Inspection on 17/01/06 for Lilliput House Rest Home

This inspection was carried out on 17th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Lilliput House Rest Home 21/08/06

Lilliput House Rest Home 06/09/05

Lilliput House Rest Home 21/02/05

Lilliput House Rest Home 07/09/04

Lilliput House Rest Home 02/02/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Lilliput House Rest Home 299 Sandbanks Road Poole Dorset BH14 8LH Lead Inspector Catherine Churches Unannounced Inspection 2.30 17 January 2006 th 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 DS0000051239.V277478.R01.S.doc Version 5.1 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. DS0000051239.V277478.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Lilliput House Rest Home Address 299 Sandbanks Road Poole Dorset BH14 8LH 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) 01202 709245 Mr Mark Edney Mrs Louise Edney Mrs Victoria Lynes Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places DS0000051239.V277478.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th September 2005 Brief Description of the Service: Lilliput House was originally two detached residential properties, which have been linked on the ground floor. It is set in a residential area of Poole and close to local shops and facilities as well as transport links. The registered providers, Mr and Mrs Edney, are frequent visitors to the home and the registered, day-to-day manager is Mrs Lynes. The home is registered to provide care and accommodation to a maximum of 20 residents in the category of OP (older people) and had no vacancies at the time of the inspection. Accommodation is offered on both the ground and first floors of the home. All bedrooms are for single occupancy and have ensuite facilities. There is a passenger lift on each side of the home therefore making all areas of the home fully accessible. The home has a comfortable main lounge and a separate dining room that also has some comfortable seating. Both of these areas are on the ground floor at the rear of the property and have views of the garden, which is attractively landscaped and well maintained. There are also communal bathrooms on both floors in addition to ensuite facilities. There is a parking area at the front of the property. DS0000051239.V277478.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place during the afternoon of 17th January 2006. The inspection took place as part of the regular, programmed inspection schedule for the home. This report should be read in conjunction with that from the inspection in September 2005 as all key inspection standards are reported on in these two reports. The purpose of this visit was to check that the home continues to run in a satisfactory manner and that the people who are living in the home are properly cared for. The premises were inspected and a number of records examined. Time was also spent time observing routines within the home and talking with residents and staff. The deputy manager was available throughout the inspection. What the service does well: What has improved since the last inspection? One recommendation was made at the last inspection regarding the introduction of an induction package for new staff. The home has addressed this very efficiently and now has a detailed and informative package for new staff that will help to ensure they have the necessary skills to provide effective care for residents. DS0000051239.V277478.R01.S.doc Version 5.1 Page 6 What they could do better: 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. DS0000051239.V277478.R01.S.doc Version 5.1 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 DS0000051239.V277478.R01.S.doc Version 5.1 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): None of these standards were assessed on this occasion as standard 3 was assessed at the last inspection and found to be met. Standard 6 is not applicable to Lilliput House. EVIDENCE: DS0000051239.V277478.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 Residents receive prescribed medicines at the correct times and in the correct amounts; those wishing to do so can manage their own medicines. Some recording procedures could be improved to provide an even higher level of risk management and further reduce the potential of harm to residents. EVIDENCE: Medicines in the medication cupboard were examined together with administration records and 3 care plans. Three residents were self-medicating. Risk assessments were found for 2 of the 3 residents. These were up to date and had been regularly reviewed. Risk assessments must be kept for all residents who retain any level control of their medication. Some controlled drugs are prescribed for residents in the home but not kept in a CD cupboard. A record of balances was not being kept. Additional medications added to the Medication Administration Record (MAR) were not being signed or counter signed to confirm that instructions and quantities were correct. DS0000051239.V277478.R01.S.doc Version 5.1 Page 10 There was no audit trail of initials of staff who sign the administration record. The deputy manager recognised signatures/initials but good practice is to keep a record of those authorised to administer medication and their signatures/initials. Records are kept of medication received but it was suggested that the MAR chart be used to its full extent with quantities received and signed for noted on this rather than another record. This also provides an improved audit trail. DS0000051239.V277478.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 15 Residents have the opportunity to choose their own lifestyle within the home and this means that their individual preferences and routines are respected. The social and recreational activities provided by the home meet the expectations of residents. Open visiting arrangements are in place enabling residents to retain contact with families and friends. Dietary needs of the residents are well catered for with a balanced and varied selection of food available that meets residents tastes and needs. EVIDENCE: There are regular in house activities provided by a nominated member of staff. Activities include visiting entertainers, quizzes, skittles, bingo and card games. A target game involving gentle exercise was taking place during the inspection. 