Inspection on 19/08/08 for Lily House

This inspection was carried out on 19th August 2008.

CSCI found this care home to be providing an Excellent service.

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

Lily House 17/11/09

Lily House 16/09/09

Lily House 30/08/07

Lily House 22/08/06

Lily House 05/10/05

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 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Lily House 143 Lynn Road Ely Cambridgeshire CB6 1DG Lead Inspector Elaine Boismier Unannounced Inspection 19th August 2008 10:00 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 Lily House DS0000065317.V370141.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. Lily House DS0000065317.V370141.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lily House Address 143 Lynn Road Ely Cambridgeshire CB6 1DG 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) 01353 666444 01353 666445 lily.house@ashbourne.co.uk www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited Care Home 44 Category(ies) of Dementia - over 65 years of age (21), Old age, registration, with number not falling within any other category (44) of places Lily House DS0000065317.V370141.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th August 2007 Brief Description of the Service: Lily House is situated on Lynn Road approximately one mile from the centre of Ely. It is a purpose built home that opened in November 2001 and offers care for up to 44 older people some of whom have dementia. Accommodation is provided on two floors and consists of 44 single bedrooms 43 of which have en-suite facilities. There are five bathrooms, one shower room and eleven additional WC’s. There are four lounge/dining rooms in the home and two quiet rooms. Enclosed gardens surround the home for people to visit and sit. Local amenities include shops, cafes pubs, restaurants and a cinema. Current fees range from to £347 to £578.24 per week. Additional costs include those for hairdressing, chiropody and newspapers. A copy of the inspection report is available at the home or via the CSCI website at www. csci.org.uk A vacancy has arisen for a registered home manager. Lily House DS0000065317.V370141.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. We, The Commission for Social Care Inspection (CSCI), carried out this key unannounced inspection between 10:00 am and 14:50 and it took just under 5 hours to complete. Before the inspection we sent out surveys to residents, their relatives and to staff and some of these we have received with the responses. The home completed an Annual Quality Assurance Assessment (AQAA) before the inspection. For the inspection we looked around the premises, spoke with some of the people, some of the staff and the Manager. Some of the people were not able to tell us their views about the home due to their communication difficulties. We observed activities in the home and looked at documentation. For the purpose of this report people who live at the home are referred to as “people”, “person” or “resident/s”. We are currently reviewing the certificates of registration: the last certificate of registration was issued in February 2008, which places a limit on the number of places for people with dementia. This is no longer the case as the home may now take up to 44 people with dementia. (Please note that this is not accurately reflected in the Service Information part of this report). What the service does well: People have a good standard of information to assist them in their decision where to live and there are systems in place to ensure the home can meet the assessesed needs of prospective residents. People’s health and personal care is of an excellent standard. We read in surveys the following comments, “The home has given my mother fantastic care” and “This is a very good home with excellent care…” People are given opportunities to live an excellent quality of life. People are listened to and there are systems in place to reduce the risk of abuse. People can be confident that they receive care from well-recruited and welltrained staff. Lily House DS0000065317.V370141.R01.S.doc Version 5.2 Page 6 People live in a welcoming, friendly home that is safe, well-maintained and clean. We received the following comments about the Manager ““The quality of the Manager is key-currently a caring ‘people-person’ ” and “The home is very well-managed”. Staff we spoke with told us that the home is very well managed and that the current Manager “Is the best we have ever had”. We saw a letter, from a relative that said “(Lily House) was always a good home but since Margaret Strijdom became manger(sic) it is excellent…” The home continues to comply with the Care Home Regulations 2001 as we have made no requirements. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Lily House DS0000065317.V370141.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 Lily House DS0000065317.V370141.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 3 Quality in this outcome area is good. People have a good standard of information to assist them in their decision where to live and there are systems in place to ensure the home can meet the assessesed needs of prospective residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information about the home, including a copy of the inspection report was available in the main entrance of the home. The majority of surveys from residents said that they had enough information about the home before they moved in. One person wrote, in this section of their survey, that there were “Very happy” living at the home. According to the AQAA ”A comprehensive pre- assessment is done to ensure all relevant needs can be met and an informative brochure is provided with each enquiry.” Lily House DS0000065317.V370141.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is excellent. People’s health and personal care is of an excellent standard. Procedures are in place to improve the standard of care records. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Close observation of three people was carried out, we spoke with the staff (to get some information about some of these three people) and these people’s care records were examined. On the whole care plans and risk assessments were actively reviewed each month and where possible reviews of people’s care, with their relatives, were carried out. We also noted that the care planning generally reflects the needs of the person. Staff were seen to interact with people and it was clear that they knew people’s individual needs and personalities. Lily House DS0000065317.V370141.R01.S.doc Version 5.2 Page 10 For one person, however we found that a risk assessment, for moving and handling and a related care plan had not been updated to reflect the change of need of the person. We discussed this with the Manager who stated that this deficiency would be addressed. Discussion with the Manager indicated that action is being taken to improve the care plan documentation, including obtaining information about people’s life histories and becoming more person centred. The Manager stated that she has attended training in caring for people with dementia and this training would be used to shape the future care plans to be more specific, with a particular regard to mental health needs, for those people admitted with a condition of dementia. The AQAA told us “The Residents and Relatives regularly express their appreciation for the quality of care given and the support provided to all parties” and “All residents undergo yearly sight tests and hearing screening. Referrals are made to the Ely Community Dental Service for Residents who need specialised oral treatments and we also make use of a local Dental Practice and dental Technician. We have used the NHS ‘Stop Smoking’ service to assist two residents to give up smoking. All our residents who have diabetes are supervised and supported by Diabetic Management Practitioners.” An examination of people’s care records, discussion with the staff and observation of activities in the home indicated that people have access to a wide range of healthcare professionals and the evidence supports what the AQAA told us (e.g. we noted that a smoking cessation health practitioner was visiting one of the residents, as they wanted assistance in giving up their smoking habit). People are weighed each month and the nutrition risk assessments are updated to reflect any recorded changes of a person’s weight. There was evidence that the home consults a dietician when a person has unintentional weight loss. The majority of the surveys from residents said that the person received the care, including medical care, and support that they needed. Both of the surveys from relatives said that the resident they were linked with, always had their care needs met. One of the relative’s survey said, “The home has given my mother fantastic care” and “This is a very good home with excellent care…” We noted that people were well dressed in clean clothes and their personal care, including nail and hair care, was generally of a good standard. Medication procures and practices were assessed on the first floor. Stock Lily House DS0000065317.V370141.R01.S.doc Version 5.2 Page 11 levels were adequate and the storage of medication was safe. A check of the temperatures of the room, where medication is stored, is recorded each day and these were satisfactory. The temperature of the fridge, where medication is also kept, is recorded each day. The thermometer was recording 9.1 degrees centigrade: the Manager stated that she would replace the thermometer (the fridge had passed a service check in July 2008). We observed a member of staff giving people their medication and this was carried out in a sensitive, dignified and hygienic manner. People were also given a choice if they wanted any medication for their pain (e.g. “as required” paracetamol). The member of staff signed the medication administration records (MARs) after people had taken their medication. The MARs noted variable doses and there were no omissions of recording in the MARs that we examined. Staff told us, and their training records confirmed this was the case, that senior people designated to give out medication have attended medication training provided by the local Primary Care Trust. Competencies of their practice are assessed and recorded by the Home Manager. We saw staff knocking on people’s doors before they entered and personal care was provided in privacy. We observed how staff interacted with the people and we noted that people were individually treated with warmth and kindness and a positive regard. Lily House DS0000065317.V370141.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is excellent. People are given opportunities to live an excellent quality of life. This judgement has been made using available evidence including a visit to this service. EVIDENCE: According to the AQAA “Lily House has provided varied and stimulating social activities and this has had a positive impact on the general well-being of all our Residents.” One of the members of staff said that the activities co-ordinator “Was doing a good job.” Seven of the 9 residents’ surveys told us that the person was satisfied with the activities provided whereas the remaining two surveys said that the home “sometimes” provided suitable activities that they could take part in. Examination of the activities record, discussion with the home’s activities cocoordinator and observation of photographs around the home indicated that there has been a considerable improvement in the range of activities provided. These include a summer fete, held at the home in August 2008, a trip to Lily House DS0000065317.V370141.R01.S.doc Version 5.2 Page 13 Hunstanton, a knitting club, arts and crafts and having lunch and entertainment at a “sister” home of Lily House. Care records gave information about what people liked, including when they choose to get up and how staff should enable people to choose what they would like to wear. Bedrooms were personalised with furniture, photographs and personal bed linen. We saw people receiving their guests in private or in the lounge areas of the home. We noted that the Manager and the staff of the home greeted visitors with a warm welcome. According to the AQAA “ Menus have been adapted to accommodate individual likes and dislikes “ and “ We have implemented the Nutmeg program which evidences the nutritional status of all meals served in the Home.” We received a range of views in the residents’ surveys from the person always liking the food (2) to sometimes the food was liked (3). Comments in the surveys included “Sometimes veg/potatoes no (sic) well cooked” and “Get to (sic) many sausages in a week. Would like a bit of cheese every night/evening. Would like more simple meals i.e. egg and chips.” An examination of the four-week menu and discussion with the Manager indicated that there had been recognition, by the staff, that week 4 of the menu programme offers sausages in three different forms, on three separate days. According to the Manager this matter is being addressed. We observed lunch on the first floor and people were offered a choice of what they would like to eat, including any other item not on the menu such as corned beef. People we spoke with said that their chosen meal of pork casserole was “Very good”. Lily House DS0000065317.V370141.