Inspection on 03/05/07 for Lilas House.

This inspection was carried out on 3rd May 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 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

Lilas House. 27/09/05

Lilas House. 27/04/05

Lilas House. 11/10/04

Lilas House. 12/05/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Lilas House 5 Cadogan Road Cromer Norfolk NR27 9HT Lead Inspector Mr Jerry Crehan Unannounced Inspection 3rd May 2007 11:50 Lilas House DS0000027466.V339569.R01.S.doc Version 5.2 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 Lilas House DS0000027466.V339569.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 Adults 18-65. 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. Lilas House DS0000027466.V339569.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lilas House Address 5 Cadogan Road Cromer Norfolk NR27 9HT 01263 511210 01603 279529 l.jeesal@virgin.net www.jeesal.org Jeesal Residential Care Services Limited 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) Position Vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Lilas House DS0000027466.V339569.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 27th September 2005 Brief Description of the Service: Lilas House is a three storey end of terrace property situated in the centre of Cromer. It is registered as a Care Home for up to six adults with a learning disability. Each service user has their own bedroom. There are two bedrooms, with a shared en suite bathroom, on the ground floor and four bedrooms on the first and second floors. There is a shared lounge and dining room on the ground floor. The Home does not have a garden but there is a small patio area to the side of the Home. The Home is very close to the shops, seafront and other facilities in the town of Cromer. Lilas House DS0000027466.V339569.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection compromised an unannounced visit to the home that took place over 6 hours on 3rd May 2007. Opportunity was taken to tour the premises, talk to service users, care staff, the manager, deputy and training managers, and to look at care records and policies. The inspection report reflects evidence from inspection of Key Standards and other National Minimum Standards. Three comment cards were received from relatives/visitors before the inspection visit. These reflected generally positive views about the service and care for tenants, which have been reflected in the report. Four comment cards were received from tenants. These also reflected very positive views about the home, its manager and care staff. The range of weekly fees for the home is £600 to £1,050. What the service does well: What has improved since the last inspection? • The new manager has managed to establish both herself and several new staff members in a relatively short space of time, in such a way as to provide continuity and stability for tenants. There were no requirements made at the previous inspection. • Lilas House DS0000027466.V339569.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Lilas House DS0000027466.V339569.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lilas House DS0000027466.V339569.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective people to use the service have their needs assessed, and access to all of the information they need about the service they may choose. EVIDENCE: The home has an assessment pro-forma and ‘application form’ used by the manager or other senior staff when collecting information. These documents are well designed to ascertain the level of support required by, and aspirations of, any prospective tenant. There is evidence of the assessment of the most recently accommodated tenant having been undertaken by the former manager of the home and another senior manager within the organisation. The tenant had stayed at the home for a period of respite care before their permanent move. The admission procedure is supported by the home providing suitable information to prospective tenants in formats appropriate to the needs of the individual. Lilas House DS0000027466.V339569.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 & 9 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are involved in decisions about their lives, and play an active role in planning the care and support they receive. EVIDENCE: Several care files were looked at during the inspection visit. Each contained individual and detailed care plans and risk assessments. There was evidence in care files of tenant participation in their care planning and reviews. The care plan for one tenant contained a comprehensive summary of their health and physical care needs, including allergies, eye care, foot care, hair and scalp, dental care, nail care, pain and other issues. Tenants communication needs are summarised in care plans and provide a clear guide for staff to be aware of and to follow. Daily living schedules are incorporated into care plans for each day, indicating what activities the tenant has chosen to participate in. There was evidence that this is flexible a tenant had changed their mind about their afternoon activity and remained at the home to speak with the inspector for a part of the time. Lilas House DS0000027466.V339569.R01.S.doc Version 5.2 Page 10 Financial care plans are in place for every tenant. These set out personal allowance monies, indicate where monies are paid into, support provided by staff in accompanying the tenant to the bank if necessary, where cheque books and/or monies are kept, where cheques are recorded, if the tenant holds a lot of money where else this may be kept safely. This is good practice that assists in protecting tenants. Tenants comments about the care they receive were very good. A tenant said they ‘liked it at the home’, another tenant said ‘staff are very good to us, if we’ve got a problem and need to speak they listen’, and another tenant said ‘we’ve got staff here who understand us’. Tenants said that they have weekly meetings at the home to discuss various topics such as activities planning, staff rotas and menu setting. There was evidence of good care delivered in a very sensitive way to a tenant who suffered an anxiety attack during the inspection visit. They were supported by two staff sensitively, patiently and with encouragement. The staff used agreed strategies to assist the tenant to gain confidence and control, which after some time they did. Care files contained clear risk management guidelines that have been completed and reviewed with the involvement of tenants. These indicate risks in aspects of daily living and in other activities undertaken by tenants. Risk management guidelines emphasise risk assessment as a means for tenants to undertake as full a range of activities and daily living tasks as possible. A comment card received prior to the inspection visit from a relative/visitor states that the home ‘considers the person’s ability and skill and helps to use them to their best advantage’. Lilas House DS0000027466.V339569.