Inspection on 07/08/08 for Lilburn Lodge and Riverview Care Centre

This inspection was carried out on 7th August 2008.

CSCI found this care home to be providing an Adequate 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... 29/07/09

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 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Lilburn Lodge Care Home Lilburn Place Southwick Sunderland SR5 2AF Lead Inspector Elsie Allnutt Key Unannounced Inspection 9:30 7th August 2008 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 Lilburn Lodge Care Home DS0000069666.V367749.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. Lilburn Lodge Care Home DS0000069666.V367749.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lilburn Lodge Care Home 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 Manager post vacant Care Home 40 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (40), of places Physical disability over 65 years of age (10) Lilburn Lodge Care Home DS0000069666.V367749.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 only - Code PC 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, over 65 years of age - Code DE(E), maximum number of places 18. Physical disability over 65 years of age - Code PD(E), maximum number of places 10. The maximum number of service users who may be accommodated is 40. 20th July 2007 2. Date of last inspection Brief Description of the Service: Lilburn Lodge is a registered care home near Sunderlands Queen Alexandra Bridge, set at the top of a steep hill close to the shopping centre of Southwick. The area is well served by public transport. It shares its grounds with a registered nursing home, River View, operated by the same company. The home provides permanent accommodation with personal care and support for up to a total of forty older people, some of who may have dementia needs. Within this total, the home may also provide a service to a limited number of older people with a physical disability. Nursing care cannot be provided. 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. Although entrance to the building may be gained via a series of ramps, there is a steep gradient, so access may be difficult for anyone who has impaired mobility or uses a wheelchair independently. There is an enclosed lawned area at the rear and car parking on site. Lilburn Lodge Care Home DS0000069666.V367749.R01.S.doc Version 5.2 Page 5 The home publishes a regularly updated service user guide that is available in a range of accessible formats. The manager also provides a range of information leaflets and a monthly newsletter that can be found in the home’s reception area. Lilburn Lodge Care Home DS0000069666.V367749.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 1 star. This means the people who use this service experience adequate quality outcomes. Before the visit: We looked at: • Information we have received since the last visit. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on 7th August 2008. During the visit we: • • • • • • Talked with people who use the service, relatives, staff, the manager & visitors. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit. We told the manager/provider what we found. What the service does well: The home has developed good information about the service that they deliver to help people to make an informed decision about moving there and people are encouraged to visit the home so that they can see the facilities available. The manager makes sure that the home can effectively meet the service users’ needs. She receives important information about people who wish to use the service and also carries out the home’s assessment of need, before she confirms that the person can move in. Lilburn Lodge Care Home DS0000069666.V367749.R01.S.doc Version 5.2 Page 7 There are good arrangements in the home for meeting the service users’ healthcare needs. Service users are supported to see their GP, visit outpatient appointments and are also able to access other healthcare services such as dentist, optician, chiropody and district nursing services when there is a need. There are good procedures in place to make sure people get their medicines at the right time. This means that service users are supported to take the medication that they need at the time the doctor advised. Service users benefit from level access on both floors and equipment and adaptations are available to help physically disabled and frail service users to get around the home. This ensures that service users with diverse needs can easily get around the home. Staff in the home work hard to meet service users’ needs, and have a good rapport with them. Staff demonstrate a good understanding of service users needs, including the needs of people with dementia. Service users spoke positively about staff members some comments include: “The staff are very good.” “They are always there for you and nothing is a trouble.” “Staff come when I call them.” A relative commented: “The staff keep me up to date with my X’s progress, they always make you feel welcome.” Written care plans provide clear guidance to staff on what service users need help with. Service users are encouraged to take part in meaningful activity that provides the opportunity to exercise and to take part in various events that they choose and that stimulates their minds. Attractively presented and nutritious meals are provided and all of the service users asked