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. People are listened to and there are systems in place to reduce the risk of abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: According to the AQAA the home has received 5 complaints within the last 12 months and all of these were resolved to within the required 28-day time period. We examined the record of complaints and we found that there was no recurring theme to the complaints and all of the complaints had been responded to in a listening and timely manner. All of the 9 residents’ surveys said that staff listened to, and acted on what the person said. Eight of the 9 residents’ surveys said that the person knew who to speak to if they were unhappy about something and knew how to make a complaint. The remaining survey said that the person did not know how to do either of these things although the member of staff provided this information to the person, whilst helping to fill out their survey. Both of the surveys from relatives said that the person knew how to make a complaint and the survey from a member of staff said that the person knew what to do if a concern about the home was made to them from any person living or visiting the home. People we spoke with told us that they knew who to speak to if they Lily House DS0000065317.V370141.R01.S.doc Version 5.2 Page 15 were unhappy about something. Within the last 12 months there have been 3 safeguarding investigations. Following one of these investigations we were informed, by the safeguarding team that the home agreed action should have been taken sooner, to prevent further untoward incidents perpetrated by a resident. We were also informed that staff training in safeguarding had been attended in house and also with the local authority. Minutes of this investigation acknowledged that the Manager was “open and helpful”. (Safeguarding was previously called protection of vulnerable adults or POVA). The staff we spoke with told us what they would do in the event of any abuse made against a resident, including which external safeguarding agencies they would contact. Staff training records indicated that the staff have attended training in safeguarding awareness and arrangements are in place for further training to be attended in this subject. Lily House DS0000065317.V370141.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. People live in a safe, clean and well-maintained home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA told us “Lily House has created an informal lounge for social use of the residents who live upstairs using their own ideas and suggestions on lifestyle issues” and “The two communal lounges have been furnished and equipped with sensory tools to stimulate the needs of our Residents.” Also the AQAA informed us “We have expanded our outdoor facilities by providing seating, shade and a sensory garden.” During the tour of the premises we found evidence to confirm what the AQAA told us. Lily House DS0000065317.V370141.R01.S.doc Version 5.2 Page 17 We noted that the home has a refurbishment programme to include redecoration, replacement of curtains and flooring. All of the 9 residents’ surveys said the home was always/usually clean and fresh and we found that this was the case. The AQAA informed us that 18 staff have attended training in prevention of infection and managing infection control. Some of the staff we spoke with said that they had attended training in managing and preventing infection control and this included staff employed for domestic duties, including the laundry area. According to the Manager she has encountered difficulties in sourcing infection control training for staff from the registered company, Southern Cross. We have received no notification that the home has had any outbreak of infection amongst residents since our last inspection, in 2007. Lily House DS0000065317.V370141.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is good. People can be confident that they are cared for by well trained and well recruited staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We noted that staff felt valued by the Manager and this was confirmed by some of the staff we spoke with. The AQAA said “Staffing levels have been reviewed and more staff are on duty at identified times of higher demand.” The survey from a member of staff said that there is usually enough staff on duty to meet the needs of the residents. The staff we spoke with told us that usually there is enough staff on duty to meet the needs of the people. Where there are unplanned absences, such as sick leave, the staff told us that the staff team “pulls together”. We saw people receiving individual 1:1 attention and care by staff in a timely and unhurried manner. The staff roster was examined and this included the full names of people: this standard of record keeping has improved since our last inspection. Lily House DS0000065317.V370141.R01.S.doc Version 5.2 Page 19 Information provided in the AQAA told us that there is 60 of care staff with a National Qualification in Care (NVQ) level 2 or above. Although we made no requirement, following our last inspection, we expected the home to take action to improve its recruitment practices. We found, during examination of two staff recruitment files that this action has been taken: all the required information about the staff was available. Discussion with the staff and examination of the staff training records indicated that the opportunities for staff to attend training have improved within the last 12 months. Staff have attended training to include caring for people with dementia and challenging behaviour, managing stress and arrangements are in place for some of the staff to develop their management skills. Induction training of new staff is now in line with the Skills for Care induction training standards, as evidenced in one of the training files of the most recently recruited members of care staff. Lily House DS0000065317.V370141.