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 & 17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to make choices about their lifestyle, and supported to develop their life skills. Social, recreational and educational activities meet individual’s expectations. EVIDENCE: The care plans set out the schedule of weekly activities preferred by tenants. These include social and educational activities that take place both at the home and in the community. Home based activity includes cooking, laundry and other general domestic type tasks, aromatherapy (an aroma therapist visits the home regularly), community based activities include adult education groups, local clubs, shopping trips and art and craft groups. A tenant was looking at holiday brochures and talked about the holiday choices they have made in the past. Some tenants attended a local community activity during the inspection visit. There is a weekly timetable of activities in ‘wigit’ symbol format to support tenants understanding of the order of forthcoming activities. Lilas House DS0000027466.V339569.R01.S.doc Version 5.2 Page 12 The home is within easy walking access to the town and seafront of Cromer and near to the railway station. The home has access to a vehicle, which it shares with a nearby service that is owned by the proprietor. Public transport is used, including the train and local bus service. Some tenants spoke about their arrangements for maintaining contact with their relatives. These arrangements vary for individuals. Some contact takes place at Lilas House, or away from the home. Other tenants are supported by the home in contact at the tenant’s relatives home. The manager indicated that in some instances staff have supported tenants care needs in these settings. Each of the three comment cards received from relatives/visitors to the home indicate that the home always helps tenants to keep in touch with them. One comment card also stated that ‘the home is always welcoming and helpful’. Each of the four comment cards from tenants indicate that they have lots of things to do. Further evidence of this was supported in comments made by tenants during the inspection visit. Some tenants choose to hold their own key for their bedroom. All staff observed throughout the inspection visit entered tenants accommodation with their permission. Tenants have unrestricted access to the home and grounds and to associate with people of their choice, unless there is a clearly identified risk indicating otherwise. All tenants participate in cooking meals or in menu planning. Menu planning takes place at tenants weekly meetings. A record of menus is kept and a pictorial menu is now on display each day. Some tenants follow their own healthy eating programmes. Lilas House DS0000027466.V339569.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 & 20 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care that people receive is based on their individual needs. Well trained staff provide excellent physical and emotional healthcare support to people who use the service. EVIDENCE: There are care plans that indicate the tenants individual support needs, and care staff are clear about the most appropriate ways to provide support, including personal and health care advice from a range of professionals. There was an example of excellent practice in the health care plan for tenant who does not communicate verbally. This sets out how they may communicate illness, for example when they may be unwell, what may help, and what may be the most effective way to explain treatment or medical procedures to the tenant. As already indicated above the care plans contain a comprehensive summary of the health and physical care needs of tenants. Staff spoken with during the inspection visit were knowledgeable and well informed about tenants physical and emotional health care needs. They have access to training in health care matters including emergency aid, medication, Lilas House DS0000027466.V339569.R01.S.doc Version 5.2 Page 14 epilepsy and diabetes. The staff have received training with regard to moving and handling which enables them to support the one tenant who requires assistance to move around. Medication practices at the home are good. There are currently no tenants who take responsibility for administering their own medication. The home uses a monitored dosage system for medication. Medication seen is stored securely and appropriate records are kept for its receipt into the home, its administration and any medication returned to the pharmacy. Each tenant has a medication care plan indicating prescribed medication and reasons for PRN (when required) medications. There are clear instructions for staff in the administration of PRN medications. On review of records no discrepancies were identified, and recording was good. Photographs of tenants support medication administration records. Lilas House DS0000027466.V339569.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 & 23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to express their concerns, have access to an appropriate complaints procedure, and are protected from abuse. EVIDENCE: Tenants are provided with the opportunity to raise concerns or complaints with care staff or with the manager. This can be done through formal meetings that take place regularly at the home, or as seen during the inspection visit, on a less formal basis as issues arise. The home has a detailed complaints procedure and information on how to make complaints is made clear in the ‘service users guide’. The complaints procedure can also be made available in other formats to suit the needs of individual tenants. All four comment cards received from tenants indicate that they feel safe at the home. All of the comment cards from relatives/visitors indicate that they know how to make a complaint about the care provided by the home if they need to. From information provided by the manager there have been no complaints received by the home in the past 12 months. The Commission has not received complaints about the home either. Each of the staff spoken with at the inspection visit were clear about the home’s policies and procedures to protect tenants from abuse, were clear about the action they would take if concerned about the possibility of abuse taking place, and were confident that their Manager would deal with this appropriately. Lilas House DS0000027466.V339569.R01.S.doc Version 5.2 Page 16 Staff have received training in the protection of vulnerable adults. Evidence of this was seen in training records. Lilas House DS0000027466.V339569.