Inspection on 29/07/09 for Lilburn Lodge and Riverview Care Centre

This inspection was carried out on 29th July 2009.

CQC found this care home to be providing an Good service.

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

Lilburn Lodge and Riverview Care... 25/06/10

Lilburn Lodge and Riverview Care... 07/08/08

Lilburn Lodge and Riverview Care... 20/07/07

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Extracts from inspection reports are licensed from CQC, this page was updated on 16/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Lilburn Lodge and Riverview Care Centre Lilburn Place Southwick Sunderland SR5 2AF Lead Inspector Key Unannounced Inspection 29th July 2009 09:00 DS0000069666.V377134.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Lilburn Lodge and Riverview Care Centre DS0000069666.V377134.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Lilburn Lodge and Riverview Care Centre DS0000069666.V377134.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lilburn Lodge and Riverview Care Centre Address Lilburn Place Southwick Sunderland SR5 2AF 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) 0191 5496331 0191 5480395 lilburnlodge@schealthcare.co.uk Southern Cross Healthcare (Focus) Limited Angela Proctor Care Home 68 Category(ies) of Dementia (46), Old age, not falling within any registration, with number other category (40) of places Lilburn Lodge and Riverview Care Centre DS0000069666.V377134.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only Care Home with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category - Code OP, maximum number of places, 40 Dementia - Code DE, maximum number of places 46 The maximum number of users who can be accommodated is 68 2. Date of last inspection 7th August 2008 Brief Description of the Service: Lilburn and Riverview Care Centre is a registered care home with nursing, situated near Sunderlands Queen Alexandra Bridge and close to the shopping centre of Southwick. The area is well served by public transport. Until recently it was two separate services known as Lilburn Lodge and Riverview Lodge and both shared the same grounds and were run by the same provider. The services have now been amalgamated into one and it is now registered with CQC as Lilburn and Riverview Care Centre with one registered manager. The home provides permanent accommodation with personal care and support for up to a total of 68 older people, some of who may have dementia care and nursing care needs. Within this total, the home may also provide a service to a limited number of older people with a physical disability. Throughout the two buildings the accommodation is laid out over three floors of the purpose built property, served by a passenger lift. Each floor has a lounge, bathing areas, WCs and single en-suite bedrooms. Open plan kitchen/dining areas are situated on the first and second floors and there is an enclosed lawned area to the rear and car parking on site. The home publishes a regularly updated service user guide that is available in a range of accessible formats and this is available to service users and visitors Lilburn Lodge and Riverview Care Centre DS0000069666.V377134.R01.S.doc Version 5.2 Page 5 along with a range of information leaflets including a monthly newsletter in the home’s reception area. The fees charged by the home range between £407 and £593.30 per week depending on assessed need. Lilburn Lodge and Riverview Care Centre DS0000069666.V377134.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means that people who use this service experience good quality outcomes. This inspection was carried out during one day in July 2009 and was a scheduled unannounced Key Inspection. The inspection included a separate look at the Annual Quality Assurance Assessment (AQAA) completed by the proprietor. The care experienced by a sample of service users was ‘case tracked’. This is where the inspector focuses on the service provided for individual service users and time was spent chatting with service users and staff and observing life in the home. The environmental standards of the home were considered and a sample of staffing and service users’ records was inspected. Meals and drinks served were observed and the quality of food and drink sampled. The judgements made in this report are based on the evidence gained from this process. What the service does well: The friendly interaction of service users and staff creates a warm and welcoming atmosphere in the home. Excellent information about the service is available for service users and other interested parties and this is well displayed in the entrance hall. This means that people can find out about the home before they make a decision to use its services. Good information is gathered about the needs of anyone wishing to move into the home or wishing to use any of the services within it. This means that the home can make an informed decision as to whether they can meet the individual’s needs effectively. Anyone interested in using the services are encouraged to visit the home and look around so that they can make an informed choice about moving in and using the service. Care plans are put in place and these record details of the persons assessed needs. Clear guidelines lead staff to support the person in the way that they prefer and the way best practice dictates. Lilburn Lodge and Riverview Care Centre DS0000069666.V377134.R01.S.doc Version 5.2 Page 7 Staff approach service users sensitively and support them with personal tasks discreetly. This makes service users feel confident, one said, The staff are smashing I get the help I need