Inspection on 11/06/08 for Lilybank Hamlet

This inspection was carried out on 11th June 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Lilybank Hamlet 07/12/07

Lilybank Hamlet 04/01/07

Lilybank Hamlet 17/10/05

Lilybank Hamlet 19/07/05

Lilybank Hamlet 07/02/05

Lilybank Hamlet 21/06/04

Lilybank Hamlet 04/11/02

Similar services:

Hillside

Applegarth

122 Scorer Street

Byars Care Home

St Marys Nursing Home

Jubilee Villa Care Home

Bramble Lodge

Parkmanor Residential Home

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Lilybank Hamlet Chesterfield Road Matlock Derbyshire DE4 3DQ Lead Inspector Rose Moffatt Unannounced Inspection 11th June 2008 09:40 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 Lilybank Hamlet DS0000002062.V366272.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. Lilybank Hamlet DS0000002062.V366272.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lilybank Hamlet Address Chesterfield Road Matlock Derbyshire DE4 3DQ 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) 01629 580919 01629 760019 lilybank@btconnect.com Progressive Care (Derbyshire) Ltd Vacancy Care Home 42 Category(ies) of Dementia (22), Old age, not falling within any registration, with number other category (20) of places Lilybank Hamlet DS0000002062.V366272.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered persons may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission are within the following category: Old age, not falling within any other category - Code OP (Maximum number of places 20). Dementia - persons aged 60 years and over - Code DE (Maximum number of places - 22). The maximum number of service users who can be accommodated is 42. 7th December 2007 2. Date of last inspection Brief Description of the Service: Lilybank Hamlet is situated in the town of Matlock. There is a range of facilities in the town, including shops, pubs, restaurants and public transport. The home provides personal care for up to 42 older people. The registration was changed in August 2007 so that the home could provide care for people whose primary care need was because of dementia and is registered to provide dementia care for up to 22 people aged 60 years and over. The home is divided into 2 units, although people living in the home can use the facilities of both units, and staff work on either unit. The home is in an older building, at one time a hotel, and still has many original features and the character of a period property. The home has accommodation on the ground, first and second floors with good views over the surrounding countryside. The home had major alterations in 2007. The provider has upgraded the top floor, which was not previously used, to create additional bedrooms. The home has a large garden at the rear of the home and car parking space at the front. The fees range from £358 to £403 per week, depending on the level of care Lilybank Hamlet DS0000002062.V366272.R01.S.doc Version 5.2 Page 5 required and the size, location and facilities provided in the person’s bedroom. This information was provided by the acting manager on 16/06/08. Information about the home, including CSCI inspection reports, is available from the home. The last inspection report is included in the Service User Guide given to all people living in the home. Lilybank Hamlet DS0000002062.V366272.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The focus of our inspections is on outcomes for people who live in the home and their views on the service provided. The inspection process looks at the provider’s ability to meet regulatory requirements and national minimum standards. Our inspections also focus on aspects of the service that need further development. We looked at all the information that we have received, or asked for, since the last key inspection or annual service review. This included: • The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. • Surveys returned to us by people using the service and from other people with an interest in the service. • Information we have about how the service has managed any complaints. • What the service has told us about things that have happened in the service, these are called ‘notifications’ and are a legal requirement. • The previous key inspection and the results of any other visits that we have made to the service in the last 12 months. • Relevant information from other organisations. • What other people have told us about the service. We carried out an unannounced inspection visit that took place over 9.5 hours on 2 days. The inspection visit focused on assessing compliance to requirements made at the previous inspection and on assessing all the key standards. Since the last inspection the registered manager, Pat Blurton, had left the home. There was an acting manager in place, Julie Gallagher who was also the operations manager for the providers of the home. There were 28 people accommodated in the home on the day of the inspection visit, including 13 people whose primary care needs were due to dementia. People who live in the home, visitors and staff were spoken with during the visit. The acting manager was available for part of the inspection visit. Some Lilybank Hamlet DS0000002062.V366272.R01.S.doc Version 5.2 Page 7 people were unable to contribute directly to the inspection process because of communication difficulties, but they were observed during the visit to see how well their needs were met by staff. ‘Case tracking’ was used during the inspection visit to look at the quality of care received by people living in the home. 6 people were selected and the quality of the care they received was assessed by speaking to them and /or their relatives, observation, reading their records, and talking to staff. During the inspection visit we used the Short