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 & 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment at the home is safe, well maintained and designed to support the needs of people who use the service. EVIDENCE: The premises are suitable for the homes stated purpose, and in keeping with the local community. The interior accommodation is in a good state of repair, with good quality furnishings and fittings. There was evidence of redecoration and the manager stated that other areas have been identified for attention by staff and tenants, adding that tenants were being involved in making choices about how these areas will be redecorated. The bedrooms belonging to tenants are decorated to a good standard, these are clearly personalised and decorated in a way that reflects the tenants choice and interests. Premises were safe, clean and hygienic throughout. Lilas House DS0000027466.V339569.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 32, 34, 35 & 36 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff at the home are trained, skilled and in sufficient numbers to support the people who use the service. EVIDENCE: There were six tenants accommodated at the home at the time of the inspection visit, cared for by three staff. There was evidence throughout the inspection visits that tenants needs were being met and that staffing levels are sufficient to meet tenants needs both at the home and to access the community. There is a care staff compliment of seven. From information provided by the manager there are currently two carers with a qualification at NVQ level 3, and a further 2 carers signed up to undertake NVQ 2. It is recommended that remaining staff are supported to undertaken NVQ 2 (or above) training. Care staff are enthusiastic about the work they do and demonstrated good communication and interaction with tenants throughout the inspection visit. From observation and the tenants’ comments it was evident that they have confidence in their carers. From discussion with support workers and a review of personnel files, it was evident that tenants are protected by good recruitment practices. Lilas House DS0000027466.V339569.R01.S.doc Version 5.2 Page 19 Training records seen at the visit provide evidence that staff receive good induction and ongoing training from the proprietor’s own training department. Care staff spoken with confirmed that the training is relevant and appropriate to their roles. Staff spoken with see their role, in part, as facilitators to enable tenants to achieve their aspirations and full potential. Training schedules for the home shows that staff are continually booked to attend a range of courses over a rolling schedule. This includes mandatory training such as medication administration, first aid, fire safety and moving and handling, and specialist training including total communication and ‘sign along’. The staff group at the home has undergone some change in the past 12 months, however, there is still a great deal of experience in the new manager and deputy. There is a good interaction between all staff and tenants, and they know each other well. There is a programme of formal supervision for staff. Staff indicate that they have periodic formal supervision with the managers. The manager and deputy manager undertake all staff supervision. It is recommended that both managers’ have access to training to carry out this role. Lilas House DS0000027466.V339569.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 & 42 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administration of the home promotes the care and the aspirations of people who use the service, and has effective quality assurance systems developed by the proprietors. EVIDENCE: The manager of the home has been in her current post for 5 months. She has worked in care for over 10 years, including experience as deputy manager in another care home. The manager stated that she has begun the process of applying for registration with the Commission. The manager is also responsible for managing another home owned by the proprietors in the same road where a further three tenants live. This situation evidently works well and the manager is aware of the need to monitor this on a regular basis to ensure that she is able to carry out both roles effectively. Lilas House DS0000027466.V339569.R01.S.doc Version 5.2 Page 21 Both staff and tenants at the home are complementary about the manager and her approach toward them. She is credited by them as helping both staff and tenants to feel relaxed and comfortable, though has authority and a robust approach when necessary. The home produces an annual development plan. The home sends out questionnaires to relatives and care/health professionals on an annual basis and these are included in the annual development plan. There are several ways in which the quality of the service is monitored. These include monthly audit visits to the home by the proprietors representative, monthly reviews of tenants care plans, tenants meetings, staff meetings, annual questionnaires to professionals and relatives, health and safety monitoring, and the ‘Tenants Forum’ meeting that takes place with tenants from other of the proprietors homes. Lilas House DS0000027466.V339569.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 2 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 3 X 3 X X 3 X Lilas House DS0000027466.V339569.R01.S.doc Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA32 YA36 Good Practice Recommendations It is recommended that all care staff are supported to undertaken NVQ 2 (or above) training. It is recommended that the manager and deputy manager undertake training in staff supervision skills. Lilas House DS0000027466.V339569.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Lilas House DS0000027466.V339569.R01.S.doc Version 5.2 Page 25 - 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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