and this helps me to get on with life.” A good range of fresh food is available that is cooked well and served attractively and if service users have a special dietary need then this is addressed, for example, some people may need their food to be cut up for them or liquidised. Service users said:The food is always good. I like the food there is always enough to eat. Service users independence is promoted and they are supported to live a lifestyle that is based on their personal preferences. A variety of activities are arranged by people especially employed and who have interest and skills in this area. Activities are arranged in and around the home and service users are supported to visit local places of interests. Furthermore people are encouraged to maintain their interests and hobbies and go out independently if they are able. Visitors to the home are encouraged and service user comments include:“We are encouraged to be involved in the running of the home.” “My sister is on the “Friends of Riverside” committee and they have been busy organising a summer fayre.” My family is always made to feel welcome and staff keep them up to date with how I am doing. An enthusiastic staff team support service users to meet their individual needs and to develop and maintain their independence and so that staff develop the skills and knowledge needed, a good training programme is in place. The service is run by a clear management team who are each designated to lead staff teams that are responsible for the care provided throughout the home. Furthermore good systems are in place that monitor the quality of care delivered to ensure that it is in the service users’ best interests. Lilburn Lodge and Riverview Care Centre DS0000069666.V377134.R01.S.doc Version 5.2 Page 8 What has improved since the last inspection? All of the requirements for improvements made following the previous key inspection have been addressed. A rolling programme that ensures that all staff receive training regarding dementia care needs is in place, which means that staff have the necessary skills and knowledge needed to support the people that they care for. Improvements have been made to the care planning system and monitoring systems are in place that ensure that changing needs are addressed directly and care plans are put in place to address them. This means that all staff are aware of service users’ needs and are guided to address them appropriately. There have been many improvements made to the dementia care unit that support and encourage service users with their independence and feelings of self worth. Thoughtfully positioned signs guide people to different areas of the home and pictures, stimulating objects and activities are arranged throughout the unit. Some comments from visitors include; “It is really good here now things have really improved there is a nice atmosphere and there seems to be more going on.” The home generally is better organised, there is no “clutter” present and passageways and communal areas are free from potential hazards. This gives service users a safer place to move around. Small furnishings and attractive pictures have improved the appearance of the bathrooms and these areas now look more inviting and a “warmer” place for service users to bathe. The fire service has recently visited the home and they were happy with the fire procedures and fire fighting equipment in place. Doors that need to be kept open are fitted with electronic devices or electronic doorguards that ensure that the door releases and closes automatically when the fire alarm sounds. This means that the fire doors will protect service users until the fire service reaches them if fire was to break out. Lilburn Lodge and Riverview Care Centre DS0000069666.V377134.R01.S.doc Version 5.2 Page 9 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Lilburn Lodge and Riverview Care Centre DS0000069666.V377134.R01.S.doc Version 5.2 Page 10 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 Lilburn Lodge and Riverview Care Centre DS0000069666.V377134.R01.S.doc Version 5.2 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5,6 People using 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. Service users are provided with good information about the home and this helps them to make an informed choice about where they would like to live. Preadmission assessments demonstrate service users’ needs and assist the home to make an informed judgement as to whether they can meet them. EVIDENCE: The home has developed a Statement of Purpose and a Service User Guide and both documents have recently been reviewed and updated to ensure that they reflect the recent changes in the service. The Service User Guide has been developed in good detail, however it does not include the range of fees charged by the home. So that service users and other Lilburn Lodge and Riverview Care Centre DS0000069666.V377134.R01.S.doc Version 5.2 Page 12 interested parties have this information the manager agreed to address this directly. An excellent A-Z Directory of Services has also been developed and this informs service users and their families/friends about the service and amenity services within the local community. This is particularly helpful for families from outside the local community especially with regard to hotels, restaurants, libraries and health facilities. This and other interesting information is kept neatly at the entrance to the home so that visitors and service users can easily use it. Service users are given contracts that include the terms and condition of their stay and this includes a break down of how the fees are paid, clearly