Observational Framework for Inspection (SOFI). This is a methodology we use to understand the quality of the experiences of people living in the home who are unable to provide feedback due to their cognitive or communication impairments. SOFI helps us assess and understand whether people who live in the home are receiving good quality care that meets their individual needs. Following the last inspection in December 2007, a CSCI management review was held and the providers were required to produce an improvement plan to address issues raised at the inspection. The improvement plan was produced in the required timescale and addressed all the requirements made. What the service does well: People living in the home were generally pleased with the standards of care and service provided. People said the staff were “friendly” and “will do anything for you”. One person said, “I thank the staff and carers for the help, love and kindness shown to me”. A relative commented that the staff “treat the residents with respect”. Staff were observed to have a courteous and respectful approach to people living in the home. There were some good interactions where staff demonstrated warmth, affection and respect for people. One person said one reason they chose the home was because “it feels so secluded, you can’t hear any traffic”. Another person commented “I couldn’t live in a more beautiful setting”. The AQAA said that just over 50 of care staff had already achieved National Vocational Qualification (NVQ) at Level 2 or above, and that another 3 staff were working towards the qualification. Lilybank Hamlet DS0000002062.V366272.R01.S.doc Version 5.2 Page 8 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. Lilybank Hamlet DS0000002062.V366272.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 Lilybank Hamlet DS0000002062.V366272.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): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was a satisfactory needs assessment process so that people were confident the home was able to meet their needs. EVIDENCE: The care records of 3 people from each unit were seen. All the records included assessment information. Assessments by social services care managers were included for people who were funded by the local authority. One person who was self-funding had an assessment carried out by staff from the home prior to admission. There was a satisfactory range of assessment information, including details of family, personal and work history. Lilybank Hamlet DS0000002062.V366272.R01.S.doc Version 5.2 Page 11 The Annual Quality Assurance Assessment (AQAA) said that people are given a full assessment, and also can visit the home and stay for a meal before making any decision about living in the home. One person commented that they had come to the home initially for a period of respite care “to allow time to get to know the home”. People spoken with and most of those responding to the surveys said their needs were usually met at the home. Standard 6 did not apply as there were no people receiving intermediate care. Lilybank Hamlet DS0000002062.V366272.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 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans were not person centred so people were not fully involved and consulted about their needs and preferences. There was a focus on perceived problem areas, rather than a holistic approach to ensure people’s needs were fully met. EVIDENCE: All of the care records seen had a care plan produced from the assessment information. The care plans had been reviewed monthly. The care plans did not cover all the person’s needs. For example, the help needed by one person with eating and drinking was not detailed in the care plan; another person was noted to have depression but there was no care plan detailing the action and support to be given by staff; there were no plans in place to address people’s spiritual needs. Lilybank Hamlet DS0000002062.V366272.R01.S.doc Version 5.2 Page 13 The care plans lacked details of the person’s preferences about care and routines, and there were few references to promoting people’s privacy and dignity. None of the care plans seen had been signed by the person, (or their representative), to indicate their involvement and agreement. People spoken with and those surveyed said they always or usually received the care and support they needed. Staff spoken with were aware of people’s care needs and personal preferences. Staff records showed that staff had training to meet people’s needs, such as training about dementia. People said they always or usually had the medical support they needed. There were records of the visits and input of GPs, District Nurse, chiropodist and dentist. The daily records were informative and showed that people were referred promptly to their GPs or other healthcare professionals as necessary. Medication was stored securely in the ground floor treatment room or in a trolley for the top floor unit. Since the last inspection the trolley had been secured to the wall, and an up to date medication reference book had been provided. Medication administration records (MARs) seen were mostly correctly completed, although there were a few gaps on one person’s MARs where there should have been a staff signature. The medication fridge minimum and maximum temperatures were recorded daily, but the maximum temperatures were consistently too high. The acting manager confirmed that she was aware of this problem and a new fridge had been ordered. Staff who administered medication had received appropriate training. Most people spoken with and those surveyed said that staff usually listened to what they said and acted on it. Staff were observed to have a courteous and respectful approach to people living in the home. People