CARE HOME ADULTS 18-65
Lilena 2 Quintrell Road St Columb Minor Newquay Cornwall TR7 3DZ Lead Inspector
Kerensa Livingstone Unannounced Inspection 10th January 2006 09:30 Lilena DS0000009273.V264868.R01.S.doc Version 5.0 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 Lilena DS0000009273.V264868.R01.S.doc Version 5.0 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. Lilena DS0000009273.V264868.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Lilena Address 2 Quintrell Road St Columb Minor Newquay Cornwall TR7 3DZ 01637 877662 01637 876547 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) Ms Lesley Richardson Mrs Angela Jeannette Warne Care Home 14 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (14) of places Lilena DS0000009273.V264868.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. To include service users who are sixty-five years of age or under on admission to the home 9th August 2005 Date of last inspection Brief Description of the Service: Lilena is a care home registered for up to 14 service users with a Mental Disorder who are admitted to the home under the age of sixty-five. The home is in St Columb Minor on the main road, near Newquay. The home offers accommodation for ten individuals within the main house, there is another part of the home for three people who live more independently and there is an attached bungalow that accommodates one person for greater independence again. There is a small patio area to the rear and a lawn to the front of the home; this is situated next to the main road that goes into Newquay. The Registered Provider owns another home catering for the same client group on the edge of Newquay and care staff work between the two homes. There is car parking to side and rear of the home. Lilena DS0000009273.V264868.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted by an Inspector who has visited the home since the beginning of 2004. The Inspector had the opportunity to speak with Service Users, staff, the Registered Manager and the Provider. The environment, documentation and Service Users records were inspected. What the service does well: What has improved since the last inspection? What they could do better:
There has been some reservation about completing certain training, the management team are planning to address this. Staff are encouraged to do the National Vocational Qualification training and are given two hours a week to study for this. Five staff are currently studying for their National Vocational Qualification Level 3, however to date no one has completed it. Therefore this does not meet the minimum recommendation of 50 of the care staff have achieved their National Vocational Qualification Level 2 by 2005. There are times that the staffing levels within the home are minimal, this reduces the staff members ability to respond to individual wishes, needs or
Lilena DS0000009273.V264868.R01.S.doc Version 5.0 Page 6 choices. At previous inspections, the numbers of staff on duty have been discussed with the Provider and Manager who have assessed them to be adequate to meet the needs of the Service Users. There are no waking night staff, two staff sleep in. On previous inspections the Inspector had understood that there were two staff during the day and night, who undertake all the roles within the home. However during this inspection the Inspector was informed that there is only one staff member on from 2pm until 9pm. The staff undertake cleaning, laundry, catering and administrative duties, in addition to caring. The Registered Manager and Inspector discussed the ability of staff to respond to their caring role with the additional demands placed upon them. Additional hours are provided for one to one activities, if additional funding is provided. The Registered Manager is available in the home Monday to Friday during office hours. The Service Users spoke highly of the staff and the support that they provide. 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. Lilena DS0000009273.V264868.R01.S.doc Version 5.0 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 Lilena DS0000009273.V264868.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&5 Prospective Service Users are provided with clear information enabling them to make an informed choice about where to live. EVIDENCE: The Statement of Purpose is a comprehensive and professionally presented document that is made available. This includes information about the environment. The Service Users Guide sets out clear and accessible information. All prospective Service Users are issued with a copy including the most recent inspection report. At the last inspection it was recommended that the Terms and Conditions should be amended to identify the individual service user’s room. New contract are due to be provided to all Service Users, as these are been updated. Lilena DS0000009273.V264868.