Inspection on 10/08/06 for Lillibet Lodge

This inspection was carried out on 10th August 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 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

Lillibet Lodge 03/08/05

Lillibet Lodge 11/04/05

Lillibet Lodge 05/10/04

Lillibet Lodge 27/05/04

Lillibet Lodge 15/03/04

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 Lodge 6 Rothsay Road Bedford Bedfordshire MK40 3PW Lead Inspector Mr Pursotamraj Hirekar Unannounced Inspection 10th August 2006 03:00 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 Lodge DS0000014928.V307804.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 Lodge DS0000014928.V307804.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lillibet Lodge Address 6 Rothsay Road Bedford Bedfordshire MK40 3PW 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) 01234 340712 01234 340414 Mrs Charlotte Chesyre Mrs Vivien Ann Stone Care Home 25 Category(ies) of Dementia - over 65 years of age (25), Old age, registration, with number not falling within any other category (25), of places Physical disability over 65 years of age (25) Lillibet Lodge DS0000014928.V307804.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is permitted to accommodate up to four service users in the category DE in the age range 55 -64 years. Date of last inspection Brief Description of the Service: The home is situated in a nice, quiet area of Bedford, not far from the town centre and with easy access to the riverside. The building provides accommodation in a homely environment, a large lounge accommodated a large number of service users who enjoyed company and there were, in addition, two smaller lounges for privacy for those who wanted a quiet corner. The home had a lift connecting the upper lounge and floors. A lower lounge was accessible down four small steps or by walking through the garden. The garden was mainly paved and is used by service users even in colder weather. A garden shed accommodated tumble driers for drying the laundry. Lillibet Lodge cared for 25 service users with dementia and general age related problems. The minimum fee is £430/- and the maximum was £525/-. Lillibet Lodge DS0000014928.V307804.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 10/08/06 over 3 ½ hours. The manager had coordinated the entire inspection. The methodology of the inspection included study of relevant care documents, discussion with the responsible individual, manager, staffs and service users’. Partial home visit was undertaken; observations were made of staffs and service users’ interaction. What the service does well: What has improved since the last inspection? What they could do better: The home must ensure appropriate statutory checks before the staffs are employed to ensure service users’ safety. The manager should ensure to take staffs signature on the staff supervision record. The manager should complete the quality assurance based on the views of the service users’ and relevant stakeholders and develop an annual development plan for the home. The home should ensure that all water points’ temperature is recorded separately. The home should revise the needs assessment tool for written evidence of holistic assessment. The home should ensure to revise the care-planning tool to Lillibet Lodge DS0000014928.V307804.R01.S.doc Version 5.2 Page 6 incorporate service user plan of care generated from a comprehensive assessment. 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. Lillibet Lodge DS0000014928.V307804.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 Lodge DS0000014928.V307804.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 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 a detailed need assessment prior to the admissions of potential service users’. However, the needs assessment tool needed revision to make it comprehensive. EVIDENCE: The previous inspection report had made a requirement that the admission assessment process must be carried out in all cases including transfer cases and there must be a written copy of that assessment held in the home. The home did not have any transfer from the sister home since mid 2005. The home has had 14 new admissions out of which 6 were respite and the rest 8 were for residential care. All the 14 service users’ had pre-admission assessment done and have been assured to the service users’ representatives that the home had the capacity to meet their assessed needs. The needs assessment tool was not comprehensive enough to record information in the case of service users’ diagnosed with dementia with regard Lillibet Lodge DS0000014928.V307804.R01.S.doc Version 5.2 Page 9 to the level and type of dementia. The home needs to revisit the needs assessment tool and update to record all appropriate information of the service users’. Lillibet Lodge DS0000014928.V307804.R01.S.doc Version 5.2 Page 10 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 at least once during a 12 month period. 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. However, the care planning tool needed revision to make it comprehensive. EVIDENCE: On this inspection 7 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 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. Elimination every day review include bowel Lillibet Lodge DS0000014928.V307804.R01.S.doc Version 5.2 Page 11 movement, diarrhoea, enemas, and laxatives. 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. The manager said that she would be reviewing the preadmission assessment tool, needs assessment tool and care planning tool with regard to service users’ with dementia. The manager had suggested 3 months time from the date of this inspection to complete the review of preadmission tool, needs assessment tool and care plan tool and transfer all the information of all the service users’ onto the new tools. The trained staffs administered the medication, the medicine was stored in a secure place and the medication records of all the service users’ were systemetically mainatained and filed with respective service user’s photagraph and the location of their bedroom. Staffs have good working relations with the service users’. The service users’ were happy and have expressed their satisfaction with the services delivered and staffs’ behaviour towards them as good. Lillibet Lodge DS0000014928.V307804.R01.S.doc Version 5.2 Page 12 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 at least once during a 12 month period. 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 home had a detailed social activity plan that included – aromatherapy, bingo, board games, cinema, cookery, craft work, gardening, hairdressers, knitting, manicure, needle work, outings, pedicure, physiotherapy, poetry, singing, story telling, visitors internal and external, art and maintaining. However, the activity plan varied based on the interest and choice of the service users’. As part of the safer food better business – food standard agency guidelines were followed for the preparation of the menu for the service users’ and their personal choices were also considered before the food menu was finalised. Service user personal property inventry had been maintainbed by the home for each individual service user and was signed by their respective representatives and a staff member. The home also had maintaibned a separate record of personal property items that were taken away by the representatives of the service users’ and appropriately signed. Lillibet Lodge DS0000014928.V307804.R01.S.doc Version 5.2 Page 13 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 inspected at least once during a 12 month period. 