said the staff were “friendly” and “will do anything for you”. One person said, “I thank the staff and carers for the help, love and kindness shown to me”. A relative commented that staff “treat the residents with respect”. There was a comment that a person living in the home was not always dressed in their own clothes. The Short Observational Framework Observation (SOFI) carried out in the ground floor lounge of the home looked at the quality of the care received by people living in the home. The SOFI showed that there were some good interactions where staff demonstrated warmth, affection and respect for people. There were a few examples of poor interactions, such as staff Lilybank Hamlet DS0000002062.V366272.R01.S.doc Version 5.2 Page 14 speaking to people in a patronising way, or not waiting for a response to a question asked. Lilybank Hamlet DS0000002062.V366272.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Routines were reasonably flexible and there was a good range of activities offered so that the lifestyle in the home generally met the expectations and preferences of people living there. EVIDENCE: An activities coordinator had been appointed since the last inspection to work with people in both units. The activities coordinator was qualified in occupational therapy and was enthusiastic about the role. Also since the last inspection, there was a weekly gentle exercise session provided by a physiotherapist. Records were seen of activities offered. On the first day of the inspection visit, people were involved in an art session, and there was also a communion service in the home. There was a display in the ground floor lounge of a recent session where people had talked about their working lives. Lilybank Hamlet DS0000002062.V366272.R01.S.doc Version 5.2 Page 16 Of the 8 surveys completed by people living in the home, 5 said there were usually activities they could take part in, and 3 said there always were. People spoken with said they enjoyed the activities offered. There was a comment that more trips out could be provided. During the SOFI in the ground floor lounge, 3 people had their fingernails manicured by a care assistant and 1 person had a game of dominoes with another care assistant. There was music playing that some people appeared to enjoy. Care staff sat and chatted with people. People spoken with said they could usually get up and go to bed when they wanted. One person was pleased they could get up early in the morning, as they had always done this. Records were seen of the regular meetings held for people living in the home and their relatives. The meetings included discussion of activities, meals and routines. People spoken with said they usually liked the meals provided at the home. There was a more mixed response from the surveys as 3 said they always liked the meals, 3 said usually and 2 said sometimes. Comments included: “normally fresh veg”, “ good presentation”, and “too much sweet food”. One person said they enjoyed the lunch on the first day of the inspection visit and said the meat was “nice and soft”. People spoken with during the inspection visit did not know what was for lunch. A menu was written on a board outside the ground floor lounge, though this was not up to date on the first day of the inspection visit. People in the top floor unit said they would like a menu displayed in their dining room. The acting manager was aware of this and had already planned to provide menus for each table in both of the dining rooms. Lunchtime was observed in the top floor unit on the first day of the inspection visit. The tables looked attractive with table cloths and flowers. The meal was well presented and looked appetising. There was a pleasant atmosphere with people chatting to each other and staff helping unobtrusively. People were offered a choice of drinks with their meal. The meals came ready plated up from the kitchen and there was no choice of main course. There was a choice for desert, including fresh fruit. Lilybank Hamlet DS0000002062.V366272.R01.S.doc Version 5.2 Page 17 The AQAA said that routine practice by care staff, such as everyone to be up by a certain time in the morning, was discouraged, and individual choice was promoted. The AQAA said that meals in the home predominantly used fresh produce from local suppliers, and that meals were in keeping with the likes and dislikes of people living in the home. Lilybank Hamlet DS0000002062.V366272.R01.S.doc Version 5.2 Page 18 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were effective systems in place and good staff awareness so that people were protected and their complaints taken seriously. EVIDENCE: The complaints procedure included in the Service User Guide provided to people living in the home included all the required details, except the correct address for CSCI. The complaints procedure displayed in the home did not have sufficient detail and did not have the correct address for CSCI. Most people surveyed and spoken with knew how to make a complaint. One person said that concerns they had raised with the acting manager had been dealt with promptly. The records of complaints received prior to the acting manager taking up her post in April 2008 could not be found. At the last inspection in December 2007 it was noted that complaints were effectively dealt with. The acting manager had dealt with 1 complaint since April 2008. The records of this showed that it Lilybank Hamlet DS0000002062.V366272.R01.S.doc Version 5.2 Page 19 had been dealt with promptly. There was no record of the outcome of the complaint, the acting manager said the complainant was happy with the action taken. The AQAA said that complaints were treated positively as a tool for evaluation and improvement. Also, that open communication was encouraged so that