reported that the food was good and made the following comments: “The food is always good here.” “There is always plenty on your plate.” “If you don’t like something you just have to say.” What has improved since the last inspection? Lilburn Lodge Care Home DS0000069666.V367749.R01.S.doc Version 5.2 Page 8 Improvements have been made regarding the storing and administration of medication. A more detailed record is now kept of the stock of medicines kept. This means that service users individual medicines are stored appropriately and the records are kept of them are accurate. A new manager has now been recruited to the home. This means that the home has a permanent person that has the responsibility to lead the staff team to deliver a service that is in the best interests of the service users. What they could do better: So that staff understand the needs of service users with dementia and are able to support them in the right way they must receive training in relation to current good dementia care practices. Staff must remember to record any changes in service users needs and describe clearly the action taken to address them. This is so everyone knows of the risks involved and the care plan in place to address them. The good work already underway to improve the dementia care unit and make it a stimulating environment that promotes service users’ independence, selfesteem and confidence, while at the same time provide an environment where people can easily orientate themselves while also welcoming to the local community, should continue. The home throughout is showing signs of wear and tear and could be improved with a complete redecoration and refurbishment programme. In addition to this the attention given to the domestic resources and routines could further improve the cleanliness of the home and provide a more hygienic place for service users to live. This would provide service users with an environment that is comfortable, attractive and safe to live in. Staff and service users must not keep doors open by propping them up with pieces of furniture as this will prevent the door from closing when the fire alarm sounds and put service users and staff at risk of harm. The door must be kept open only by an automatic release device that is connected to the fire alarm system and releases it when the alarm system is activated. If this is broken then it must be repaired quickly. So that the manager can establish that any person to be employed to work with service users in the home is a reliable and suitable person, she must have evidence of the CRB check. Disclosures should be kept and not destroyed until after the CSCI inspection is complete to enable CSCI inspectors to see a sample at the next inspection. This is one of the legal requirements for retaining Disclosures. Lilburn Lodge Care Home DS0000069666.V367749.R01.S.doc Version 5.2 Page 9 In the event of a CRB check not being received and a decision has been taken to employ a person on the evidence of a clear application form, two good references and a clear POVA list check the person must follow a comprehensive induction programme. While at the same time until the CRB check has been received, be supervised by a named member of staff at all times. A record should be kept of these arrangements. So that the health and safety of service users is promoted the manager must ensure that the quality monitoring of the service is carried out carefully so that improvements can be made where necessary and the home is kept to a standard that is in the best interests of the service users. 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. Lilburn Lodge Care Home DS0000069666.V367749.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 Care Home DS0000069666.V367749.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with good information about the service and the terms and conditions, this helps people to make an informed decision about where to live. Pre-admission assessments demonstrate service users’ needs and assists the home to make informed judgements as to whether they can meet these needs. This ensures that the resident receives the appropriate sort of care and support from the home. EVIDENCE: The home has developed a Statement of Purpose and a Service User Guide. Both documents are regularly reviewed to ensure that the information is up to date. This information clearly informs service users of the home’s terms and conditions. Lilburn Lodge Care Home DS0000069666.V367749.R01.S.doc Version 5.2 Page 12 Contracts from the contracting agencies explain in detail the fees to be paid and the people responsible for paying these. The home receives comprehensive information from the referring agency and other people involved in an individual’s care, prior to making a decision that they can meet their needs. For example assessments from the referring care manager or information from the discharging hospital are received. The home also carries out a full assessment of need that includes addressing risks, for example for one person an assessment regarding a pressure ulcer and a nutritional screening assessment tool were used. When the decision is made that the home can meet a prospective resident’s needs, a letter is sent out to the person to confirm this. This home does not provide intermediate care. The residents’ needs are addressed by competent staff who have received training regarding different issues and illnesses relating to old age. Although the manager is experienced in working with people with dementia type illnesses and is able to guide staff in this area, not all staff are trained in relation to current good practice in dementia care. Lilburn Lodge Care Home DS0000069666.V367749.