Inspection on 30/08/07 for Lily House

This inspection was carried out on 30th August 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Lily House 17/11/09

Lily House 16/09/09

Lily House 19/08/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Lily House 143 Lynn Road Ely Cambridgeshire CB6 1DG Lead Inspector Elaine Boismier Key Unannounced Inspection 30th August 2007 9:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lily House DS0000065317.V344582.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.V344582.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 ***Post Vacant*** 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.V344582.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd August 2006 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. Accommodation is provided on two floors and consists of 44 single bedrooms 43 of which have en-suite facilities. The home has 21 places for service users who have dementia care needs. 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 £343 to £542.20 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.V344582.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This summary includes references to two unannounced random inspections carried out between the last key inspection of 22nd August 2006 and up to this key unannounced inspection of 30th August 2007. 23rd January 2007 A random unannounced inspection was carried out between two Inspectors on the 23rd January 2007. The purpose of this inspection was to assess the progress that had been made following the key unannounced inspection of 22nd August 2006. There was evidence to suggest that an offence had been committed, against Section 24 of the Care Standards Act 2000, as there has been a failure to comply with conditions of registration. A requirement was made. There was evidence to suggest that people’s care plans failed to provide sufficient details and guidance for staff in how to meet the assessed needs of the residents. This requirement had not been met and was carried forward with a new timescale for action. There was evidence to suggest that a requirement had been met, with regards to people having access to a dentist, although a recommendation was made for residents to receive routine dental check ups, should they chose to do so, and this choice was to be recorded in the care plan documentation. There was evidence to suggest that a requirement was not met with regards to the safe storage of medication and an immediate requirement was made. There was evidence to suggest that a requirement had been met with regards to investigating missing controlled medication although it was disappointing that the police were not consulted on this issue. There was evidence to suggest that people were not offered a meal between tea, the previous day, and breakfast the following day. A requirement was made about this. A requirement made with regards to records of food provided had not been met and this requirement remained. Two requirements had been made with regards to the maintenance and cleanliness of the home. Neither of these requirements had been met. Lily House DS0000065317.V344582.R01.S.doc Version 5.2 Page 6 Two staff files were examined and all required information was available. This requirement was met. Evidence suggested that the home had introduced a more formal method of staff induction to the home and as result of this, a requirement was met. Evidence suggested that on the whole staff had attended training in fire safety and, as a result of this, a requirement had been met. During the tour of the premises it was noted that a bottle of (hazardous) cleaning agent and air fresheners were kept in an unlocked cupboard that was accessible to residents. An immediate requirement was made. 10th April 2007 On the 10th April 2007 a Pharmacist Inspector carried out an unannounced random inspection. He reported that, “ Practices for handling and recording of medicines within the home are generally adequate. Records of medication administered for some residents show that supplies had run out and they had therefore not been given. Not all staff training files carry evidence of an assessment of competence to administer medicines.” As a result of this inspection of April 2007, the Pharmacist Inspector made six requirements, one of which had been carried forward (with regards to care records) from previous inspections of the home. Copies of the inspection reports, for both 23rd January and 10th April 2007 can be obtained on request from the home or from the local Cambridge and Peterborough Area. 30th August 2007 Before the inspection we sent out 44 surveys for residents to complete and we received 19 of these. We sent out also 20 surveys for relatives, carers and advocates and we received 10 of these. An Annual Quality Assurance Assessment (AQAA) form was sent and we received this on the 9th August 2007. This inspection was unannounced and was carried out between 9:30 and 13:40 and took 4 hours and forty minutes to complete. At the time of the inspection there were 42 residents living at the home and some of these people were spoken to. We spoke also to staff, including the Manager, examined documentation and observed staff working. A tour of the premises was carried out also as part of the inspection process. Lily House DS0000065317.V344582.R01.S.doc Version 5.2 Page 7 Evidence suggests that, due to the commitment of staff and the Manager, Lily House has improved from providing an adequate quality service to provide that of a good quality service. This improvement however is at risk of being sustained. We have been informed that there has been a number of changes within the Company, that owns Lily House, and that this has influenced the level of support that the home and Manager have received. Evidence indicates that at operational level there are delays in responding to requests made by the Manager, to the Company, to maintain a safe level of care to people living, working and visiting the care home. For the purpose of this report people living at Lily House are referred to as “people”, “residents” or “service users”. What the service does well: What has improved since the last inspection? What they could do better: Full and satisfactory information, about staff, must be obtained about staff before they start work at the home. We expect the home to manage this rather than we make a requirement on this occasion. Lily House DS0000065317.V344582.R01.S.doc Version 5.2 Page 8 A registered person should manage the home. This recommendation was made at the last key inspection and this recommendation remains. 