people could feel comfortable in complaining and active solutions were discussed and implemented without cause for written complaint. There were regular meetings with people at the home and their relatives. There were records of issues raised at the meetings and of the action planned. No complaints had been received directly by CSCI about the home since the last inspection. Staff training records showed that most staff had received training about safeguarding vulnerable adults. Staff spoken with were aware of safeguarding issues and the procedures to follow if abuse was suspected. There had been no safeguarding vulnerable adults referrals made to CSCI or social services about the home since the last inspection. There was information available in the home about the Mental Capacity Act 2005, and one of the senior staff had attended training about this. There was also information available about local advocacy services. Lilybank Hamlet DS0000002062.V366272.R01.S.doc Version 5.2 Page 20 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was generally well maintained so that people had a safe, clean and pleasant environment. EVIDENCE: Parts of the home were seen, including the lounges and dining rooms, some of the bedrooms and bathrooms, and the kitchen. On the top floor, one bedroom and the lounge needed redecoration of areas where there had been a water leak. During the inspection, work was carried out to improve ventilation in the kitchen. Lilybank Hamlet DS0000002062.V366272.R01.S.doc Version 5.2 Page 21 Before the inspection, a concern had been raised with CSCI about the safety of the cooker. During the inspection a report was seen from a CORGI engineer to say that the cooker was safe to use. The provider confirmed by telephone that a new cooker would be installed as part of a major upgrade and refurbishment of the kitchen. No further work had been carried out to improve the garden. The acting manager said the providers were still looking into how the garden could be landscaped to provide a safe, accessible and pleasant space for people living in the home. People spoken with said they liked to use the garden in good weather. At the last inspection it was noted that there was only one washing machine in working order and a requirement was made that the second washing machine must be repaired or replaced. The acting manager said that new laundry equipment was to be installed in the week following the inspection. There would be 2 washing machines and 2 dryers to replace all the existing equipment. Most people spoken with and those who responded to surveys said the home was always fresh and clean. The home appeared clean and was free from offensive odours during the inspection visit. People were pleased with their bedrooms and the environment of the home. One person said they liked sitting next to the window in the top floor lounge so they could enjoy the views. This person said one reason they chose the home was because “it feels so secluded, you can’t hear any traffic”. Another person commented “I couldn’t live in a more beautiful setting”. One person commented “the heating is erratic”. Lilybank Hamlet DS0000002062.V366272.R01.S.doc Version 5.2 Page 22 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were satisfactory recruitment practices, a good staff training programme and sufficient staffing levels so that people were protected and well supported. EVIDENCE: The current staff rotas showed that although the usual staffing for the top floor unit was 2 care assistants, (including a senior care assistant or the team leader), there was an additional care assistant on duty who was also providing support to people living in the apartments adjoining the home. There were agency staff covering shifts on most days on the current rota. Staff spoken with said the use of agency staff had reduced since the last inspection, although it had risen again recently due to annual leave of permanent staff. Staff said that the agency usually sent the same staff so that there was some continuity. Staff spoken with said that staffing levels were sufficient to meet the needs of people living in the top floor unit. Lilybank Hamlet DS0000002062.V366272.R01.S.doc Version 5.2 Page 23 In the unit for people with dementia there were usually 3 care assistants on duty, (including a senior care assistant or the team leader). Staff spoken with said there was little use of agency staff for this unit. The rotas showed that shifts were covered by the home’s own permanent or bank staff. Staff spoken with said that the staffing levels were usually sufficient to meet people’s needs. During the afternoon of the first day of the inspection visit, when SOFI was used, the staffing appeared adequate to meet people’s needs. Of the 8 people who responded to the surveys, 2 said staff were always available when needed, 5 said staff were usually available, and 1 said they were sometimes available. People spoken with said staff were usually available when needed. Since the last inspection several new care staff had been recruited. Records were seen for 2 of these staff and nearly all the required information and documents were in place, also for a third record seen. The records did not have a recent photograph of the member of staff, although it was seen that photographs were normally included in staff records. Staff spoken with confirmed that their recruitment had included all the required checks, such as references, proof of identity and a Criminal Records Bureau disclosure. Staff records showed that new staff completed an induction that met Skills For Care standards. Staff said they had a period of shadowing a more experienced care assistant during their induction. Most staff were up to date with required training, such as manual handling, fire safety, basic