demonstrating the actual amount the individual is responsible for paying. Prior to accepting a person into the home a full assessment of need is carried out by the referring agency and the home. This is to ensure that the home receives as much information about the person as possible, so that they can effectively judge whether they are able to meet their needs. The assessments are kept in the service users care files so that they can be easily accessed. Those received for service users who recently moved into the home are comprehensive and cover all aspects of their health and social care needs. They also identify assessed risks. The care staff who support the service users are trained in relation to their roles and service users’ needs and they are guided by the care plans to address individuals’ needs effectively. Social profiles are also developed at the assessment stage and these are included in the service users’ files. These documents include important information about the person and their history, including the way they prefer to live and the things they enjoy doing. All of the information gathered at the assessment stage is used to develop individual care plans. A six week review is carried out with the care manager following admission to the home and it is during this process that service users confirm that they are happy with the service provided and that they wish to stay at the home permanently. Lilburn Lodge and Riverview Care Centre DS0000069666.V377134.R01.S.doc Version 5.2 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 People using 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. Care plans guide staff to effectively address service users’ social and healthcare needs in a flexible and respectful manner and in a way that promotes their dignity and their right to privacy. Furthermore medication arrangements are managed safely and maintain and promote service users’ wellbeing. EVIDENCE: The home has developed a clear care plan format that is accessible and effective. This is used with the assessment document to ensure that the identified care needs and risks are addressed effectively. The care plans are developed in good detail and guide staff to appropriately support individual service users in their preferred way, while at the same time they promote service users’ independence. Lilburn Lodge and Riverview Care Centre DS0000069666.V377134.R01.S.doc Version 5.2 Page 14 Changing needs are identified during weekly and monthly monitoring which senior staff carry out and care plans are adjusted where and when needed. Individual risk assessments are in place and clear risk strategy plans guide staff to minimise the identified risk. Such plans are used as an integral part of the care plan. One risk assessment clearly demonstrated how the changing needs of one person put them at risk regarding the use of bedsides. The bedsides have been removed and strategy plans to reduce the risk are in place. These clearly guide staff to use alternative ways to keep the person safe from harm from falls out of bed. For example a special profiling bed is used and positioned at the lowest height once the person is settled for the night and in addition to this crash mats are positioned on the floor either sides of the bed. Good monitoring and record keeping has proved that this good care practice has been successful and in the service user’s best interests. This, like other risk assessments is regularly monitored. Although the care plans are generally explicit, one examined could have included more detail, for example instead of writing “X likes to have a shave on a daily basis,” more detail could describe the sort of shave preferred and the abilities the person has to carry out full or part of the task independently. The manager agreed to address this. Although staff are trained to carry out their role effectively and to address their duties professionally, they are aware of their limitations and gain further advice from specialist healthcare professionals when needed, for example district nurses, GPs and occupational therapists. One service user has recently been referred to an occupational therapist regarding an easy chair that meets their physical needs. Records are kept of individual healthcare visits and appointments, with the outcomes. District nurses keep their notes separate to the homes care files when visiting service users, but clearly communicate advice and guidance to staff relating to service users needs. Such advice is recorded in the daily notes and then transferred to the care plan if appropriate. When needed the daily intake of food and fluid is recorded on a separate sheet. This is in response to the completion of a malnutrition screening tool which is carried out when a risk assessment identifies a dietary need. The dignity of service users is promoted throughout the service. Reference to service users in records and the way staff carry out care tasks and interact with service users reflect this. Lilburn Lodge and Riverview Care Centre DS0000069666.V377134.R01.S.doc Version 5.2 Page 15 If falls occur these are recorded in the person’s daily notes and professional advice regarding any injury caused is sought, for example, the advice of a GP or a district nurse. If the home continues to have concerns about the person further advice is sought from hospital accident and emergency units. Such incidents are recorded in the person’s daily notes. Comprehensive medication policy and procedures are in place and all senior staff who are responsible for administrating medication follow these. Incoming and outgoing records of medicines are kept and audited monthly and all senior staff are trained in the Safe Handling of Medicines. The home complies with the administration and storage of Controlled Drugs and also with the Misuse of Drugs Regulations 1973. Receipt, administration and disposal of Controlled Drugs are recorded in the Controlled Drugs Register. Advice if needed, regarding medication is sought from the pharmacist who supplies the home. Staff are trained to identify any side effects or reaction to medication and seek advice from the service user’s GP. Lilburn Lodge and Riverview Care Centre DS0000069666.V377134.