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Suitable and effective arrangements are in place to meet service users’ healthcare needs and good procedures are in place for the safe administration of medicines. This promotes the health and welfare of the service users and ensures that a consistent service is delivered. EVIDENCE: A care plan document that reflects the corporate image of the company is in place. It is used with the assessment document to ensure that the identified care needs and any identified risks are addressed. The manager and staff, who have been trained in its use, are happy with the document and feel that they can use it to record clear information. The care plans are written clearly and include good information about the service users’ needs and how they are supported to maintain independence. Lilburn Lodge Care Home DS0000069666.V367749.R01.S.doc Version 5.2 Page 14 They are person centred and guide staff to address individual needs and the individuals’ preferred ways of daily living and the way they like to be supported. The care plans are monitored monthly and reviewed annually, however for one person the care plan had not been monitored since June and the loss of weight demonstrated on the weight chart had not been addressed, neither had their food intake been recorded. This was brought to the manager’s attention. Any risks identified are assessed and guidelines regarding the strategies used to reduce the risk are included as part of the plan of care. For example for one person with Parkinson’s disease guidelines lead staff in a consistent way in relation to the amount of support needed to ensure independence and in relation to the safe use of the special equipment. For example, the type of bath used and the prompt to ensure that the walking aids are in a state of good repair. A pressure relief mattress and cushion are in place as a precautionary measure for a service user who is frail and at risk of developing pressure sores. Staff are well informed and receive the necessary training regarding service users’ diverse needs. This is reflected in the standard of care practices carried out and the competent and sensitive approach to service users. Although staff have not received specialised training regarding Parkinson’s disease the district nurse is referred to if any advice is needed. The manager stated that she would contact the Parkinson’s specialist nurse for future training. Staff have received training regarding sensory impairment from a specialist organisation and by being involved in practical sessions themselves, they felt they had a better understanding of the difficulties met by sensory impaired service users. There are suitable arrangements in place regarding the administration of medication and staff receive appropriate training regarding this. Medicines are safely stored and managed. Lilburn Lodge Care Home DS0000069666.V367749.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff encourage service users to exercise and maintain choice and control over their lives by arranging activities and other forms of stimulation, while also maintaining contact with family and friends. This means that residents are provided with different opportunities to lead fulfilling lifestyles and do not become socially isolated. Residents’ individual dietary needs are met by being served food that is appropriate to their needs, healthy and nutritious. EVIDENCE: Two activity organisers, who share a full time post, are employed to arrange and coordinate activities throughout the home. Service users are informed about these from notices, detailing individual events, displayed around the home. Photographs in the entrance hall of recent and past events and activities that have taken place are there for residents, friends, families and visitors to see. Lilburn Lodge Care Home DS0000069666.V367749.R01.S.doc Version 5.2 Page 16 Events include visits to the theatre, cinema afternoons in the home where ices and popcorn are sold, visits to the seaside, crafts and exercise classes. As well as organising group events, the activity organiser who described herself as being “passionate about her work,” stated that she includes 1:1 work with service users who may need stimulation in an activity individual to their own needs or as a way of offering distraction from an upsetting situation. For example for one person who was showing signs of agitation a walk around the garden discussing the plants and flowers had relaxed and refreshed them on return into the home. For others it might be a card game or a thought provoking quiz that stimulates the brain. Service users are empowered to live the lifestyle of their choice within the home, two service users who had chosen to get up late were enjoying their breakfast at 10.30 am. One service user is independent and comes and goes from the home throughout the day making sure that they inform someone of their whereabouts. Another service user explained that they have their paper delivered to the home and another stated that: “After many years in the forces I now enjoy making my own decisions and living the lifestyle that I chose.” Several visitors called to the home and were made welcome by staff and some happily collected prizes from the office following their success at a recent raffle. Visitors commented that they are kept up to date regarding their relatives’ health and welfare and also encouraged to take part in different events in the home. The chef leads a competent kitchen staff team and is aware of the diverse dietary needs of the residents and the training needs of the staff to address these. Although staff support service users appropriately during mealtimes some service users might benefit from having the content of what they eat recorded in the care plan. This will assist staff to monitor more accurately certain people whose dietary intake is not enough to keep their weight stable. Lilburn Lodge Care Home DS0000069666.V367749.