Inspection on 19/07/05 for Lilybank Hamlet

This inspection was carried out on 19th July 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

Lilybank Hamlet 11/06/08

Lilybank Hamlet 07/12/07

Lilybank Hamlet 04/01/07

Lilybank Hamlet 17/10/05

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Lilybank Hydro Chesterfield Road Matlock Derbyshire DE4 3DQ Lead Inspector Rose Veale Unannounced Inspection 19 July 2005 9.40am 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 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 Hydro C52-C02 S2062 Lilybank Hydro V240210 190705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Lilybank Hydro Address Chesterfield Road Matlock Derbyshire DE4 3DQ 01629 580919 01629 760019 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Bakewell Care Homes Limited. Vacant PC Care Home only 40 Category(ies) of 40 places - OP Old Age registration, with number of places Lilybank Hydro C52-C02 S2062 Lilybank Hydro V240210 190705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. 4 Day Care. Date of last inspection 07/02/2005 Brief Description of the Service: Lilybank Hydro is situated in the town of Matlock. There is a range of facilities available in the town, including shops, pubs, restaurants and public transport. The home provides personal care and accommodation for up to 40 older people, and 4 day care places. The home is an older, converted building with accommodation on the ground floor and two upper floors with good views over the surrounding countryside. There are attractive and well maintained gardens to the rear of home. The home and gardens are fully accessible to residents. Lilybank Hydro C52-C02 S2062 Lilybank Hydro V240210 190705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over 5½ hours on one day. There were 27 residents accommodated in the home on the day of the inspection, including 3 residents for respite care. Residents, visitors and staff were spoken with during the inspection. The care records of 4 residents were examined, plus other records relating to the staffing and management of the home. A tour of the building was carried out. The acting manager was available and helpful during the inspection. Lilybank Hydro had recently been taken over by a new provider and, understandably, this was causing some concern amongst residents, their relatives, and the staff at the home. What the service does well: What has improved since the last inspection? What they could do better: At present, residents can ask for an alternative if they do not want the meal offered at lunchtime. It would improve residents’ choice if an alternative to the main meal was planned and included on the written menus. To ensure residents safety, risk assessments were needed for the radiators in certain rooms, and the practice of wedging open fire doors must end. Lilybank Hydro C52-C02 S2062 Lilybank Hydro V240210 190705 Stage 4.doc Version 1.40 Page 6 The first floor bathroom needed redecorating to make it a more pleasant place for residents to use. The acting manager was included as part of the staffing levels and had no planned time to focus on her management responsibilities. It is necessary for the organisation and smooth running of the home that the acting manager should have specific time to carry out her job properly. The management arrangements under the new provider must be communicated effectively to residents, relatives, staff and to the Commission for Social Care Inspection. 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. Lilybank Hydro C52-C02 S2062 Lilybank Hydro V240210 190705 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Lilybank Hydro C52-C02 S2062 Lilybank Hydro V240210 190705 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 4 Sufficient assessment information was obtained so that residents could be assured that the home could meet their needs. EVIDENCE: The care files of four residents were examined and all contained assessment information obtained before admission to the home, plus a profile and assessment completed soon after admission. The acting manager said that all prospective residents were seen and assessed before admission. Two of the files seen were of residents recently admitted to the home and had copies of the letter sent to the resident confirming that the home was able to meet their needs. It was a requirement at the last inspection that the home should provide this confirmation. Lilybank Hydro C52-C02 S2062 Lilybank Hydro V240210 190705 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 10 Residents’ health and personal care needs appeared to be fully met, with good liaison with other healthcare professionals and evidence of respecting residents’ privacy and dignity. EVIDENCE: Care plans were in place for all the files seen. The care plans were detailed and easy to follow. There was clear information for staff on the action to take to meet the needs of residents. Residents’ individual preferences were recorded regarding daily routines. All the care plans seen had been reviewed weekly up to date. The care files contained records of the input from healthcare professionals, such as GPs, District Nurse, and chiropodist. It was clear that access to health care services was sought as required to meet the changing needs of residents. For example, one resident had increasing continence problems and was referred to the District Nurse for assessment. The care files seen all contained assessments of the risk of developing pressure sores, moving and handling needs, and nutritional needs and these assessments had all been reviewed monthly up to date. Lilybank Hydro C52-C02 S2062 Lilybank Hydro V240210 190705 Stage 4.doc Version 1.40 Page 10 Residents spoken with said that staff treated them with respect and upheld their right to privacy. One resident gave an example of being assisted into the bath, then being left in private to enjoy the bath. The family of one resident said that staff always knocked on the bedroom door before entering and always spoke to the resident in a courteous way. Staff spoken with were knowledgeable about the individual needs of residents and were able to give examples of