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 People using 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. Staff support service users to live the lifestyle of their choice and activities in the home are developed and arranged around their needs and aspirations. Good contact with family and friends is encouraged and service users dietary needs are addressed individually with the provision of good quality food. EVIDENCE: The different lifestyles and routines preferred by service users are respected and reflected in their care plans. Promoting independence is encouraged throughout this service and service users who are physically able to move around the home do so with ease and confidence and those less able are supported by staff to access parts of the home of their choice. A range of activities is arranged throughout the home by activity organisers, who may set up a group activity for care staff to supervise, while they give one to one attention to individual service users. Activity programmes are advertised throughout the home and in the entrance lobby where a digital Lilburn Lodge and Riverview Care Centre DS0000069666.V377134.R01.S.doc Version 5.2 Page 17 viewing screen shows different activities enjoyed by service users and visitors. This particularly helps families and friends to see what their relatives/friends have been daily occupied in. Good information is also provided for family and friends, for example, regarding local amenities, information about TV licenses, advocacy services, information regarding dementia and other services available for advice i.e. the Alzheimer’s Society. Relative and friends are encouraged to pay an active part in the running of the home and Relative Meetings are encouraged and minutes are kept. Some comments from visitors include:“We had a sponsored walk and raised money for a local charity.” “We are always made to feel welcome and we are encouraged to be involved in our loved ones care.” “I like the “banter” I get in here while I am visiting my X it is friendly and a nice place to come.” Activities are varied and according to service users’ needs and the dementia care units have been developed to ensure that stimulating objects, pictures and prompts for orientation purposes, have been thoughtfully and carefully placed. For people who may have dementia care needs, records that are developed regarding their social histories i.e. their interests, employment and activities enjoyed in their past lives, are particularly important and can be used to guide the person into different activities that are or have been important in their lives. For one person who, as part of their role during employment, had particular responsibility for ensuring that the electricity was safe and electric plugs were pulled out of their sockets, non active electric sockets and plugs have been placed at eye level along passageways, so that they can safely carry out their old routine. This particularly has engaged the person in activity while at the same time promoted their independence and self worth. One person discussed how they continue to take part in activities they have always enjoyed doing, by attending college and attending church each week with the support of staff and other service users who were enjoying making greeting cards said that they loved doing craft work and appreciated the time given by staff. Lilburn Lodge and Riverview Care Centre DS0000069666.V377134.R01.S.doc Version 5.2 Page 18 As well as having various activities going on and local entertainers and visitors coming into the home, the home works hard to develop a presence and support to the local community. Local community facilities are used and promoted and money is raised to support local charities. Local businesses have been invited to have stalls at the home’s forthcoming summer fayre and a sponsored walk recently raised money for the organisation Elder Abuse. A variety of meals are served with choices given at each meal time and during the day a variety of drinks and snacks are available. Special diets are catered for and also any dietary supplements and special requests. Picture cards are used to enable service users to make an informed choice about what they want for specific meals and staff are at hand to assist service users with their meals if needed. If families show an interest they are encouraged to visit at meal times to assist their relatives with their food. All of the dining areas throughout the service are attractive and comfortable. and tables are attractively set using linen tablecloths, crockery and cutlery. The following comments were made:“I enjoy coming in to assist my X with their dinner, I have done this for a long time now.” “The food is always good.” “If you don’t like something they will give you something different.” Lilburn Lodge and Riverview Care Centre DS0000069666.V377134.