Inspection on 09/08/05 for Lilena

This inspection was carried out on 9th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Lilena 15/03/07

Lilena 10/01/06

Lilena 13/12/04

Lilena 25/05/04

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

CARE HOME ADULTS 18-65 Lilena 2 Quintrell Road St Columb Minor Newquay Cornwall, TR7 3DZ Lead Inspector Alan Pitts Unannounced 9 August 2005 10:00 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 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 Stationary 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 D52 D04 9273 Lilena V235406 090805 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Lilena Address 2 Quintrell Road, St Columb Minor, Newquay, Cornwall, TR7 3DZ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01637 877662 01637 876547 Ms Lesley Richardson Mr Neil Harrison Mrs Angela Jeannette Warne Care Home 14 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (14) of places Lilena D52 D04 9273 Lilena V235406 090805 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: To include service users who are sixty-five years of age or under on admission to the home Date of last inspection 13/12/04 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 D52 D04 9273 Lilena V235406 090805 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Lilena is well managed and meets its stated purpose. Service users are comfortable, and clearly benefit from the support available to them from the staff. What the service does well: What has improved since the last inspection? What they could do better: Lilena D52 D04 9273 Lilena V235406 090805 stage 4.doc Version 1.40 Page 6 The home could improve the security of medicines, and the induction training available to new staff. 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 D52 D04 9273 Lilena V235406 090805 stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Lilena D52 D04 9273 Lilena V235406 090805 stage 4.doc Version 1.40 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 standard(s) 2, 3, 4, 5 Service user’s care needs are assessed, and they are provided with the information they need. EVIDENCE: All admissions previously unknown to the home are preceded by a riskassessment and a care needs assessment from the referring health care team. The staff are knowledgeable of the service users. Service users spoken with confirmed their needs are met. Care plans and risk-assessments are in operation for each service user. Prospective service users visit the home, meeting the registered manager and the existing service users. All new service users have a 4-week trial period. Service users sign a key agreement and property disclaimer. Each service user has a Statement of Terms and Conditions. The Statement of Terms and Conditions should be amended to identify the individual service user’s room. Lilena D52 D04 9273 Lilena V235406 090805 stage 4.doc Version 1.40 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 standard(s) 6, 7, 8, 9, 10 Service users have their needs assessed and are able to take risks and make decisions about their lifestyle. EVIDENCE: Care plans are in operation for each service user, which show evidence of review, are up-to-date, and are signed by the respective service user. The care plans show evidence of input from other healthcare professionals. Riskassessments are in place for each service user. Staff will attempt to persuade a service user if they think they are making a decision that may adversely affect their welfare or that of others. The staff will liaise with other healthcare professionals. Any restrictions placed on service users are clearly recorded in the risk-assessments and care records. Service users participate in daily chores, such as room cleaning and meal preparation. There is a monthly, recorded, service user meeting. The Registered Provider should consider the possibility of a ‘policy group’, consisting of senior staff and service users from Lilena and Pentree Lodge, with the remit of developing and reviewing policies and procedures. Lilena D52 D04 9273 Lilena V235406 090805 stage 4.doc Version 1.40 Page 10 Comprehensive risk-assessments and care plans are in operation. A confidentiality policy is in operation, and the care staff showed that they had a good understanding of the issues. Lilena D52 D04 9273 Lilena V235406 090805 stage 4.doc Version 1.40 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 standard(s) 11, 12, 13, 14, 15, 16, 17 Service users have opportunities for personal development, participate in the local community, and have their rights respected. EVIDENCE: Afternoon and evening activities are available to service users every day. The permanent service users have an annual holiday. There is an annual trip to the pantomime in January. There are usually three trips planned during the summer months that are decided by the service users. Two service users attended college and now have work placements. All the service users have some external contact via such things as day centres, coffee groups and church. Some service users have access to other professional inputs, such as an art therapist. The service users make use of the local facilities such as the shops, cafes and pubs. Most of the service users have family contact, but all have a professional contact. There is comprehensive care documentation, and policies and procedures, which allow service users independence and choice within the home. Staff sign to say that they have read policies and procedures. Lilena D52 D04 9273 Lilena V235406 090805 stage 4.doc Version 1.40 Page 12 All the service users spoken with confirmed that the food provided was of a good standard. The home is now recording when an alternative to the planned menu is provided (though care should be taken to ensure that all staff do this). Service Users are supported to participate in the preparation of the meals. Vegetarian and special diets will be catered for. There is the opportunity for Service Users who live in the ‘annexe’ attached to the home to have their own shopping budget and prepare their own food. Information is gathered about the food that Service Users like and dislike. Lilena D52 D04 9273 Lilena V235406 090805 stage 4.