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Effective arrangements are in place to help protect service users from abuse and to address complaints and concerns about the service seriously. EVIDENCE: The home has a comprehensive complaints procedure of which service users and their representatives are aware. Service users are confident that their concerns or complaints are addressed appropriately and they are encouraged to discuss their concerns on a daily basis and these are addressed directly. The complaints file demonstrates that complaints have been taken seriously and addressed appropriately. Staff receive training regarding the local authority’s safeguarding adults procedures and they are aware of the action they would take if an abusive incident was observed or reported to them. A copy of the procedures is available in the home to which staff can make reference. Service users are encouraged to look after their own finances when appropriate. For those who need support with this, comprehensive procedures are in place for staff to follow and these help safeguard service users from the possibility of financial abuse. The records are kept by the home’s Lilburn Lodge Care Home DS0000069666.V367749.R01.S.doc Version 5.2 Page 18 administrator and monitored by the manager. A monthly reconciliation report is carried out and submitted to the head office. In the event of service users having their finances controlled by Social Services a statement of all monies kept and the current balance is made available to the service user. One service user approached the office to enquire about the current balance in their account and by using up to date information on the computer system the information was given directly. The service user then withdrew what they required. This followed the procedures in place. Lilburn Lodge Care Home DS0000069666.V367749.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is spacious, easily accessible and offers service users a homely environment in which to live. However more effective domestic and maintenance routines could further promote a positive image for service users and ensure that they remain safe. EVIDENCE: There is easy access to the home via a ramp to the front door and the grounds surrounding it are furnished with attractive shrubs and plants that are well maintained. The home is divided over three floors. The ground floor houses bedrooms only and further bedrooms as well as communal living areas are situated on the first and second floors. People with dementia care needs use the second floor. Lilburn Lodge Care Home DS0000069666.V367749.R01.S.doc Version 5.2 Page 20 Work is currently underway to develop the dementia care unit in a way that will motivate and support service users to orientate themselves effectively and be content and independent in their environment. Some ideas for example making the doors to individual rooms more identifiable by painting them different colours and putting knockers or post boxes on depending on the choice or previous memory of the service user. Additional ideas were discussed regarding how placing “prompts” and familiar objects around the home might guide and stimulate service users into activity or reminiscence. Further plans are in place to address such ideas. The service users rooms are clean and many include furniture and possessions personal to the individual. The carpets throughout the home are bright and clean having been replaced prior to the last inspection. However the home throughout is looking “tired” and showing signs of wear and tear. This includes the armchairs in the dementia care unit that are worn on the arms and on the cushions. The paintwork is marked and scratched and décor throughout could be brighter and more attractive if renewed. Due to one domestic being on holiday there was only one on duty to cover three floors. Although basic areas to the home were clean there were areas, particularly in the bathrooms and toilets that showed lack of care and cleanliness. The radiators in the bathrooms were marked and dirty and mildew was growing around the base of the baths and at the back of one of the electric chairlifts. There was dirt accumulating under the grab handles on the baths and one of the bathroom ceilings was water marked. One of the baths had a sign saying “out of order.” Furthermore the dishwasher in the small kitchen next to the dining room was broken and also had a sign saying “out of order.” This machine is rusting in parts and has a dirty appearance. There were cups and mugs usually washed in the machine draining on the bench having been washed by hand. It was confirmed that both broken appliances