food hygiene, and safeguarding vulnerable adults. Some staff had completed training about infection control, and tissue viability. Most staff had received training about the care of people with dementia. The AQAA said that more than 50 of care staff had already achieved National Vocational Qualification (NVQ) at Level 2 or above, and that another 3 staff were working towards the qualification. Lilybank Hamlet DS0000002062.V366272.R01.S.doc Version 5.2 Page 24 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 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There had been improvements in management and communication so that people benefited from a better organised service. Care planning lacked detail and a person centred approach, and the quality assurance system was not fully developed so it was not clear that the home was run in the best interests of the people living there. EVIDENCE: Lilybank Hamlet DS0000002062.V366272.R01.S.doc Version 5.2 Page 25 The registered manager, Pat Blurton, had left the home in April 2008. The acting manager, Julie Gallagher, was also the operations manager for the company and so had been involved with the home for some time. The acting manager said she intended to apply for registration with CSCI as soon as possible. People spoken with were positive about the acting manager and were pleased with improvements she had initiated. A team leader had been recently appointed for ancillary services in the home. The acting manager had a daily meeting with the three team leaders. Staff spoken with felt this had improved communication and organisation in the home. The AQAA was completed by the acting manager and was returned to us by the due date. All sections of the AQAA were completed and gave a reasonable picture of the current situation at the home. The evidence to support the comments made was satisfactory, although there were areas where more supporting evidence would have been useful. The data section of the AQAA was completed, although there were some inconsistencies. The quality assurance system included surveys sent out to people living in the home and their relatives / representatives. The acting manager said the surveys were sent out annually and were due to go out soon. The acting manager said that a report would be produced from the findings of the surveys with details of action taken to address any issues raised. There were no surveys or report available from the previous year. Regular meetings were held for people living in he home and their relatives / representatives. Records of the meetings showed that issues and concerns were raised and action planned to address them. The personal money of people living in the home was kept securely with access limited to the acting manager. Satisfactory records were seen. Information from the AQAA showed that equipment and systems were maintained and serviced as required. Lilybank Hamlet DS0000002062.V366272.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 2 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 2 17 X 18 3 2 X X X X X X 2 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 2 X 2 X 3 X X 3 Lilybank Hamlet DS0000002062.V366272.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES 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. 1. Standard OP7 Regulation 15 Requirement Each person must have a care plan that includes all their assessed needs and is prepared and reviewed in consultation with the resident and / or their representative. This will help to ensure that person centred care is planned and delivered to fully meet people’s needs and preferences. Previous timescales of 31/01/07 and 07/04/08 not met. Extension given as some work had been carried out. 2 OP19 23(2)(b) The areas of water damage in the identified rooms must be repaired/redecorated to ensure a well maintained and pleasant environment for people living in the home. The second washing machine must be repaired or replaced to ensure adequate facilities for laundry are in place. Previous timescale of 07/04/08 not met. Short extension given as the new equipment was due Lilybank Hamlet DS0000002062.V366272.R01.S.doc Version 5.2 Page 28 Timescale for action 30/09/08 31/08/08 3 OP19 16 (e) (f) 30/06/08 4 OP20 23 (2) (o) to be installed soon after the inspection visit. External grounds must be accessible, suitable for and safe for use by the people using the service. Grounds must be appropriately maintained. Previous timescale of 07/04/08 not met. Extension given as some work has been carried out. 31/03/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP15 Good Practice Recommendations Staff should have training about a person centred approach to care planning and delivery to ensure people’s needs are met in the way they prefer. Menus should be provided in the dining rooms so that people are aware of the choices available to them. menus should be in an appropriate format for the needs of people living in the home. Complaints records should include details of the outcome and whether the complainant is satisfied. This will ensure that people know their complaints are taken seriously. Signs should be in place on the doors of toilets and bathrooms that are appropriate for people with dementia. The quality assurance system should include a report that is made available to residents / their representatives. This will help to ensure that people know their views are used to shape the service, and that the home is run in their best interests. 3 4 5 OP16 OP19 OP33 Lilybank Hamlet DS0000002062.V366272.R01.S.doc Version 5.2 Page 29 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 Lilybank Hamlet DS0000002062.V366272.R01.S.doc Version 5.2 Page 30 - 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. 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