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35 & 38 Quality in this outcome area is excellent. People benefit from a home that is managed to an excellent standard. This judgement has been made using available evidence including a visit to this service. EVIDENCE: According to the Manager she has experienced some unsettlement in how she is managing the home due to the frequent operational management changes, made by Southern Cross. One of the surveys from a relative said, “The Manager is very pressured by Southern Cross…” Nevertheless we received positive comments about the Manager in the two surveys from residents’ relatives such as “The quality of the Manager is keycurrently a caring ‘people-person’ ” and “The home is very well-managed”. Lily House DS0000065317.V370141.R01.S.doc Version 5.2 Page 21 Staff we spoke with told us that the home is very well managed and that the current Manager “Is the best we have ever had”. We saw a letter, from a relative that said “(Lily House) was always a good home but since Margaret Strijdom became manger(sic) it is excellent…” Satisfactory action has been taken in response to our findings of our last inspection and we have made no requirements at this inspection. We have received information about any untoward incidents as required under regulation 37. The Manager stated that, within the last 12 months, she has attended training to be a trainer for staff in mandatory training to include moving and handling, food hygiene, fire safety, infection control and safe keeping of substances hazardous to health (COSHH). We recommended the home to be managed by a person that we have registered. Discussion with the Manager indicates that she is in the process of making an application to be the registered manager of Lily House. Staff told us that the Manager operates an “open-door “ policy and they felt confident in approaching her with suggestions. Copies of the last two minutes of the relatives’/residents’ meetings were seen and these included evidence that there is active consultation with people about activities within the home. We observed the Manager warmly receiving visitors when they arrived at the home. Examination of the last two reports of visits, made by a representative of Southern Cross, indicates that the registered provider is not carrying out these visits on a monthly basis, to review the quality of the care and management of the home: one report was dated 5th December 2007 and the last report was dated 22nd April 2008. Discussion with the Manager, and evidence recorded in this inspection report, indicates that the assessed standard of the home might be as a result of the commitment of the Manager and the team of staff working at Lilly House. Surveys are carried out by the home to ask people their views about their care and about the activities provided. The AQAA was completed in a detailed manner and it identified what the home does well in and areas for improvement have been identified. The home safeguards people’s monies, should they so wish, and records of these were examined. There is no cash kept at the home as this is deposited in an interest bank account. Records indicated that such deposits are in individual people’s names. There are clear audit trails for money brought in and money that is spent by the residents. Transactions are coded and any code is transferred directly on to the home’s computer database. Lily House DS0000065317.V370141.R01.S.doc Version 5.2 Page 22 The AQAA told us that 100 of catering staff and 70.2 of care staff have attended training in safe food handling. According to the AQAA service checks have been carried out in 2008 for portable electrical appliances, hoists and lifts and fire detection and fire fighting equipment and we saw records of these checks. The staff we spoke with said that they had attended training in moving and handling, fire safety, and food hygiene. Records for hot water temperatures and fire drills were seen and these were satisfactory. Reports from the Environmental Health Officers for 23rd October 2007 and 19th November 2007 said that “Satisfactory inspection. Very high standards of H&S” (health and safety) and “Excellent standards” (regarding the kitchen area). We received a copy of the Fire Safety Officer (FSO) report of their inspection carried out in November 2007. There were a number of areas that the home had to address to ensure that people at the home were safe from the risk of fire. These areas included the emergency lighting system; the safe storage of combustible materials; unsatisfactory door closures and provision of tumescent strips on identified doors; smoke detectors to be installed in designated areas and staff were to attend evacuation training procedures. The FSO was to follow up, on or before, 23rd February 2008 to assess what progress the home had made to improve the fire safety of the home. According to the Manager the FSO has since visited the home and they are satisfied with the action taken to ensure the home is safe from the risk of fire. A copy of this last FSO report was not available for inspection. Lily House DS0000065317.V370141.R01.S.doc Version 5.2 Page 23 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 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 4 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 x 3 x x 4 Lily House DS0000065317.V370141.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Lily House DS0000065317.V370141.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lily House DS0000065317.V370141.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!