version 5.2 Page 23 included a need to put intumescent strips on the side and top edges of doorframes in Lilac, and smoke seals on the side and top edges of doorframes in Lilac. There was also a need to put high melting point hinges on older doors in Lilac and to fit a positive self-closing device. These had not been addressed at the time of the inspection, although the Registered Manager advised that they had put a request through to head office maintenance, evidence of this was seen. The fire officer also required that the premise’s fire evacuation policy had to show that the home ensured that adequate staff numbers are provided to implement horizontal and vertical evacuation in an emergency. A copy of a report of a recent environmental health officer’s inspection of Lilac Lodge, only, was provided. This included four requirements; a food safety management system to be put in place; a damaged lid to a chest freezer to be repaired or replaced, seals to the milk dispenser to be changed and an accumulation of rubbish behind a chest freezer to be removed. A cleaner spoken to advised that this final requirement had been attended to, this was checked and found to be the case. Lilac Lodge And Lavender Cottage DS0000024434.V305542.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 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 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 2 X X X 3 X 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 1 Lilac Lodge And Lavender Cottage DS0000024434.V305542.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. 5. Standard OP2 OP3 OP9 OP10 OP18 Regulation 5(1) 14(1)(a) 13(2) 12(4)(a) 13(6) Requirement All residents must have a contract agreed by the end of the trial period. Pre admission assessments must detail all relevant considerations concerning care needs. Medicine administration records must be complete. Incontinence pads must be discreetly stored. 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, and that the home must not proceed to do this until and unless that has been agreed by Social Care Services. A number of badly scuffed bedroom doors must be renovated. Evidence must be provided that the in house induction programme meets Skills for Care Standards. All staff must be appropriately DS0000024434.V305542.R01.S.doc Timescale for action 01/09/06 31/08/06 07/08/06 31/08/06 14/09/06 6. 7. OP19 OP30 23(2b) 13(4)(c) 30/11/06 01/10/06 8. OP36 18(2) 30/10/06 Page 26 Lilac Lodge And Lavender Cottage Version 5.2 9. 10. 11. OP38 OP38 OP38 13(4) 13(4) (a)(c) 13(6) 13(4)(c) supervised. The fire risk assessment must be updated and a copy forwarded to the CSCI. The requirements of the fire officer as set out in letter dated 19/07/06 must be met. The home must meet the requirements of a recent environmental health inspection. 07/09/06 19/10/06 31/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. Refer to Standard OP7 OP7 OP9 OP9 OP9 OP25 Good Practice Recommendations Residents’ care plans should have clear goals. Care plans should be reviewed on a monthly basis. A controlled drug cabinet that meets Misuse of Drugs (safe custody) regulations requirements should be provided for safe storage. If a resident is eating when drug administration occurs, they should be returned to and given medication after they have finished. Returns of medication should de done routinely and regularly. The stair gate at the top of a flight leading to the hall should be on the maintenance checklist as it has worked loose in the past. Lilac Lodge And Lavender Cottage DS0000024434.V305542.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: 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.V305542.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. 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