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.V344582.R01.S.doc Version 5.2 Page 9 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.V344582.R01.S.doc Version 5.2 Page 10 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 & 4 Quality in this outcome area is good. Prospective residents have a good standard of information about the home to help them in their decision where to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Copies of the Statement of Purpose and Service User’s Guide were examined and these contained detailed information about what people can expect should they decide to live at Lily House. The AQAA informed us that, “The Home Manager personally meets all prospective residents and their next of kin. Relevant information is suppliedi.e. services provided, finances, accessibility (sic) and suitability of needs.” Lily House DS0000065317.V344582.R01.S.doc Version 5.2 Page 11 Examination of people’s care records and discussion with the Manager indicated that prospective residents area assessed by the Manager and, where relevant, by care managers of the local authorities. People that we spoke to said that they knew about the home from their relatives who acted on their behalf before moving in. Sixteen of the 19 residents’ surveys said that the person had received enough information about the home before moving in. Two of the 19 residents surveys said that the person did not have such information. The remaining survey indicated that a relative had information about the home and had acted on the resident’s behalf. Although staff and residents said that they had not seen the most of our recent inspection reports, we found these were located, on a shelf, under other documents, in the main entrance hall. We suggest that these reports could be positioned in a more noticeable place for people to see and read if they so wish. A requirement was made, following the inspection in January 2007, for an application to be made to vary the conditions of registration. Due to a change in how we now approach registration of care services, the home can admit any number of people, over the age of 65 years of age, with dementia. As such the requirement associated with this, is no longer applicable. The Manager informed us that the Responsible Individual, as named on the current certificate of registration, no longer occupies this role. We expect formal notification of this change, from the registered provider. Lily House DS0000065317.V344582.R01.S.doc Version 5.2 Page 12 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 good. People receive an appropriate and proper level of care that is safe and provided by staff in a respectful way. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A requirement was made at the key unannounced inspection of August 2006 and this was considered not met during random inspections of January and April 2007. This requirement was related to care records. Care records for 4 people were examined and evidence suggests that this requirement has been met. There was detailed guidance in how to care for the person, including specialist communication needs, social care needs and health and personal care needs. Lily House DS0000065317.V344582.R01.S.doc Version 5.2 Page 13 Although a person said that they were not aware of their care plan we noted that another person’s care plan had written evidence of the involvement of a family member, acting on behalf of this person. We discussed this with the Manager and she agreed to improve existing practices to ensure that there is recorded evidence to prove that all people are consulted about their care plan. Observation of staff working, examination of care records and discussion with people and the Manager indicated that residents have access to a range of health care professionals including dieticians, community psychiatric nurses, chiropody services and district nurses. Twelve of the residents’ surveys stated that the person considered that they always received the care and support that they needed; 7 of the residents’ surveys sated that the person considered that they usually received the care and support that they needed. Twelve of the residents’ surveys stated that the person considered that they always received the medical support that they needed; 7 of the residents’ surveys stated that the person considered that they usually received the medical support that they needed. Of the 10 surveys for relatives, carers and advocates, 8 people considered that the home always met the needs of the resident and 2 of the 10 of these surveys said that the home usually met the needs of the resident. Of the 10 surveys for relatives, carers and advocates, 7 people considered that the resident always received the support that is expected of the home; 3 of the remaining 10 surveys said that the home usually offered such support. The AQAA informed us that, “Residents present neat and groomed and express their satisfaction with personal care and health issues….District Nurses assist carers in a positive manner and co-operation is very good with all service providers.” We observed people were presented well with clean clothes and hair. We observed also staff consulting the district nursing service for advice. The AQAA told us that the home has improved in caring for people who have been assessed as at risk of pressure sores. Since August 2006 up to the present date of when the AQAAA was sent to us, the home has had one person who had developed a pressure sore. The AQAA told us that there has been a “Provision of pressure-relieving aids; Profiling beds, Air Mattresses and cushions.” During the tour of the premises we noted that people had been provided with such equipment. Lily House DS0000065317.V344582.R01.S.doc Version 5.2 Page 14 Following the random unannounced inspection of April 2007, which was carried out by our Pharmacist Inspector, 5 requirements were made and one requirement was considered