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6&8 Service Users demonstrated that they are able to make choices and decisions about how they live their lives. EVIDENCE: All service users have an individual plan of care, which are reviewed at least every 6 months, earlier if necessary. This is based upon a Care Management assessment and full assessment by the home, prior to admission. External professionals such as Community Psychiatric Nurses attend review meetings as appropriate. There is evidence within the documentation that Service Users and their representatives are involved in this process. Service Users demonstrated during the inspection that they felt able to express their wishes at their reviews. Risk factors and risk management strategies are included within this documentation. Restrictions of choice and freedom are clearly documented with in these documents, the Inspector and Registered Manager discussed the importance of Service Users agreeing to any restrictions in freedom or choice. Following a recommendation at the last inspection, the Registered Manager is setting up a ‘policy group’, consisting of staff and service users from Lilena and
Lilena DS0000009273.V264868.R01.S.doc Version 5.0 Page 10 Pentree Lodge, with the remit of developing and reviewing policies and procedures. Service Users informed the Inspector that they felt able to express their wishes and knew who to speak with if they had any concerns. Lilena DS0000009273.V264868.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not assessed formally during this inspection, however they all met or exceeded the minimum standards at the last inspection. Lilena DS0000009273.V264868.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 & 19 Service Users are able to access personal and healthcare support in a way that respects their choice and privacy. EVIDENCE: Individuality is respected and independence promoted. All Service Users rooms have a door lock. Service Users choose who may or may not enter their room. Personal support is provided in their room or in the clinical room. All Service Users have single room accommodation. The Inspector was informed by Service Users that their privacy was respected and they felt able to make decisions about their lives that are respected. The care documentation shows that the service users have access to the relevant healthcare professionals needed such as Community Psychiatric Nurse, General Practitioner, Outpatients specialist advice, Optician and Dentist. Annual health checks are being arranged with the local General Practitioner and medication is reviewed regularly. The service users informed the Inspector that they were able to access all the healthcare services that they need and this was reflected within their care documentation. Following the recommendations at the last inspection the Registered Manager is ensuring that there are two staff initials when it is necessary to transcribe
Lilena DS0000009273.V264868.R01.S.doc Version 5.0 Page 13 MAR sheets, toughened glass has been provided for the window of the medicines room to enhance the security of the medicines and the medicines cupboard has been fixed to the wall. Lilena DS0000009273.V264868.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Service users have the opportunity to express any concerns and are protected from abuse. EVIDENCE: The home has Complaints policy and procedure. The procedure includes the stages and timescales as required. This document is reviewed annually and staff sign to say they have read and understood it. Service users have a copy of the Complaints Procedure within the Service User Guide, this includes that the complainant can contact the Commission at any stage. A record is kept of complaints. At inspection the Service Users demonstrated they felt able to discuss any issues. There is a clear policy and procedure for the Protection of Vulnerable Adults, this includes local procedures and contact details. The Registered Manager has attended the Alerter’s training and staff have watched the ‘No Secrets’ training video. Evidence of staff training is available for inspection. Lilena DS0000009273.V264868.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 & 30 The Service Users live in a homely and comfortable environment. Their accommodation is personalised and promotes independence. EVIDENCE: The home is appropriate to meet the needs of the service users who live in there. The home is safe, comfortable and homely. There is a designated smoking area in the conservatory at the front of the home. There is evidence that redecoration is taking place within the home. The Inspector spoke with Service Users who stated that the premises met their needs and felt homely. There are 10 bedrooms in the main home, 3 in the flat and one in the bungalow. All bedrooms provide satisfactory space for the service users who live in the home. The inspector observed that the bedrooms were suitably equipped to meet the needs of the service users. Service users have locks on their bedroom doors. Service users are able to have their own furniture in the home and personalise their bedrooms according to individual tastes. Service Users told the Inspector that they liked their accommodation and the privacy that it afforded them, but with the back up of support if needed.