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People using 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. Appropriate arrangements are in place to protect service users from abuse and to address complaints and concerns about the service. EVIDENCE: Service users are issued with a copy of the home’s Complaints Procedure and they confirmed that if they have any concerns they discuss them with the manager or the staff and they put things right. Visitors to the home also confirmed this. One person said, “If there is a problem the manager discusses it and things are put right.” The complaints procedure is comprehensive and is kept at the front of the Complaint’s book, so that staff have clear guidelines to follow when recording in it. The complaints recorded since the last inspection clearly state the actions taken to address the issues raised. However a discussion between staff that is noted in the staff meeting minutes referred to a concern made by two different relatives and although the issue had been successfully addressed it had not been recorded in the complaints book. A discussion took place with the manager regarding concerns and Lilburn Lodge and Riverview Care Centre DS0000069666.V377134.R01.S.doc Version 5.2 Page 20 complaints and although concerns might be addressed directly, to show everyone that they have been taken seriously, thought should be given to recording them in the same way as a complaint. This advice was accepted. The majority of staff have attended recent training regarding the local authoritys procedures on safeguarding adults and there is a rolling programme in place for the remaining staff to attend. In relation to safeguarding, staff have also attended training about the Deprivation of Liberty and copies of both policies and procedures are kept in the home for staff to refer to. Safeguarding issues raised in the home are addressed following the appropriate safeguarding procedures and one raised recently has been referred to the local authority. Service users said that they felt safe living at the home and trusted the staff to care for them in a dignified way. Comments include:The staff are good, they treat you well and talk to you nicely. “We feel that our X is treated very well, the staff are good and the home is managed well.” There are robust procedures in place for the handling of service users monies. Fees are paid to the home directly through the bank and any money kept by the home for individual service users, is kept with individual records that are open and clear. Receipts are kept for all transactions and if the money exceeds an agreed amount, the excess is given to the service users family to bank. Some service users take charge of their own money and have locked facilities for the safe storage of it in their rooms. Lilburn Lodge and Riverview Care Centre DS0000069666.V377134.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 People using 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 home is clean, warm and well maintained offering service users a homely and safe environment in which to live. EVIDENCE: Although two different homes are now amalgamated as one, as the buildings stand adjacent to each other, the site is easily managed as one home. All of the areas within the home are accessible to service users as the different floors are accessible by lifts. There is an ongoing refurbishment programme in place and many areas throughout the home have been redecorated and refurnished. New furniture, carpets and small furnishings have enhanced many of the service users’ Lilburn Lodge and Riverview Care Centre DS0000069666.V377134.R01.S.doc Version 5.2 Page 22 individual rooms and seating in some lounge areas now provide more comfortable areas to sit. Much thought has been focussed towards making areas throughout the home stimulating and easy to access for people who may have dementia type illnesses. Photographs of old film stars, the royal family and old areas of Sunderland, including places where people would have worked, decorate the walls in different areas and provide stimulation for reminiscing and discussion. Service users can identify their individual rooms from photographs of themselves pinned to their doors. Different stimuli for activity are placed thoughtfully around the home and pictures of bathrooms and toilets hung out from the walls on brackets guide people and promote their independence. The home generally is more organised and provides a tidy environment. The number of domestic staff has been increased and they are managed well and led by a designated team leader who monitors the effective cleaning routines. The laundry is well organised and dissolvable bags are used for soiled articles. There is very little loss of individuals’ clothing. The clinical waste bins are now kept in the sluice rooms away from communal areas. An infection control policy has been developed with the advice and guidance from Sunderlands clinical nurse specialist. The policy is in depth and includes procedures to follow when working with people with MRSA, clostridium difficile and when transferring service users to hospital care settings; it also includes procedures to follow during a break out of a pandemic influenza type illness. The staff team has received training regarding the infection control policy and procedures and carry out their duties in relation to them. The good standard of the cleanliness throughout the home reflects this. Lilburn Lodge and Riverview Care Centre DS0000069666.V377134.R01.S.doc Version 5.2 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 People using 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 home has a competent and qualified staff complement that effectively meets the care needs of the service users. EVIDENCE: Staff work with enthusiasm and interact with service