as not met (with regards to care plan documentation). At this inspection of 30th August 2007 we observed medication practices on the first floor of the home, spoke to staff and examined documentation. The storage of medication was safe. The door was locked to the medication room. Temperatures of the room and drug fridge were recorded on a daily basis and were of a safe limit. No medication was stored at temperatures other than those instructed by the manufacturer (e.g. insulin and eye drops). No medication was out of date and stock levels of medication were adequate. Following examination of the medication records, there was no indication that stock of medication had run out. We observed a member of staff contacting the dispensing pharmacy to ensure that the amount of medication ordered was delivered to the home. Records of medication, including those for controlled medication, were satisfactory. Staff confirmed that they had attended training in safe medication practices and certificates to demonstrate that they had been assessed as being competent in this care practice, were available. All medication that was seen remained in their original container and we observed staff administering this medication. We noted that when the person needed to leave the medication trolley, another member of care staff watched over this, to ensure that medication was kept safe at all times. We observed staff interacting with residents and it was clear that caring and attentive staff respected people’s dignity. Lily House DS0000065317.V344582.R01.S.doc Version 5.2 Page 15 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 good. People are offered opportunities to live a good quality of life. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Eleven residents’ surveys said that the person considered the home always provided suitable activities; 3 residents’ surveys said that the person considered the home usually provided suitable activities and 5 residents’ surveys said that the person considered the home sometimes provided suitable activities. Two people wrote to say that although they preferred their own company but were given the choice of activities. The AQAA told us that, “The Activities Manager delivers high level of service with assistance of Care Assistants and volunteers…..Individual and Group activities.” A requirement was made for surveys to be carried out to seek views of people about activities provided by the home. These surveys were carried out in July 2007 and as such this requirement has been met. Lily House DS0000065317.V344582.R01.S.doc Version 5.2 Page 16 People told us that a choice is available for activities and we saw care plans and care records about activities that the person liked and engaged in. Information about activities is available for people to know what is going on. We noted that the activity for the morning, as described in this information, was taking place in a lounge area for a number of people living on the ground floor of the home. Five of the 10 surveys for relatives, carers and advocates said that the home always supported the person to live the life they choose; 2 of the 10 surveys for relatives, carers and advocates said that the home usually supported the person to live the life they choose; one of the 10 surveys for relatives, carers and advocates said that the home sometimes supported the person to live the life they choose. (See also Standard 27 of this inspection report). Although the AQAA did not provide information, how the home ensured that contact, with families and friends, was maintained, we observed residents receiving their guests. Examination of care records indicated also that people maintain contact with their families, including going out of the home to visit. Eight residents’ surveys said that the person always liked the food; 10 residents’ surveys said that the person usually liked the food and one person said that sometimes they liked the food. One person wrote to say that they would like more fish dishes. People we spoke to said that the food was generally good and that there was a choice. Two requirements were made following previous inspections of the home with regards to meal times and food. Although we did not observe the mealtime we spoke to staff about how the assisted people with their food. Evidence suggests that people are helped with their meals in a respectful way. We spoke to catering staff and examined food records and evidence suggests that a meal is offered between 17:00 and breakfast the following day. As a result of these findings, both of these requirements have been met. The AQAA told us that within the last 12 months there has been an improvement in “Catering-inclusion of requested dishes on menu. Provision of milky drinks snacks after 8pm.” Lily House DS0000065317.V344582.R01.S.doc Version 5.2 Page 17 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 are safe from the risk of abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Seven of the residents’ surveys said that the person always knew who to speak to if they were no happy; 12 of the residents’ surveys said that the person usually knew who to speak to if they were not happy. Sixteen of the 18 completed residents’ surveys, in this section, told us that the person knew how to make a complaint although the remaining two residents’ surveys indicated that these people did not know how to make a complaint. People who we spoke to said that they knew what to do if they were unhappy about something, including how to make a complaint. Information about the home’s complaints procedure was on clear display in the main foyer of the home. All of the completed surveys for relatives, carers and advocates said that the person knew how to make a complaint. Seven of these 10 surveys said that the home had always responded appropriately to the person’s concerns; one of these 10 surveys said that the home had usually responded appropriately to the person’s concerns; one of these 10 surveys said that the home had sometimes responded appropriately to the person’s concerns. Lily House DS0000065317.V344582.R01.S.doc Version 5.2 Page 18 The record of complaints was examined and responses to these complaints were made within 28 days. There was no recurring theme to these complaints and the home does not generate a high number of complaints. The AQAA told us of how complaints are managed and that “…Requested ongoing training in POVA and abuse issues.