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21 Service user’s physical and emotional health needs are met. EVIDENCE: The care documentation shows that the service users have access to the relevant healthcare professionals needed, and active appointments were evident at the inspection. The service users spoken with were effusive about the quality of care and support provided by the home’s staff. There are no controlled drugs stored on the premises and no facilities to do this. The medicine cupboard is not fixed to the wall. The Registered Provider is required to ensure that medicines are administered and stored safely, in adherence with the Royal Pharmaceutical Guidelines 2003; in the context of this report specifically to provide a suitable facility for storing the medicines. The Registered Provider should consider the provision of toughened glass on the window of the medicines room to enhance the security of the medicines. A medicines policy is in operation, and medicine information is available to staff. Medicines are administered from the medicine room. Medicine Administration Records (MAR) were inspected and seen to be in order, and these are largely printed by the supplying pharmacist. Where it is necessary to transcribe prescriptions onto a MAR sheet the Registered Manager should ensure that Lilena D52 D04 9273 Lilena V235406 090805 stage 4.doc Version 1.40 Page 14 there are two staff initials to indicate that the instructions have been checked. The home uses a monitored dosage system. Service user’s wishes in respect of illness and death is recorded. Lilena D52 D04 9273 Lilena V235406 090805 stage 4.doc Version 1.40 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23 Service users have the opportunity to express any concerns or feelings, and are protected from abuse. EVIDENCE: A number of service users have planned 1 to 1 time with staff. There is a comprehensive complaints procedure in operation (it is suggested that the Registered Manager change the response timescale to 28 days rather than the existing 5 days). There is a clear policy and procedure for the Protection of Vulnerable Adults, and this includes local procedures. Training is included in the staff induction programme. Lilena D52 D04 9273 Lilena V235406 090805 stage 4.doc Version 1.40 Page 16 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 standard(s) These standards were not inspected at this time. EVIDENCE: Lilena D52 D04 9273 Lilena V235406 090805 stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 34, 35 Staff have clear responsibilities. Service users are protected by the home’s employment procedure. EVIDENCE: Clear job descriptions are in place for all staff. One member of staff has achieved the BTEC in Health and Social Care. Five staff are undertaking NVQ training. The Registered Manager has completed the Registered Manager Award. Distance learning course have been made available to staff via a local college: 1st Aid, Health and Safety, medication, dementia care, and the Basic Food Hygiene Certificate. Those staff yet to undertake this training are booked to commence later this year. A sample staff personnel file was inspected and found to show that a robust employment procedure is in operation. There is an induction programme for new staff, which has been adapted from a National Training Organisation programme. Lilena D52 D04 9273 Lilena V235406 090805 stage 4.doc Version 1.40 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 41 Service users benefit from a well run home, and their rights and best interests are protected. EVIDENCE: The Registered Manager provides the day-to-day management in the home and has a Degree in Youth Work and Community Studies. She has worked at Lilena for approaching eight years and has achieved the Registered Manager’s Award. In addition the Registered Manager has completed Adult Protection training. The Registered Provider is involved managerially with the home and is a Registered Mental Nurse. Service users were complimentary about the attitude and approachability of the staff at Lilena. A visitor’s book is used, though this is sometimes prone to damage and the Registered Manager is looking into ways this arrangement can be improved. The general standard of record keeping is noteworthy and staff are to be commended. Lilena D52 D04 9273 Lilena V235406 090805 stage 4.doc Version 1.40 Page 19 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 x 3 3 3 2 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 2 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 3 3 3 4 3 3 3 Standard No 31 32 33 34 35 36 Score 3 x x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Lilena Score x 3 2 3 Standard No 37 38 39 40 41 42 43 Score 4 4 x x 3 x x D52 D04 9273 Lilena V235406 090805 stage 4.doc Version 1.40 Page 20 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 20 Regulation 13 Requirement The Registered Provider is required to ensure that medicines are administered and stored safely, in adherence with the Royal Pharmaceutical Guidelines 2003; in the context of this report specifically to provide a suitable facility for storing the medicines. Timescale for action 01/11/05 2. 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 5 8 Good Practice Recommendations The Statement of Terms and Conditions should be amended to identify the individual service user’s room. The Registered Provider should consider the possibility of a ‘policy group’, consisting of senior staff and service users from Lilena and Pentree Lodge, with the remit of developing and reviewing policies and procedures. Where it is necessary to transcribe prescriptions onto a MAR sheet the Registered Manager should ensure that there are two staff initials to indicate that the instructions have been checked. The Registered Provider should consider the provision of D52 D04 9273 Lilena V235406 090805 stage 4.doc Version 1.40 Page 21 3. 20 4. Lilena 20 toughened glass on the window of the medicines room to enhance the security of the medicines. Lilena D52 D04 9273 Lilena V235406 090805 stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection 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 © 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 Lilena D52 D04 9273 Lilena V235406 090805 stage 4.doc Version 1.40 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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