Inspection on 05/10/05 for Lily House

This inspection was carried out on 5th October 2005.

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 30/08/07

Lily House 22/08/06

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 Andy Green Unannounced Inspection 5th October 2005 1.30pm 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.V253377.R01.S.doc Version 5.0 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.V253377.R01.S.doc Version 5.0 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 Ashbourne (Eton) Limited Louise Kent 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.V253377.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th June 2005 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. The home has well maintained gardens with seating areas. Ashbourne (Eton) Limited are now the registered provider for the home. Lily House DS0000065317.V253377.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Regulation Inspector, Andy Green undertook this announced inspection on 5th October 2005. The inspector met with the manager, care staff and service users to gather views regarding the care and services provided in the home. A number of records were inspected including care plans, training records and staff files. A tour of the building and grounds was also undertaken. What the service does well: 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. Lily House DS0000065317.V253377.R01.S.doc Version 5.0 Page 6 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.V253377.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,5 The home produces a variety of information so that prospective service users can decide if they wish to live in the home. EVIDENCE: The Statement of Purpose has been amended to show the names of the recently Registered Manager and the ‘Head of Care’ which is a newly created post in the home. The document also shows the name of the regional Operations Manager and contact details for CSCI have been amended. The home receives assessment information from the local authority and a copy of the care plan. A member of the management team carries out a needs assessment as required by this standard. These documents are reviewed during the year to ensure they remain effective and provide up to date information. Prospective service users and their family/relatives continue to be encouraged to visit Lily House as part the assessment process, prior to admission. This ensures that the prospective service users need’s can be fully assessed and also gives the person a chance to experience life in the home. Lily House DS0000065317.V253377.R01.S.doc Version 5.0 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The home has care plans, which are clear and well laid out to ensure that the assessed needs of service users can be met. EVIDENCE: The health of service users is monitored and ranges of healthcare professionals visit the home on a regular basis including district nurses, GPs, dietician, and an outreach worker from the Alzheimer’s Society. Three service user files were inspected and they showed sufficient detail to ensure assessed needs are being met. There was evidence that regular reviews are carried out and any changes in care are clearly documented. All care plans have been updated and are presented in a standardised format, which is used by Ashbourne Healthcare. The Head of Care, which is a newly created post in the home, proactively monitors the care planning system and ensures that reviews are undertaken on a regular basis. Training is being organised by the Head of Care, for senior staff, to ensure that care plans and daily notes are consistent and recorded in sufficient detail. Medication administration records were inspected and they are accurately recorded. Lily House DS0000065317.V253377.R01.S.doc Version 5.0 Page 9 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15 Staff provide support to ensure that service users have access to activities in the home and access to the community appropriate to their needs and abilities. EVIDENCE: The manager stated that an Activities Co-ordinator has been employed who will be organising both individual and group activities for service users. The manager stated that the Activities Co-ordinator would have regular contact with other Activities Co-ordinators employed in Ashbourne care homes to update knowledge, skills and practice. The Activities Co-ordinator will also have contact with the local Alzheimer’s Society representative receive training regarding dementia care to ensure that appropriate activities are organised. There was a lively and busy atmosphere in the home and service users were socialising with each other and staff in the lounge. There are quizzes, crafts sessions organised and paid musical entertainers visit the home on a regular basis. There is a varied range of meals offered throughout the day and service users have choice of alternatives to the suggested menu choices. Snacks and drinks are also available at all times during the day. Service users met during the inspection confirmed this to be the case. Lily House DS0000065317.V253377.R01.S.doc Version 5.0 Page 10 Three service users spoken to were most complimentary about the services, food and support that they received and found living in the home a positive and comfortable experience Lily House DS0000065317.V253377.R01.S.doc Version 5.0 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The home has a satisfactory complaints process to make sure that service users and their representatives have their complaints or concerns listened to and actioned properly within agreed timescales. EVIDENCE: The home has a clear complaints procedure, which includes agreed timescales to make sure that all complaints are fully investigated and actioned appropriately. The home has a satisfactory policy regarding Adult Protection, which is in line with the Local Authority policies. Staff receive training in the protection of vulnerable adults to make sure that service users are protected from abuse. Ashbourne Healthcare also has an in house course entitled “Resident Welfare” which covers issues regarding abuse and whistle blowing which is given to care staff as part of ongoing training in the home. It was observed during the inspection that care staff spoke to service users in a sensitive, social and respectful manner. Lily House DS0000065317.V253377.R01.S.doc Version 5.0 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,23,24,25,26 The environment of the home provides service users with a safe and comfortable place in which to live. EVIDENCE: The manager stated that there is an ongoing maintenance and decoration programme and 3 bedrooms have recently been re-decorated. A carpet cleaner has been purchased so that carpets in the home can be regularly maintained. The home has employed a new maintenance person who attends to repairs and refurbishments in the home as required. Service user bedrooms contained a variety of personal possessions and furnishings to suit their individual preferences. All bedrooms, except one, are ensuite. The communal areas are well presented and the furnishings are domestic and of good quality. Bathrooms and toilets are adequate for the service user’s needs. A variety of aids and equipment are available to assist service users. The home was observed to be in a clean and hygienic state providing a homely atmosphere for service users. Lily House DS0000065317.V253377.R01.S.doc Version 5.0 Page 13 There has been no further adaptations or changes to the environment since the last inspection. Lily House DS0000065317.V253377.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The home’s recruitment policy and processes make sure that service users are protected from potential harm. Training is provided to make sure that care staff are competent to deliver personal care to the service users they support. EVIDENCE: On the day of inspection there were sufficient numbers of staff to meet service users needs. There were 7 carers between 7am-2pm, 7 carers between 2pm9pm and 3 carers between 9pm-7am. The manager stated that there has been four carers appointed and will commence induction in the home when satisfactory CRB checks have been received. NVQ training continues in the home with staff involved in level 2 & 3 courses. Training has been updated to ensure that staff are working safely and are up to date with current care practices. Staff spoken to stated that training in general had improved in the home and they confirmed that they had received recent updates in Health & Safety, POVA, Moving & Handling and Dementia Care training. Photographs have been added to a number of staff files. Lily House DS0000065317.V253377.R01.S.doc Version 5.0 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,36,38 The home is well managed and the Manager and Head of Care provide supportive leadership and guidance to staff to ensure that service users receive high quality care. EVIDENCE: Ashbourne (Eton) become the new registered provider of the home on 16th September 2005. The inspector was satisfied that policies, guidelines and procedures have been implemented. The new manager has registered with the Commission for Social Care Inspection. Care staff spoken to were complimentary about the new manager and stated that they felt well supported and were receiving regular recorded supervision sessions. Staff also confirmed that the newly appointed Head of Care provides supportive and ongoing clinical input, which has been a beneficial development in the home. Health and Safety risk assessments are undertaken and contracts to maintain equipment in the home are in place. Lily House DS0000065317.V253377.R01.S.doc Version 5.0 Page 16 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 3 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 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X 3 3 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 3 3 X X X 3 X 3 Lily House DS0000065317.V253377.R01.S.doc Version 5.0 Page 17 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement 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.V253377.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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