-Most Staff members have attended to date.” (POVA =protection of vulnerable adults against abuse). Staff confirmed that they had attended training in increasing their awareness in POVA. According to the manager she has attended training, to become a trainer for staff, in POVA. She stated that this training has increased her awareness of POVA. Lily House DS0000065317.V344582.R01.S.doc Version 5.2 Page 19 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 home that has improved to become more comfortable and cleaner. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA told us that there is “An ongoing maintenance programme of painting and decorating is in place. Gardens are maintained and have been =developed….A request has been made to re-decorate the Lotus-Lounge to suit specific needs of dementia clients. Request has been made to S.C.H.C. to provide appropriate signage for Dementia Unit i.e. “Dining Room”, “Lounge” etc.” (S.C.H.C. = Southern Cross Health Care). A refurbishment programme was seen that included planned redecoration of rooms and replacement of carpets and curtains. Two requirements were made with regards to the maintenance and decoration of the home. The AQAA has informed us that improvements have been made Lily House DS0000065317.V344582.R01.S.doc Version 5.2 Page 20 to the home environment, within the last 12 months, “Painted most of interior of Home. Built a wooden pergola to provide shaded area for residents.” During the tour of the premises we noted that the home had improved due to redecoration and carpets had been replaced in some areas of the home. Both of these requirements have been met. A recommendation remained with regards to the existing design on the floors of the ground floor. This recommendation was made as evidence suggested that some of the people living here had difficulties understanding the design. During this inspection staff confirmed that some people avoided this area (as they were wary of it) and there had been incidents where a person stooped down to try and pick the design up. Such activity posed a risk to the person falling over. According to the Manager she has consulted a community psychiatric nurse who considered that the design helps people to find their way about the home. Nevertheless we consider that there might be other safer methods to help people find their way. Although this recommendation has been considered the Manager has agreed to explore this issue further, to ensure that the design on the floor has a positive, rather than negative, effect on people living on the ground floor of the home. Gardens were better maintained and the home has been approved to receive a grant to improve the garden area. The letter about this grant was seen. Discussion with the Manager indicated there are plans to design the garden to meet the specialist needs of the people that Lily House takes care of. Twelve of the 19 residents’ surveys indicated that the person considered that the home was always clean and fresh; 7 of the of the 19 residents’ surveys indicated that the person considered that the home was usually clean and fresh. At the time of the inspection there were no offensive odours. Staff reported that due to the existing systems of the Company, ordering items, such as disposable hand towels, toilet rolls, disposable gloves and pots for commodes, there has been a delay in the provision of these essential items. Such delays pose risks to the health of people living, working and visiting the home due to the risk of infection. Such delays pose a risk also to the dignity of people living at Lily House. Staff confirmed that they had attended training in infection control to include how to care for people with MRSA and clostridium difficile. Lily House DS0000065317.V344582.R01.S.doc Version 5.2 Page 21 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 are safe from well trained staff although recruitment practices could be improved upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Eight of the residents’ surveys said that the person considered that staff were always available when the person needed them; 11 of the residents’ surveys said that the person considered that staff were usually available when the person needed them. The AQAA told us that there is “Almost no need to use Agency Staff at Lily House. Limited sickness and absence of staff. Adequate cover of staff for all shifts.” Staff indicated that due to recent staff shortage, during July and August 2007, people’s choices were not always respected. Discussion with staff and the Manager and examination of the duty allocation records and duty rosters, indicated that a shortfall in numbers of staff were due to unplanned sickness. The Manager and staff confirmed, that the home now uses agency staff when needed and we saw that this was the case on the day of the inspection. The duty roster contained first names of staff only. We expect that the home improves this standard of records, to include the full names of staff, on the duty roster. Lily House DS0000065317.V344582.R01.S.doc Version 5.2 Page 22 A relative wrote in their survey that, “There does not appear to be enough staff or a system so that my mother can get outside to exercise, whether accompanied to a visit to do some shopping, or alone down to the small garden.” The AQAA told us that the home employs 23 care staff of which 18 of these have an NVQ level 2, or above, qualification in care. This makes the home to have 78 of staff with this qualification. Eight of the 10 surveys for relatives, carers and advocates said that the staff always had the right skills and experience to look after people properly; 2 of the 10 of the 10 surveys for relatives, carers and advocates said that the staff usually had the right skills and experience to look after people properly. The AQAA made no indication how staff are recruited except within the data set that confirms all staff that have been recruited have had satisfactory preemployment checks. However examination of 3 staff files indicated that not all full and satisfactory information was available. This