Inspection on 07/09/04 for Lilliput House Rest Home

Care Home For Older PeopleLilliput House Rest Home299 Sandbanks Road Poole Dorset BH14 8LHUnannounced Inspection7th September 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Lilliput House Rest Home Address 299 Sandbanks Road, Poole, Dorset, BH14 8LH Email address mark@ashwell-lodge.co.uk Name of registered provider(s)/company (if applicable) Mr Mark Edney Mrs Louise Edney Name of registered manager (if applicable) Mrs Victoria Lynes Type of registration Care Home No. of places registered (if applicable) 20 Tel No: 01202 709245 Fax No:Category(ies) of registration, with (number of places) Old age, not falling within any other category (20) Registration number D080000670 Date first registered 11th December 1991 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 27th November 2003 YES NO 02/02/04 If Yes refer to Part CLilliput House Rest HomePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 37th September 2004 10:30 am Catherine ChurchesID Code072712Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMrs V LynesLilliput House Rest HomePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementLilliput House Rest HomePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Lilliput House Rest Home. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Lilliput House Rest HomePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Lilliput House was originally two detached residential properties, which have been linked on the ground floor. It is a residential area of Poole and close to local shops and facilities as well as transport links. Mr and Mrs Edney who own the home are frequently at the home which is managed by Mrs Lynes. The home is registered to provide accommodation for a maximum of 20 service users in the category 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, with all bedrooms being single and offering en-suite facilities. A passenger lift is available to the first floor on both sides of the home. There is a comfortable main lounge on the ground floor, with a separate dining room that also has some comfortable seating. There are communal bathrooms on both floors. There is parking at the front of the house and at the back of the property there is a wellmaintained garden, which offers shady areas, raised beds and various areas for sitting as well as a sun house.Lilliput House Rest HomePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This was an unannounced inspection that took place during the morning of on 7th September 2004. The home is owned Mr and Mrs. Edney and managed by Mrs Lynes the registered manager. Mrs Lynes was present throughout the inspection. The Inspector appreciated her assistance and that of the staff. At the time of the inspection there were 20 service users accommodated at the home. The inspection concentrated on the requirements/recommendations of the last inspection together with a review of some of the other National Minimum Standards. Not all standards were assessed during this visit and the reader is referred to previous inspection reports available from the home. Nine Service Users were spoken with during the course of this inspection: all were satisfied with the level of care provided and the facilities and services at the home. Five ladies were seated together in the lounge drinking coffee. They were clearly a close community and enjoyed being able to meet together as well as watching some of the soaps together. The Inspector found that Lilliput House provides a good standard of care within a truly homely and caring environment. The home continues to perform well and to strive to make improvements for the benefit of Service Users. Very few issues were identified for attention during this inspection. Choice of Home (Standards 1-6) All 2 of the 3 standards assessed on this occasion were met and 1 was partially met. The documentation available to service users is informative and should help a service user to make an informed choice about whether they wish to live at Lilliput House. Systems are in place to ensure that Service Users and their representatives know that, when they enter the home, their needs will be met. Health and Personal Care (Standards 7-11) All 3 of the standards assessed on this occasion were partially met. Service users confirmed that they are happy with the standard of care they receive in the home. The Service Users health, personal and social care needs are set out in an individual plan of care that is updated and reviewed as required. Recommendations on further improvements to records have been made in this report. Service users rights to make decisions about their lives are supported and assistance provided as necessary. They confirmed that they are treated with respect and that their right to privacy is upheld. Lilliput House Rest Home Page 6 Daily Life and Social Activities (Standards 12-15) One standard was assessed and this was found to be met. The home provides an interesting and varied menu and service users confirmed that they were happy with the food. Complaints and Protection (Standards 16-18) 1 of the standards was assessed and found to be fully met. The home also has a policy and procedure in place for the Protection of vulnerable adults and training for all staff in this very important matter has already taken place in house for a number of staff. Environment (Standards 19-26) 3 of the 4 standards assessed were fully met and 1 was partially met. The home has a cosy, relaxed atmosphere and those areas seen were clean and free from unpleasant odours. Communal areas, as well as bedrooms, are nicely decorated and furnished. There was evidence of personalisation in all of the Service Users rooms. Staffing (Standards 27-30) 2 of the 3 standards were assessed and found to be met Staffing levels and the skill mix of the staff ensures that the care needs of the service users are met. Management and Administration (Standards 31-38) 5 of the standards assessed were met. The registered manager is well qualified and has a great deal of experience in the care of the elderly. The Inspector noted that there is an open and positive atmosphere in the home and Service Users and