9 people were taking part and enjoying interaction both with one another and the staff. Residents confirmed both in discussion and in comment cards that they were satisfied with the activities provided. The visitors book showed that there is a constant stream of visitors to the home and discussions with staff confirmed this as well as the fact that many residents are taken out by visitors. Food records and discussions with residents confirmed that a suitable and varied diet is provided in the home. Stocks were also inspected and it was found that there was a variety of different foods available with plenty of fresh, DS0000051239.V277478.R01.S.doc Version 5.1 Page 12 frozen and dried goods. Lilliput House is a relatively small home and therefore does not routinely provide a choice of meals. However, staff seek residents preferences and menus are displayed to enable residents to say that they do not like the meal that is planned and an alternative is then provided. DS0000051239.V277478.R01.S.doc Version 5.1 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 The home has a satisfactory system for making complaints. This means that residents and others involved in the home that may wish to make a complaint should feel confident that they would be taken seriously and that matters of concern will be acted upon. EVIDENCE: The home has a satisfactory complaints procedure that is included in the Service Users Guide. Those spoken to said that they would feel comfortable in making a complaint. No complaints have been made either to the home or the Commission for a considerable period. DS0000051239.V277478.R01.S.doc Version 5.1 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): None of these standards were assessed on this occasion as both key standards were assessed at the last inspection and found to be met. EVIDENCE: DS0000051239.V277478.R01.S.doc Version 5.1 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): 28,29, and 30 The home has a stable and consistent staff group providing consistency of care for the residents. Staff have not yet received the required NVQ training but a training programme is in place to address this. Residents should feel assured that they are in safe hands; training will provide further support and knowledge for staff. Staff vetting and recruitment practices are out of date. The home has therefore potentially put residents at risk. The arrangements for the induction of staff have improved which enables staff to have a clear understanding of their roles. EVIDENCE: Historically the home has classed most staff as housekeepers rather than carers and have therefore not implemented an NVQ training plan. However, it has become evident that the role of housekeeper does involve a care tasks and therefore a minimum of 50 of staff must be trained to NVQ level 2 or above. The deputy manager stated that a training programme for this is already being developed. Two new staff have been employed since the last inspection. Records for both staff were examined. Both had commenced duties without the required Criminal Records Bureau (CRB) and Protection of Vulnerable Adults list (POVA) checks and there was also only one of the two required references for one of the employees. DS0000051239.V277478.R01.S.doc Version 5.1 Page 16 The home has continued to provide various in-house courses in areas such as first aid, medication, and infection control. Evidence was available to demonstrate that new staff receive the necessary induction and foundation training. DS0000051239.V277478.R01.S.doc Version 5.1 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 and 33 The management arrangements of the home support good care practices for residents. A new quality assurance system has been introduced thereby helping to ensure that the home is run in the best interests of the residents. EVIDENCE: The registered manager of the home is currently on maternity leave. A deputy manager was recruited prior to her absence. The home has continued to be well run by the deputy manager together with some additional input from the registered providers, Mr and Mrs Edney. Residents confirmed that they were happy with the arrangements that had been put in place and staff appeared to have a good relationship with the deputy manager. The deputy manager has developed and implemented a comprehensive quality assurance system that has involved seeking residents, relatives and other stakeholders views. Their responses have been analysed and used to create a plan for further improving the services offered at Lilliput House. DS0000051239.V277478.R01.S.doc Version 5.1 Page 18 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 X X X x HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X X DS0000051239.V277478.R01.S.doc Version 5.1 Page 19 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. Standard Regulation Requirement The registered persons must ensure that all persons employed are fit to work in the home. The registered persons must obtain in respect of each person the documents listed in schedule 2 of the Care Homes Regulations 2001 and must be satisfied as to the authenticity of the references and information received. New staff must only be confirmed in post following completion of a satisfactory CRB and POVA check Timescale for action 1 OP29 19 31/01/06 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 OP9 Good Practice Recommendations Controlled drugs should be stored in the appropriate cupboard and running balance kept to enable quick identification of any missing medication. Minor improvements to the recording system for medication should be made to improve traceability and audit. A minimum of 50 of staff must be trained to NVQ level 2 or equivalent in care top ensure that staff are suitably qualified and competent. DS0000051239.V277478.R01.S.doc Version 5.1 Page 20 1 2 OP28 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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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