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 Lodge DS0000014928.V307804.R01.S.doc Version 5.2 Page 14 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 at least once during a 12 month period. 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 need to record water temperature seperatly for all the water points. EVIDENCE: The home was clean and maintained hygienically. Fire system, monthly emergency lighting, weekly fire alarm testing were regular. Weekly checks were carried out for loose wires or cables, electrical plugs and sockets, curtains and rails, carpet clean, carpet frayed, wardrobes of all the service users’ rooms. Water temperatures were recorded every month, which do not have clear information of all water points and was recorded in one place for all the points as the same temperature. The home had now clear marking on the bathrooms, toilets and and the residents rooms. Lillibet Lodge DS0000014928.V307804.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. 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. The home must ensure statutory checks prior to the appointments of the staffs’. EVIDENCE: The home has been using the tools developed by the Mulberry house for Induction, Foundation and Training record, which was comprehensive. The record included statutory checks, role of care worker, maintaining safety and welfare, accidents, fire safety, safe moving and handling, safe food handling, infection control, COSHH, security, emergency first aid, confidentiality, care values, promoting individuality and identity, promoting rights, promoting choices, promoting privacy, promoting dignity and respect, promoting independence, promoting achievement and fulfilment, promoting partnership, promoting equal opportunity, promoting anti-discriminatory practice, communication, delivering person centred services, providing personal care, eating and drinking, promoting continence, preventing pressure wounds, relationships, responsibility and limitations, abuse and neglect, reporting, specific syndrome and conditions, dementia care, challenging behaviour, medication, wheel chair, dying, death and bereavement. The home has had employed 3 new staffs and their individual files were seen on this inspection and the details are as follows; Staff-1 working as care assistant, job application, staff contract, interview notes, and 2 references were appropriate. The staff member did not have CRB and POVA and the staff member was working since April 2006 three days a week. Staff-2 working as Lillibet Lodge DS0000014928.V307804.R01.S.doc Version 5.2 Page 16 care assistant since 31/07/06, had job application, one reference, no CRB no POVA, and no contract. Satff-3 working as care assistant since 17/7/6, had made a job application, no CRB or POVA checks done, and had no references received yet. The manager had agreed to keep all the above 3 staffs’ out of the rota until their statutory checks were obtained. The home had planned a series of training g programmes for the staffs, both in house and with the support of external trainers’. The trainings that were implemented during May and June 2006 included moving and handling, infection control, nutrition, dementia, fire, health and safety, food hygiene, medication, first aid and POVA. On this inspection discussion with 2 staff members on duty were held and the summary outcome is as follows: Staff –1 working at the home for the last 2 years as assistant care worker and promoted to senior relief since June 2006. Responsibilities include making sure the needs of the service users’ are attended by the staffs, to ensure that the service users’ are taken to bed properly and oversee administration of medication. Training received include POVA, moving and handling, fire, medication, health and safety, currently pursuing for NVQ 2. Had supervision once month. No suggestions for improvement at the moment. Staff-2 working as care assistant since 2 years, responsibilities include help resident with personal care, take them to toilets, feed them, give brake fast. Trainings received include dementia awareness, health and safety, POVA, first aid, moving and handling, abuse, infection control, fire, food and hygiene. Currently pursuing for NVQ2. Suggestions for improvement include the repair and maintenance of equipment needs to be attended immediately when they fail like hovers and hoist. Lillibet Lodge DS0000014928.V307804.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home manager was competent and ensured good service delivery to meet the assessed needs of the service users’. Which, the manager should continue to sustain and improve further. EVIDENCE: The manager and the staffs work as a good team that enable all the staffs to give there best in the interest of the service users’. The manager was planning to undertake quality audit of the service delivered by the home through a structured questionnaire and seek feedback from various stakeholders that include service users’, service users’ representatives/carers/ family members/advocates, social; services, nurses, GP, and all other relevant professionals. This information would be analysed and used for development plan. Lillibet Lodge DS0000014928.V307804.R01.S.doc Version 5.2 Page 18 As part of staffs supervision the home had developed a monthly observation plan and a structured format was used to record observations for each staff member – that include bathing, attitude towards resident, satisfaction of resident, bathroom and bedroom was tidy and clean, service users’ reaction to the staff, toileting, all the training received was used in day to day work, did the staff need more training, are the staff interested in the service users’ and their job. All the staffs were supervised every six months. The manager has agreed to obtain the signatures of the concerned staff member on the supervision notes. The home does not manage any money of any service user. Lillibet Lodge DS0000014928.V307804.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 2 X X 2 HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 Lillibet Lodge DS0000014928.V307804.R01.S.doc Version 5.2 Page 20 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 OP29 Regulation 19 Requirement The home must ensure appropriate statutory checks before the staffs are employed to ensure service users’ safety. Timescale for action 20/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP3 OP19 OP33 Good Practice Recommendations The home should revise the needs assessment tool for written evidence of holistic assessment. The home should ensure that all water points’ temperature is recorded separately. The manager should complete the quality assurance based on the views of the service users’ and relevant stakeholders and develop an annual development plan for the home. The home should ensure to revise the care-planning tool to incorporate service user plan of care generated from a comprehensive assessment. The manager should ensure to take staffs signature on the staff supervision record. 4. 5. OP7 OP36 Lillibet Lodge DS0000014928.V307804.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: 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. 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