had been reported. Although some of the issues raised above are the outcome of ineffective cleaning routines they also highlight the lack of effective infection control procedures and as a result put service users at risk. Other health and safety issues found throughout the home that could potentially put service users at risk of harm include: • One of the service users room doors was propped open with a stool. This was because the door guard, that is fitted to the door and releases the open door to close on the sound of the fire alarm, was broken. DS0000069666.V367749.R01.S.doc Version 5.2 Page 21 Lilburn Lodge Care Home • • The cleaning cupboard door was left open and the cleaning trolley was left unattended. Both allowed service users, who were possibly unaware of the dangers, access to potentially harmful domestic materials. Several door handles were loose and could not easily be used to close the doors effectively. This included the door of the cleaning cupboard and to a toilet. Lilburn Lodge Care Home DS0000069666.V367749.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a competent and qualified staff complement that effectively meets the service users’ care needs and the robust recruitment procedures ensure that their welfare and interests are protected. However ineffective domestic resources and routines could put service users at risk. EVIDENCE: The home employs a team of staff with diverse experience and qualifications. The number on duty meets the needs of the service users currently living at the home. Five carers, plus a deputy/senior member of staff were on duty. This number was divided between the different floors and in addition to this the manager and administrator who is also a trained carer, were also available. A sufficient number of kitchen staff is employed with the cook leading the team however the standard of cleanliness in some parts of the home reflects the lack of domestic resources. Only one domestic member of staff was on duty. The poor standard of cleanliness found in some identified areas of the building has Lilburn Lodge Care Home DS0000069666.V367749.R01.S.doc Version 5.2 Page 23 demonstrated the need to review the required domestic staffing numbers and the cleaning routines followed. Staff work competently interacting with service users in a sensitive and knowledgeable way that reflects an effective training programme. A well-established training programme has resulted in a well-qualified staff team. Staff spoke positively about the training received. All but one member of staff are either working towards or are qualified in NVQ, however not all staff working with the service users on the dementia care unit have received specific training regarding dementia care. Such training is very important so that staff have an understanding of different aspects of dementia and the reasons for the related behaviours sometimes demonstrated. The manager stated that plans are in place for this to be addressed. Staff files demonstrate comprehensive induction systems as well as other training courses attended. The home has robust recruitment procedures to be followed and the records of staff recently employed demonstrate that these are mainly addressed. Application forms identifying a clear, up to date record of employment and two written references are in place, however although a satisfactory POVA list check was evident two records did not include evidence of a satisfactory CRB (Criminal Records Bureau) check, nor was there evidence that plans had been put in place to directly supervise the recently employed staff by a more experienced member of staff prior to the outcome of the check being available. Although it was finally established that CRB checks had been received by the company’s main office, this information had not been received by the home therefore the manager was not aware of this. A discussion took place with the manager how this should be addressed in the future. Lilburn Lodge Care Home DS0000069666.V367749.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A competent senior team and comprehensive quality assurance systems support the manager to maintain good management routines that aims to deliver a service in the best interests of service users. However the monitoring of some systems in the home has failed to identify poor standards relating to health and safety. EVIDENCE: The management structure in this home is going through a period of change. Although a new manager has been employed for the home she also oversees the management of the home next door. Lilburn Lodge Care Home DS0000069666.V367749.R01.S.doc Version 5.2 Page 25 Discussions are currently going on with CSCI (Commission for Social Care Inspection) in relation to the management of both homes. The manager who is currently going through the registration process with CSCI is qualified as a 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. Future training planned includes Formal Supervision and Disciplinary Procedures. The supervision of staff is organised by allocating mentors from the senior staff team to carry out supervision sessions with identified groups of staff. To carry out this effectively an identified agenda has been developed that includes aspects of practice, policies and procedures and personal development. The manager feels that she is well supported by other managers within the company and the operations manager who visits at least monthly to