Lilena DS0000009273.V264868.R01.S.doc Version 5.0 Page 16 Bathroom and toilet facilities are suitable to meet the needs of the service users who live in the home. There are five toilets in the main house, three baths and one shower. The hot water in the home is unregulated, this includes bathing facilities; advice has been sought from the Environmental Health Officer and risk assessments completed. The Inspector discussed their concerns with the Registered Provider regarding this and the risk it poses with an aging client group. One bathroom was closed on the day of the unannounced inspection during to a maintenance problem, the maintenance person was addressing this. The lounge, conservatory and dining area provides communal space for shared activities or private use. These are made homely and comfortable. There is a designated smoking area. There is a small lawned area to the front of the home. There are no environmental adaptations in the home as all service users currently accommodated are fully mobile and do not have any sensory impairments. There is no call bell system, the Registered Manager has previously advised the Inspector that a risk assessment had been undertaken and it was not felt that this was needed. Adaptations would be arranged on an individual basis, as required. The home was clean, hygienic and free from odours throughout at the inspection. The laundry facilities of the home meet the needs of the Service Users. There are up to date Policies and Procedures relating to Infection Control. Lilena DS0000009273.V264868.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33 & 36 The staff undertake generic roles, in addition to caring within the home which may reduce the staff members ability to respond to individual wishes, needs or choices. There has been some reservation about completing certain training, the management team are planning to address this. EVIDENCE: There is a staff training and development plan. The Registered Manager informed the Inspector that all new staff complete the Skills for Care induction the Inspector was advised, this includes support, working alongside another more experienced member of staff and regular reviews. Staff appeared to be suitably skilled, knowledgeable and experienced to carry out their roles. The staff are encouraged to do the National Vocational Qualification training and are given two hours a week to study for this. Five staff are currently studying for their National Vocational Qualification Level 3, however to date no one has completed it. Therefore this does not meet the minimum recommendation of 50 of the care staff have achieved their National Vocational Qualification Level 2 by 2005. Lilena DS0000009273.V264868.R01.S.doc Version 5.0 Page 18 At previous inspections, the numbers of staff on duty have been discussed with the Provider and Manager who have assessed them to be adequate to meet the needs of the Service Users. No one under twenty one is left in charge of the home and no one under eighteen is providing personal care. There are no waking night staff, two staff sleep in. There are two staff during the day and night, who undertake all the roles within the home. In addition to the permanent Service Users, there is a ‘sanctuary’ provision and a ‘crisis’ bed, which may require more interventions from staff. The staff undertake cleaning, laundry, catering and administrative duties, in addition to caring. Additional hours are provided for one to one activities, if additional funding is provided. The Registered Manager is available in the home Monday to Friday during office hours. The Service Users spoke highly of the staff and the support that they provide. There is a designated maintenance person who usually works one day a week. Staff receive regular informal supervision from the Registered Manager on a day-to-day basis as required. This is supplemented by formal one to one supervision that takes place every two months. An appraisal is completed annually. Comprehensive records are kept of supervision sessions. Staff have confirmed that they felt supported in their work and enjoyed working at Lilena. Lilena DS0000009273.V264868.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 40, 42 & 43 Service users benefit from a well run home, their rights and best interests are protected. There is evidence that practices within the home are monitored and reviewed. The health and safety of the Service Users is protected. EVIDENCE: The Registered Manager has a comprehensive quality assurance system in the home, which has resulted in a very thorough and comprehensive report on various stakeholders’ views of the service. This has involved surveys of staff, service users, family members and external professionals. This is conducted annually and is addition to other internal regular audits. The report also outlines a plan of service improvements. This information is made available to the Service Users in a file in the communal area and is provided to all prospective Service Users. The home has a comprehensive manual of policies and procedures, which all staff have signed to state they have read and understood. Policies are reviewed on a regular basis. A ‘policy group’ is due to be commenced involving Service Users.
Lilena DS0000009273.V264868.R01.S.doc Version 5.0 Page 20 Appropriate Policies and Procedures relating to Health, Safety and Riddor are available within the home. Health and safety risk assessments are completed and reviewed. No water is regulated within the home and hot surfaces are uncovered. The Registered Provider and Inspector discussed concerns regarding unregulated water in facilities that offer full immersion particularly with an ageing client group and it was agreed that this would be reconsidered, seeking advice from the Environmental Health Officer, if this had not been previously done. The Inspector was advised that all first floor windows are restricted. A legionella risk assessment has been completed. There is a Fire risk assessment in place. Staff are provided with regular Fire training the records confirmed this. The Accident Book complies with the Data Protection legislation. Certification was available at inspection to confirm that equipment and utilities are checked regularly, for example Gas 05/05, Portable appliance testing 11/05, hard wiring certification 01/04. A record is kept of all visitors to the care home. Suitable records are maintained in regard to the home’s finances. Evidence of financial viability is to be provided as part of the annual inspection process. Employers Liability Insurance is in place. There is evidence of redecoration and refurbishment within the home. Lilena DS0000009273.V264868.R01.S.doc Version 5.0 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 3 X X Standard No 24 25 26 27 28 29 30
STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 3 X X 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Lilena Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score X X 3 3 X 3 3 DS0000009273.V264868.R01.S.doc Version 5.0 Page 22 No Are there any outstanding requirements from the last inspection? 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 YA32 Regulation 18 (1c) Requirement The Registered Provider is required to ensure that persons employed in the home receive training appropriate to the work that they perform, for example a minimum of 50 qualified to National Vocational Qualification Level 2 or more. Timescale for action 01/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Lilena DS0000009273.V264868.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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