Inspection on 15/11/06 for Lillibet House

This inspection was carried out on 15th November 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Lillibet House 09/09/05

Lillibet House 05/04/05

Lillibet House 09/12/04

Lillibet House 05/04/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Lillibet House Lillibet House 65 De Parys Avenue Bedford Bedfordshire MK40 2TR Lead Inspector Mr Pursotamraj Hirekar Unannounced Inspection 15th November 2006 03:30 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 Lillibet House DS0000014927.V318240.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. Lillibet House DS0000014927.V318240.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lillibet House Address Lillibet House 65 De Parys Avenue Bedford Bedfordshire MK40 2TR 01234 272206 01234 345545 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) Mrs Charlotte Chesyre Care Home 30 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (30), of places Physical disability over 65 years of age (30) Lillibet House DS0000014927.V318240.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Including one resident under the age of 65 years, agreed with the CSCI. 9th September 2005 Date of last inspection Brief Description of the Service: Lillibet house is a residential home for older people situated in a residential street, not far from the centre of Bedford. The home was registered for 30 service users over 65 years of age, but specialised in caring for dementia, Alzheimers disease and minor physical disabilities. The home offered accommodation with 30 single rooms that corresponded to the required size, all with washing facilities (wash basin). The rooms were fully furnished, but the home encouraged service users to bring in their own personal items, such as items of furniture, TV, music systems, ornaments and pictures. This threestorey building, has 12 rooms on the ground floor, 12 on the first and 6 on the top floor, it also offered pleasant communal areas that created a homely environment. There is a lift to all three floors. There are two steps connecting the new extension to the rest of the building and this limited the access to this area for the less mobile of the service users. The home had ramps that allowed easy access to the garden for all, including the wheelchair users. The bathrooms and toilets were evenly positioned throughout the home and were equipped with appropriate facilities, rails, raising seats etc. An additional shower room on the ground floor provided choice to service users who preferred to shower rather than use the bath. At the front of the house, there is provision for 3-4 parking spaces. The back garden was secure, there is a brick wall protecting the grassed area in the middle and paving slabs surrounds it. The fee was in the range of £475/- to £525/-. Lillibet House DS0000014927.V318240.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced key inspection carried out by pursotamraj hirekar on 15/11/06 over 2 hours. The manager had coordinated the entire inspection. The methodology of the inspection included study of relevant care documents, discussion with the manager, staffs and service users’. Partial home visit was undertaken; observations were made of staffs and service users’ interaction. Post inspection, study of service users’ survey forms and manager’s pre-inspection questionnaire was taken into account. What the service does well: What has improved since the last inspection? What they could do better: The must ensure that there are adequate staffs working in such numbers as are appropriate for the health and welfare of service users’. The registered provider must ensure that the home had a registered manager. The registered provider shall visit at least once a month unannounced and prepare a report on the conduct of the home and shall make available for inspection. (Previous time scale 30/06/06). The home should revise the needs assessment tool for written evidence of holistic assessment. Lillibet House DS0000014927.V318240.R01.S.doc Version 5.2 Page 6 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. Lillibet House DS0000014927.V318240.R01.S.doc Version 5.2 Page 7 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 Lillibet House DS0000014927.V318240.R01.S.doc Version 5.2 Page 8 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): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had ensured need assessment prior to the admissions of potential service users’. EVIDENCE: The home had carried out pre-admission assessment for the potential service users’ and had assured to the service users’ representatives that the home had the capacity to meet there assessed needs. In an emergency 1 new admission of a service user had taken place on the 15/11/06, an initial assessment was carried out, the detailed assessment was planned to be completed on the 16/11/06. The 8 service users’ who have responded to the survey had said that they all had prior-information about the home and their families were satisfied that their needs will be met by the home. Lillibet House DS0000014927.V318240.R01.S.doc Version 5.2 Page 9 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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had carried out detailed need assessments and developed individual care plans. The care plans implementation were regularly reviewed. EVIDENCE: On this inspection 5 care plans were seen on a random basis and found that, the home had carried out needs assessments and developed care plans that included information on physical assessment and care plan – personal cleansing, personal dressing, eating and