carry out Regulation 26 monitoring visits, the latest one recorded July 2008. There is a good quality assurance system in place that aims to ensure that the home’s policies and procedures are put into practice and that the service is delivered in the best interests of the service users. However the monitoring of some procedures have failed to address some inadequate standards in the home which in turn have put the health and safety of service users at risk. There are systems in place to collate service users’ views about the care and service delivered in the home. Service users’ and relatives’ meetings take place monthly and comment cards are available to pick up in the home. Annual surveys are sent to service users and when returned these are sent to the operations manager who collates the information and sends out a report to the manager in September each year. This highlights the strengths and any weaknesses of the home. The administrator confirmed the positive impact of a new IT system in the home which has meant more effective administration systems, including the ordering and paying of goods and service users’ individual financial records which can now be immediately accessed on request. Although generally risks identified throughout the home are monitored and addressed well some health and safety issues have been identified and brought to the manager’s attention. Fire safety is practiced appropriately and accidents to both residents and staff are recorded and addressed satisfactorily. Lilburn Lodge Care Home DS0000069666.V367749.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Lilburn Lodge Care Home DS0000069666.V367749.R01.S.doc Version 5.2 Page 27 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 Standard OP4 Regulation 12(1) Requirement Timescale for action 31/12/08 2 OP8 3 OP19 4 OP19 So that the needs of the service users are appropriately met the manager must ensure that all staff are trained regarding current good practice in relation to dementia care. 14(2) The manager must ensure that the service users changing health care needs are monitored and recorded and that any changes are followed up and addressed appropriately, in particular in relation to weight loss. 23(1)(a) The manager must ensure that & the work started in the dementia 23(2) care unit continues to develop so that this area is stimulating and addresses the needs of the people who live there. 23(4)(a)(c The manager must ensure that )(i) the building complies with the local fire service requirements and guidance and regarding this doors must not be kept open with anything other that will allow the automatic release of the door on the activation of the fire alarm system. DS0000069666.V367749.R01.S.doc 30/09/08 31/03/09 30/09/08 Lilburn Lodge Care Home Version 5.2 Page 28 5 OP19 23(2) 6 OP26 13(3) 7 OP27 18(1) 8 OP29 18 & 19 The manager must ensure that the building is well maintained and the identified repairs needed throughout the home and recorded in the body of this report are addressed quickly. These include: • The broken door guard • The broken door handles • The broken bath • The broken dishwasher The manager must ensure that the domestic routines currently followed are reviewed taking into consideration the implementation of effective infection control measures. The manager must ensure that the number of domestic staff needed is reviewed so that there is an assurance that the cleanliness of the home is kept to a good standard and service users are safeguarded by good infection control measures. The manager must ensure that the following points regarding CRB checks are adhered to: • Disclosures should be kept and not destroyed until after the CSCI inspection is complete to enable CSCI inspectors to see a sample at the next inspection. • In the event of a CRB check not being received and a decision has been taken to employ a person on the evidence of a clear application form, two good references and a clear POVA list check the person must follow a comprehensive induction programme while at the same time, until the CRB check has been received, be supervised by a named DS0000069666.V367749.R01.S.doc 30/09/08 30/09/08 30/09/08 30/09/08 Lilburn Lodge Care Home Version 5.2 Page 29 9 OP33 24(1)(a) (b) 10 OP38 12(1) member of staff at all times. The internal audits carried out 30/09/08 must realistically reflect the quality of the standard of the service delivered, so that improvements are made where needed and service users are safeguarded. 30/09/08 The health and safety issues highlighted in the body of this report must be addressed so that service users are safeguarded. These include: • Doors must not be kept open with anything other than an appliance recommended by the Fire Service and these must monitored and recorded with the regular fire checks. • The broken: door handles, dishwasher and bath must be repaired or replaced. • Effective infection control procedures must be reflected in the daily domestic routines and all staff must be aware of these. • The daily domestic routines must be reviewed. • The number of domestic staff to address these effectively must be reviewed. • CRB guidance must be followed. Lilburn Lodge Care Home DS0000069666.V367749.R01.S.doc Version 5.2 Page 30 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Lilburn Lodge Care Home DS0000069666.V367749.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. 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