users in a warm and professional way. Service users made the following comments:The staff provide excellent care, and staff are always there to help.” Some of the staff have worked at the home for many years and know service users very well and when staff move on new staff are employed to fill their posts. The home has a diverse staff group with different experiences, expertise and qualifications. A varied training programme is in place for all staff that includes mandatory training and other courses related to their roles and a clear training matrix identifies when training needs to be updated. Lilburn Lodge and Riverview Care Centre DS0000069666.V377134.R01.S.doc Version 5.2 Page 24 Over recent months staff have attended training including, dementia care, the safe administration of medicines, the Mental Capacity Act and the Deprivation of Liberty and infection control. Staff have also received training in good dementia care practices. The staff team are well qualified and most of the staff team has achieved NVQ and others are working towards it. In addition to this senior staff have achieved NVQ 3 and are working towards level 4 and all staff who are responsible for running the unit where nursing care is provided, are qualified registered nurses. The domestic and kitchen staff team are qualified in health and safety, food handling and infection control. There are greeting cards in the home from relatives of service users complimenting the staff for the good care service users receive. The robust recruitment procedures carried out by the service ensures that the welfare and interests of the service users are protected. Fully completed application forms, 2 references and CRB (Criminal Record Bureau) checks are all in place. Lilburn Lodge and Riverview Care Centre DS0000069666.V377134.R01.S.doc Version 5.2 Page 25 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 People using 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. A competent manager and good management systems ensures that the service is run in the best interests of the service users. EVIDENCE: The manager who is now registered with CQC is a qualified RMN (Registered Mental Health Nurse) and has achieved the RMA (Registered Managers Award). She is also up to date with mandatory training and is a trainer for the dementia care training course Yesterday Today and Tomorrow. Recent training includes Formal Supervision and Disciplinary Procedures. Lilburn Lodge and Riverview Care Centre DS0000069666.V377134.R01.S.doc Version 5.2 Page 26 She has an open door policy that enables service users, their families and staff to freely approach her for discussion, guidance and advice and keeps up to date with changing legislation and improved ways of working. She has recently attended training regarding the Deprivation of Liberty and Infection Control. The manager has worked closely with Sunderlands Infection Control Nurse to develop and implement policies and procedures in the home regarding good care and hygiene practices. The manager is seen as a positive lead in the home and is well informed regarding her knowledge of dementia and she is proactive in passing this information on to the staff team and service users’ relatives. Positive and respectful relationships have developed between the manager, service users and staff and efforts to promote good working relationships between all has been successful. Comments from service users and their families include:“There is a different atmosphere in this home due to the manager and staff.” “It is good when the manager is experienced and has so much knowledge, you can trust them more.” “The staff work hard with good results.” Appropriate health and safety records are maintained and this demonstrates that all staff receive appropriate training in fire procedures, moving and handling and first aid regularly. There are records of hot water temperatures and thermometers are in place in each bathroom for staff to test hot water. Records are kept of any accident in the home and individual records including the action taken and the outcome, are kept in individual residents care files. The manager has worked hard to develop an effective quality assurance system which ensures that the home is run in the best interests of the service users. Good monitoring systems are in place and where action has needed to be taken, details are recorded demonstrating how the service has improved. Lilburn Lodge and Riverview Care Centre DS0000069666.V377134.R01.S.doc Version 5.2 Page 27 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 4 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 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 X X 3 Lilburn Lodge and Riverview Care Centre DS0000069666.V377134.R01.S.doc Version 5.2 Page 28 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 OP1 OP7 Good Practice Recommendations The Service User Guide should include the range of fees charged by the home. Care should be taken that all care plans are developed in the same way to include sufficient detail that guides staff to support service users with tasks in their preferred way and in a way that promotes their independence. The home should ensure that all concerns made to the home are recorded appropriately, so that it is evident that they have been taken seriously. 3 OP16 Lilburn Lodge and Riverview Care Centre DS0000069666.V377134.R01.S.doc Version 5.2 Page 29 Care Quality Commission Care Quality Commission North Eastern Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.northeastern@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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