drinking, breathing, mobility, sleeping, elimination, vision, bowels, hearing, oral health, foot care, skin integrity, history/risk of falls, personal safety and risk and medical practitioners. Psychological assessment and care plan – communications, daily routines, social contacts, likes to do, does not like to do, cultural and spiritual needs, personal history, mental state, memory, numeric, expressing sexuality, emotional well being, interests, medical report, family details, social aims and Lillibet House DS0000014927.V318240.R01.S.doc Version 5.2 Page 10 objectives, home circumstances and hospital stays. Personal cleansing every day review include of shave, face wash, body wash, general bath, shower, hair wash and bed linen change. Manual handling – equipment used, behavioural constraints, physical constraints, handling constraints, history of falls, weight and assessment for risk to resident and staff when standing, walking, stairs, toileting, bathing, transfers, access to home, handling into/out of bed. However, the care planning tool needs revision to accommodate intervention plans in response to assessed needs in this case dementia. Service user –1 mobility risk assessment was carried out on the 05/11/06, nutritional risk assessment was carried out on 06/01/06, 09/05/06, 14/09/06. care plan was reveiewed on 09/05/06, 18/08/06, 18/09/06 and 31/10/06. personnal hygeine record was maintained that included bath, shave, sower, face wash, bodywash and hairwash, bed linen change. Service user –2 date of admission 06/02/02 and the latest care plan review was carried out on the 09/05/06. Service user -3 date of admision was 29/01/05 and the care plan reviews were carried out on 07/01/06, 09/05/06, 31/07/06, 07/09/06 and the latest was 05/10/06. Service user -4 date of admission was on 27/09/05 and the care plan review was carried out once in every 2 months the latest was carried out on the 27/10/06. the home had also carried out dependency review every month, nutrition review every 4 months or when necessary and weight every month. Service user –5 date of admission was on 15/03/06 and the care plan review was carried pout on the 08/05/06, 20/06/06, 07/07/06, 06/08/06 and the latest was on 14/09/06. The nutrition reveiew was carried out on the 14/05/06, 07/07/06 and the latest was on the 15/09/06. The administartion of medication was carried out by the staff members’. The medicine was stored in a secure place and the medication records of all the service users’ were systemetically mainatained The home had maintained regular daily contact records of the service users. Lillibet House DS0000014927.V318240.R01.S.doc Version 5.2 Page 11 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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users’ were engaged in appropriate activities. The dietary needs of the service users’ were taken care. EVIDENCE: the service users’ daily activities included radio, art & craft, music movement, church service, day centre, singing, garden, walking and going to the local shops. A daughter of service user user who normally vists her mother 3 to 4 times a week, on this inspection had said that ‘ my mother was living at this home for the last 8 years and this is a good home, good food and good people’. All the 8 service users’ have said in the survey that the home provided good food, enough quantity and presented well. 1 service user said that ‘i need more walk’. 1 service user said ‘ we understand staff are very busy but we would like to get out more to local shops in two’s or three’s for exercise, otherwise everything is very well run’. Lillibet House DS0000014927.V318240.R01.S.doc Version 5.2 Page 12 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s complaints policy and procedure that ensured the service users’ were protected from abuse. EVIDENCE: The complaints policy and procedures were in place and displayed appropriately. There has been no complaint since the previous inspection. Lillibet House DS0000014927.V318240.R01.S.doc Version 5.2 Page 13 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean and tidy. EVIDENCE: The home was clean and maintained hygienically. The home had carried out monthly service users’ room checks that included water temperature, light switch, light bulb, curtain rail, frayed carpet, wardrobe doors, taps, windows locks, commodes, air mattress, drawers, head board, cot sides, sink shelf, and door lock. The communal area water, fridge and freezer temperature records were maintained on a daily basis. The responses by the manager to the preinspection questionnaire received indicated that the recent fire drill was carried out on 31/10/06, the Environment Health Officer had visited on 29/08/06 and the recommendations were implemented, central heating system was checked Lillibet House DS0000014927.V318240.R01.S.doc Version 5.2 Page 14 on 16/11/06, emergency lighting was checked on 30/10/06. The various policies and procedures were recorded as available. These records were not verified on this inspection as the commission received this information after the inspection was carried out. Lillibet House DS0000014927.V318240.R01.S.doc Version 5.2 Page 15 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had a good skill mix of staffs and work as a team. EVIDENCE: The home had appointed 3 new staff members; staff member –1 had joined 4 weeks prior to this inspection POVA check was carried out and CRB clearance was awaited, the manager had said that reference from the former employer was received, the contract and the reference were at the head office. Staff member – 2 joined on the 14/10/06 CRB received was ok and the reference from