staff clearly had a good relationship with the manager.Lilliput House Rest HomePage 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard 3 OP22 A qualified person such as an occupational therapist should assess the premises.CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)Lilliput House Rest HomePage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action The service uses plan of care should be drawn up with the involvement of the service user and agreed and signed by the service user whenever capable and/or representative (if any). Service users psychological health must be monitored regularly to ensure that preventative and restorative care is provided. This must be recorded. Nutritional screening must be undertaken on admission and subsequently on a periodic basis. A record must be maintained of nutrition including weight gain and loss and the action taken. The registered person must ensure that service users wishes concerning terminal care and death are discussed, recorded and carried out.115(1)OP730/12/04213(1)(b)OP830/12/04314(1)OP830/12/04412(1)OP1130/03/05Lilliput House Rest HomePage 9 RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * It is recommended that all documents giving information regarding the Commission for Social Care Inspection should be updated to reflect the change of the Authoritys name from National Care Standards Commission to Commission for Social Care Inspection. It is recommended that suitably qualified persons including a qualified occupational therapist with specialist knowledge of the client group that the home caters for make an assessment of the premises and facilities1OP12OP22* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Lilliput House Rest HomePage 10 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES NA YES YES YES NO NA NO YES YES YES NO YES NA NA NA YES NO YES 10 X X YES YES YES YES X 0 07/09/04 10:30 2Lilliput House Rest HomePage 11 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Lilliput House Rest HomePage 12 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) 385.00 420.00Any charges for extras If yes, please state what the extras are: Key findings/EvidenceNO Standard met? 2The home has produced an informative and interesting Statement of Purpose and Service Users Guide. The information provided should enable prospective Service Users to make an informed choice about whether they wish to choose to live at Lilliput House. The inspector advised that all documents should be updated to reflect the change of the Authoritys name from National Care Standards Commission to Commission for Social Care Inspection.Lilliput House Rest HomePage 13 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 3 Key findings/Evidence Standard met? Since the last inspection this document has been reviewed and additional information included. The inspector checked 3 service users files and signed copies of the contract were found on these files. Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion. At the last inspection in February 2004, this standard was assessed as met and exceeded. (With a score of 4 given). Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? The home has a very clear policy of only admitting service users who require minimal assistance. Discussions with the manager confirmed that staff are experienced and have received training in the mandatory subjects. The manager was also clear that should specialised assistance be required for service users then this would be sought. One person who has had a stroke regularly attends a stroke club and another person who is blind has been provided with various pieces of equipment including a talking watch and talking books. Mrs Lynes confirmed that following pre-admission assessment she writes to the service user to confirm that their needs can be met. A letter such as this was noted on one of the service user files that were checked on this occasion.Lilliput House Rest HomePage 14 Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion. At the last inspection in February 2004, this standard was assessed as met. (With a score of 3 given). Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? This standard is not applicable, as Lilliput House does not provide intermediate care.Lilliput House Rest HomePage 15 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 2 Key findings/Evidence Standard met? Two files were checked. Each file contained the required information and photograph as well as clear information about each persons needs and how these needs are to be met. There was evidence available that care plans and various risk assessments are reviewed at the required intervals. The need to provide evidence of service users involvement in the care plan was discussed. The manager advised that needs change very infrequently but as and when a complete assessment is required then she will ensure that service users are involved. The inspector advised that the service users preferred form of address must be recorded.Lilliput House Rest HomePage 16 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) Key findings/Evidence X 0 Standard met? 2Examination of records, discussion with the manager and deputy manager and observation of service users confirmed that Mrs Lynes takes all reasonable steps to promote and maintain service users health. All service users are registered with a GP and records showed that visits are requested as and when necessary. Records also provided evidence that the service users have access to health care services such as dentists, opticians, audiologists and chiropodists. The inspector advised that further information should be recorded with regard to service users nutrition and psychological health. It is also good practice to record that there are no needs in certain areas rather than to leave blanks in the documentation. Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 0 Key findings/Evidence Standard Met? This standard was not assessed during this inspection. A visit was made later in the week by the CSCI Pharmacy Inspector during which time the requirements of this standard were fully assessed.Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion. At the last inspection in February 2004, this standard was assessed as met. (With a score of 3 given). Lilliput House Rest Home Page 17 Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 2 Key findings/Evidence Standard met? Discussion with Mrs Lynes evidenced that much of the information required for this standard is known but not recorded. The inspector advised that full reference should be made to this standard and information recorded as necessary.Lilliput House Rest HomePage 18 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion. At the last inspection in February 2004, this standard was assessed as met. (With a score of 3 given).Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion. At the last inspection in February 2004, this standard was assessed as met. (With a score of 3 given). Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion. At the last inspection in February 2004, this standard was assessed as met. (With a score of 3 given).Lilliput House Rest HomePage 19 Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? This standard is partially met. Observation of menus and discussion with service users confirmed that meals at Lilliput House are varied, appealing, wholesome and nutritious. Records of the food provided and fridge and freezer temperatures were satisfactory. Meal times are set at regular times throughout the day: Breakfast is served in service users rooms between 7.30 and 8.00am. A mid morning drink and biscuits are provided at 10.30am with lunch served at 12.30pm. Tea and biscuits or cakes is served at 3:00pm, supper is provided at 5pm and further drinks are served at 7.30 pm and 9.00pm. Lunch on the day of the inspection was trout with hollandaise sauce, boiled potatoes, carrots and peas followed by homemade sherry trifle. The cook advised the Inspector that alternatives are always available. On the day of the inspection a number of service users had requested alternatives and ham had been provided instead of trout. There were plentiful stocks of good quality fresh, frozen and dried goods and the food preparation areas were all found to be clean and well equipped. Those service users spoken with during the inspection confirmed that they enjoyed the food. The manager confirmed her awareness of various special diets and was confident in seeking further advice regarding this should the need arise.Lilliput House Rest HomePage 20 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days Key findings/Evidence This standard was not assessed on this occasion. At the last inspection in February 2004, this standard was assessed as met. (With a score of 3 given). X X X X X X X 0Standard met?Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion. At the last inspection in February 2004, this standard was assessed as met. (With a score of 3 given).Lilliput House Rest HomePage 21 Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists Key findings/Evidence Standard met? YES 0 3The home has a satisfactory policy for the Protection of Vulnerable Adults. Staff have signed to confirm that they have read this and some in-house training has taken place.Lilliput House Rest HomePage 22 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? The home is nicely decorated and furnished and has a homely relaxed atmosphere. The grounds are well maintained and provide a further facility for the Service Users, as there are level pathways and benches as well as a summerhouse. The layout and location of Lilliput House is suitable for its stated purpose. The home is accessible, safe and well maintained. At the time of the inspection no hazards were found. Discussions with the manager confirmed that there is a programme of routine maintenance as well as a long-term programme for more major works. The home has recently held meetings with all the service users and relatives to advise them of the planned works which will include a new garden room, new bedrooms and re landscaping the gardens. The home has suitable fire equipment, which, an examination of records confirmed, was appropriately maintained and checked.Lilliput House Rest HomePage 23 Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion. At the last inspection in February 2004, this standard was assessed as met. (With a score of 3 given). Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion. At the last inspection in February 2004, this standard was assessed as met. (With a score of 3 given). Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 2 Key findings/Evidence Standard met? As with many other homes, at present, the building has not been assessed by a suitably qualified person. This standard cannot be met until such an assessment has been undertaken. Mrs Lynes explained that she had sourced a provider to meet requirement but with the impending building works had decided that it should be held over until all works are completed. The inspector observed that various pieces of equipment are in place throughout the home such as grab rails, handrails, and ramps, through floor passenger lift, raised toilet seats, and commodes.Lilliput House Rest HomePage 24 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite Key findings/Evidence This standard was not assessed on this occasion. At the last inspection in February 2004, this standard was assessed as met. (With a score of 3 given). YES NO NO X X X X Standard met? 0 X XX X X XLilliput House Rest HomePage 25 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion. At the last inspection in February 2004, this standard was assessed as met. (With a score of 3 given). Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 3 Key findings/Evidence Standard met? During a tour of the property the Inspector noted that all rooms are individually and naturally ventilated with easily operable windows. The manager confirmed that all windows above the ground floor have restricted opening and that a restrictor would only be removed following a risk assessment. Pipe work and radiators throughout the communal areas of home have either been guarded or have low surface temperatures. The manager confirmed that a risk assessment has been undertaken for all rooms and a programme has been put in place to address those areas of highest risk first. The lighting in all those areas of the home that were visited on this occasion was satisfactory. It was noted that there is an emergency lighting system installed throughout the home and records showed that contractors regularly maintain this. Since the inspection, the manager has confirmed that the hot water is stored and circulated at the required temperatures and stated that the evidence for this will be available at the next inspection. Fail-safe devices are fitted locally on baths to prevent scalding. Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? The home was found to be clean, hygienic and free from offensive odours. The laundry is sited well away from the kitchen area to prevent any cross contamination and was undergoing refurbishment at the time of the inspection.Lilliput House Rest HomePage 26 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff Key findings/Evidence X 20 345 No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X XX X X Standard met? 3The manager agreed to forward a copy of the rota to the inspector for analysis. Discussions regarding staffing levels with staff and service users confirmed that levels are appropriate to the needs of the service users. As a pre-existing home, Lilliput House does not yet have to comply with the Residential Forum calculator that is a tool used to calculate the required staffing levels. However, it is good practice to check the levels actually provided against this.Lilliput House Rest HomePage 27 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 Key findings/Evidence X X Standard met? 9Full compliance with this standard is not required until 2005.Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? No new staff have been employed since the last inspection. During the previous visit this standard was assessed as met (with a score of 3 given).Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? Mrs Lynes has obtained relevant induction and foundation training packages to comply with this standard and confirmed that these are undertaken in a timely manner.Lilliput House Rest HomePage 28 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 3 Key findings/Evidence Standard met? Mrs Lynes has completed the NVQ 4 in management and throughout her time as the registered manager of the home has demonstrated that she is suitably competent and experienced to run the home. There is a detailed, clear job description for the registered managers post and clear lines of accountability between the owners of the home and the manager. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The service users and staff confirmed that they found the manager easy to communicate with and approachable. Two service users commented that they have never had any problems and seemed quite surprised to think that there may ever be any. In line with the homes quality assurance policy, the manager issues regular questionnaires to stakeholders in the home in order to gain feedback and also holds meetings with both service users and relatives whenever any issues need to be discussed.Lilliput House Rest HomePage 29 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion. At the last inspection in February 2004, this standard was assessed as met and exceeded. (With a score of 4 given). Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 3 Key findings/Evidence Standard met? Insurance documents were checked and these confirmed that the recommended levels of insurance are in place.Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders Key findings/Evidence Standard met? 3 X X XThe manager confirmed that the information regarding the power of attorney status of service users is kept in a confidential file. All service users look after their own financial affairs and the manager confirmed that the home has no involvement with this.Lilliput House Rest HomePage 30 Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion. At the last inspection in February 2004, this standard was assessed as met and exceeded. (With a score of 4 given). Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion. At the last inspection in February 2004, this standard was assessed as met. (With a score of 3 given).Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? A tour of the premises and analysis of records such as the accident book, fire records and training programmes confirmed that the manager, at the time of the inspection, was taking reasonable steps to ensure the health and safety of the Service Users and staff.Lilliput House Rest HomePage 31 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Regulation Manager Date Public reportsCatherine ChurchesSignature Signature SignatureCatherine ChurchesIt should be noted that all CSCI inspection reports are public documents. Lilliput House Rest Home Page 32 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on Tuesday, 7th September 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleLilliput House Rest HomePage 33 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary YESComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESYESYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. Please provide the Commission with a written Action Plan by 12th October 2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. D.2 Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required NOAction plan was received at the point of publicationNOAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther: enter details here NOLilliput House Rest HomePage 34 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 We Mr & Mrs Edney of Lilliput House confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 We .................................... of ................................. are unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons: Louise Edney, Mark EdneyL Edney, M EdneyProprietors 01/10/04Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Lilliput House Rest HomePage 35 Lilliput House Rest Home / 7th September 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000051239.V163741.R01© This report may only be used in its entirety. 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