included unexplained gaps in employment history for one person and for another staff file, although there were two references, the content of one of these was brief and did not provide information about the person. All other information obtained was satisfactory to include CRB and POVA checks. We have taken a reasonable view that we will not make a requirement on this occasion as we expect the home to manage this issue. The AQAA stated that improvements that have been made with regards to the management of staff to include “…information sessions to staff on various topics-CPN workshops. Dept. of Health- current issues i.e. C diff MRSA.” During the inspection staff confirmed that they had attended such training. Staff informed us that the home provides care for a number of people with dementia and challenging behaviours that include physical aggression. Discussion with the Manager and examination of documentation indicates that arrangements have been made for staff to attend training in how to care for people with dementia and challenging behaviours. Lily House DS0000065317.V344582.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 35 & 38 Quality in this outcome area is good. People benefit from a well managed home This judgement has been made using available evidence including a visit to this service. EVIDENCE: A vacancy has arisen for the registered manager’s position and a recommendation was made about this. Currently a registered general nurse, who has worked in the care industry for a number of years, manages the home. She has worked as the deputy manager at Lily House since 2005 until her promotion as home manager, in the summer of 2006. Lily House DS0000065317.V344582.R01.S.doc Version 5.2 Page 24 Written comments received in surveys for relatives, carers and advocates include “Since the current Care Home Manager has been in place, response and general care has been excellent.” and “…currently (the Manager) ensures a high quality of care and concern and family environment and consistency of approach. Stability of staff is important and (the Manager) has had a significant, positive, affect (sic) on Lily House.” Staff told us that the management of the home is good and that the Manager is catering and kind to the residents. Staff considered that the Manager receives insufficient support from the Company and the Manager considers this also to be the case. The AQAA informed us that the Manager has completed the Registered Manager’s Award. A vacancy remains for the home to be operated by a registered manager. This was a recommendation made at a previous inspection. Although this recommendation will not appear in the recommendation table of the inspection report, this recommendation remains. The AQAA is the first one received and this was of an adequate standard that could be improved upon. For example there was no indication what action had been taken to improve medication practices or how choices of people are met, or how contacts with families and friends are maintained. These are examples only and not wholly inclusive of other areas that the AQAA could be improved upon. A copy of the regulation 26 report was seen, for July 2007. This included an audit of the environment and views of residents. In June 2007 we received a Regulation 37 notification to inform us that during the period between May and June residents’ personal allowances of £141 were missing. The notification reported that the last audit of the monies was carried out in April 2007. The action taken was for an audit of money to be carried out every month and access to money was to be restricted to a named few and changes were made to increase the security of how residents’ personal monies wee safeguarded by the care home. Discussion with staff and examination of records indicated that no personal monies are kept at the home but are kept in a bank account. Records indicated that transactions are in individual residents’ names to include money coming in and money going out. Records were examined for temperatures of hot water; temperatures of food and temperatures of fridges and freezers (for food storage); service checks for hoists and lifts; portable appliance tests; fire alarm and emergency lighting checks. All of these records were satisfactory. An Environmental Health Officer Lily House DS0000065317.V344582.R01.S.doc Version 5.2 Page 25 report dated 14th November 2006 was seen and there were advisory comments made but no formal proceedings to be made. Staff records for moving and handling were seen and according to the Manager were to be updated. All staff that we spoke to confirmed they had received training in safe moving and handling. An immediate requirement was made, at the time of the inspection in January 2007, as there was unsafe storage of hazardous chemicals. During this inspection we saw no hazardous chemicals that were kept in an unsafe manner. This requirement has been met. The AQAA informed us that 100 of catering staff and 80 of care staff have received training in safe food handling. Records for fire risk assessments were out of date. Fire drills were carried out on a regular basis although not all staff have received fire training within 6 months. We saw an email of the Manager’s request, to the Company, for assistance in food hygiene training and fire training for staff. The request informed the Company that 22 staff were overdue for fire safety training. The request asked also for assistance for fire risk assessments to be updated, as these were due in June 2006. There was evidence that this request was sent on 11th July 2007 but no response has been received from the Company. We advised the Manager to contact the local fire safety officer for advice on fire safety and she has agreed to do this. Lily House DS0000065317.V344582.R01.S.doc Version 5.2 Page 26 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 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 x x 2 Lily House DS0000065317.V344582.R01.S.doc Version 5.2 Page 27 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.V344582.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office 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.V344582.R01.S.doc Version 5.2 Page 29 - 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!