the former employer was receieved. the manager had said that the reference and the contract papaers were at the head office. Staff member – 3 working since 01/06 as care assisstant, application, 2 references and CRB was made available on this inspection. However, the contract was not yet signed by the employer. Staff member – 4 was working as care assisstant for sometime now, whose application, contract, 2 refernces and CRB were all made avilable on this inspection. The staff deployment record for the month of 10/06 was seen on this inspection and found that the home had deployed 6 staffs in the morning, 5 in the afternoon and 3 for the night shift. The responses to the survey from 8 service users’ who said that they had appreciated the care and the services Lillibet House DS0000014927.V318240.R01.S.doc Version 5.2 Page 16 they received from the home as good. However, a couple of concerns surrounding the staffing levels have also been voiced by them, which the home must address in the best interest of the service users’. Currently, the home had 29 service users of which 11 service users’ who required 2 or more staff to undertake their care at day and night. The concerns as experienced by the service users’ were; 1 service user said ‘the home need to have adequate wheel chairs to reduce waiting time for the service users’. When asked do you receive the care and support you need 1 service users said ‘sometimes timing upsets – delays’. When asked do the staff listen and act on what you say – 1 service user said ‘invariably, depending on how many requests or availability’. 1 service user said that ‘I need more walk’. 1 service user said ‘ we understand staff are very busy but we would like to get out more to local shops in two’s or three’s for exercise, otherwise everything is very well run’. The home had carried out staffs training in the areas of moving and handling, fire, food hygeine, infection control, first aid, health and safety, dementia awareness, and update the staffs’ training record. Lillibet House DS0000014927.V318240.R01.S.doc Version 5.2 Page 17 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, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered provider, home manager and the staffs’ had good working realtion with the service users’ and their families to ensure good service delivery to meet the assessed needs of the service users’. The registered provider must prepare a monthly report on the conduct of the home and ensure to have a registered manager for continuity of good work and further improvements as necessary in the best interest of the service users’. EVIDENCE: The manager had returned form the maternity leave on the 26/06/06 and is yet to become a registered manager. 5 staffs’ supervision record was seen on this inspection. Staffs’ supervision was carried out every alternate month, the Lillibet House DS0000014927.V318240.R01.S.doc Version 5.2 Page 18 manager was in the process of broadening the areas of staff supervision. Currently, the areas included issues discussed, action taken and further comments. A daughter of service user user who normally vists her mother 3 to 4 times a week, on this inspection had said that ‘ my mother was living at this home for the last 8 years and this is a good home, good food and good people’. The finances records of 3 service users’ was seen on this inspection, the home had maintained well. The registered providers monthly report was not made available on this inspection. The registered provider had said on the random inspection of 10/05/06 that she is the sole owner of the service and visits a minimum of three times a week and sometimes more, and was involved in all management affairs of the home on a day to day basis. Furthermore, the registered provider had also mentioned that the place where she lives was connected by the internet to both the homes she owns, and also has an internal telephone system connected to both places. This enables her to keep an eye and watch both the homes even when not physically present at these homes. The registered provider said that she has full control of the home and does not feel the need to do a Reg 26 report to CSCI, as this will be an additional burden of paper work to the registered provider. Towards the recommendations made by the fire authority ‘that all fire exit doors that are required to be locked when the building is in use should be secured by a means that does not require the use of a key’ the home had carried out a risk assessment and decided that a key was in a secured box and access to the key is guaranteed at all times and the staff are informed of the location. Lillibet House DS0000014927.V318240.R01.S.doc Version 5.2 Page 19 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 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Lillibet House DS0000014927.V318240.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? Yes 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. 2. Standard OP31 OP33 Regulation 9 26 (4)(c) (5)(a) Requirement Timescale for action 30/01/07 The registered provider must ensure that the home had a registered manager. The registered provider shall visit 30/12/06 at least once a month unannounced and prepare a report on the conduct of the home and shall make available for inspection. (Previous time scale 30/06/06) 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 Lillibet House DS0000014927.V318240.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lillibet House DS0000014927.V318240.R01.S.doc Version 5.2 Page 22 - 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. 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