how they would maintain residents’ privacy and dignity. Lilybank Hydro C52-C02 S2062 Lilybank Hydro V240210 190705 Stage 4.doc Version 1.40 Page 11 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 standard(s) 12, 13 and 15 Residents needs and preferences were appropriately met by the flexible daily routines, a good range of activities, a varied menu, and a welcoming attitude to visitors. EVIDENCE: The care files seen contained information about the preferences of residents regarding leisure and social activities. There was a record of activities the residents had taken part in, including trips out, quizzes, bingo, dominoes, manicures, and music from outside entertainers. There were also examples of one to one activities, such as reading a magazine or chatting over a coffee. Residents spoken with said they enjoyed the activities offered. One resident particularly enjoyed having the local newspaper read to her. Information about activities was displayed in the main lounge. The acting manager explained that the current activities organiser had only been employed recently on a part-time basis. The previous activities organiser had worked for more hours and had established a good range of activities in the home. Some concern was expressed by residents, visitors and staff that the previous standard of provision should be maintained. Residents preferences with regard to daily routines were recorded in their care plans. Two residents spoken with were pleased with the flexibility of the Lilybank Hydro C52-C02 S2062 Lilybank Hydro V240210 190705 Stage 4.doc Version 1.40 Page 12 routines in the home. One resident said that she “only had to ask” staff and they would ensure she had what she wanted. There was an open visiting policy at the home. Residents spoken with said their visitors were made welcome by staff. Some residents liked to use the conservatory to see their visitors. Visitors spoken with said that staff were always welcoming and courteous. The menus for the home were seen and these were varied. There was no choice given on the menu for the main meal of the day. Residents spoken with said they could choose an alternative if they did not like the meal offered on the menu. The acting manager and staff spoken with confirmed that residents would ask for an alternative if they did not like the offered meal. The meal served at lunchtime on the day of the inspection looked appetising. The dining room was pleasant and the meal was served in an unhurried way. Residents spoken with were generally pleased with the food offered and with the dining room. Some staff spoken with felt that the dining room could feel cramped for space when there were several residents in wheelchairs. Lilybank Hydro C52-C02 S2062 Lilybank Hydro V240210 190705 Stage 4.doc Version 1.40 Page 13 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 standard(s) 18 The policies and procedures in the home, and staff awareness and attitudes, ensured that residents were protected from abuse. EVIDENCE: The acting manager and staff spoken with had all had training in adult protection issues and awareness. Staff spoken with were aware of adult protection procedures and said they would be happy to go to the acting manager with any suspicions. The home’s policy referred to the Derbyshire County Council multi-agency guidelines. Lilybank Hydro C52-C02 S2062 Lilybank Hydro V240210 190705 Stage 4.doc Version 1.40 Page 14 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 standard(s) 19, 20 and 24 The home was clean and generally well maintained, providing a pleasant environment for residents. EVIDENCE: The home appeared well maintained and well decorated. Work had been carried out to meet the requirements made at the last inspection, including repairs to the grilles in the floor of the main corridor and risk assessments to specified radiators to ensure residents safety. Two more radiators were identified as requiring risk assessment as they were not sufficiently guarded. The bathroom on the first floor was in need of general redecoration, and repair or replacement of the floor covering near to the hairdressing washbasin. Several bedroom doors had been wedged open and this appeared to be a common practice as door wedges were seen in other rooms. The gardens were pleasant, well kept and accessible to residents. One resident spoken with said she and her family had enjoyed being in the garden in the recent good weather. Lilybank Hydro C52-C02 S2062 Lilybank Hydro V240210 190705 Stage 4.doc Version 1.40 Page 15 The large lounge was comfortably furnished, with chairs arranged in groups and tables available for residents or visitors to sit at. The small conservatory was pleasant and quiet. Both rooms had good views over the local countryside. The bedrooms seen were all clean, pleasant, well decorated and comfortably furnished. Residents had brought their own possessions to personalise the rooms. Residents or their representatives had been asked if they would like a key to their room and this was noted on the care records. Lilybank Hydro C52-C02 S2062 Lilybank Hydro V240210 190705 Stage 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 Staffing levels were sufficient for the assessed needs of the residents. However, these levels included the acting manager who did not have any planned time to focus on management responsibilities. Staff records were generally satisfactory, however, proof of identification was needed to fully ensure the protection of residents. EVIDENCE: The staff rotas seen showed that there were sufficient staff on duty. The acting manager was counted in as one of the carers on duty and so did not have adequate time allowed to carry out her management responsibilities. Staff spoken with felt that staffing levels were adequate and said that although the workload could be very busy, there were quieter periods in the day when they were able to spend more time with residents. Residents and relatives spoken with felt that staff were always available when needed. Staff records were examined, including the records of a new member of staff. The new employee was working before a satisfactory Criminal Records Bureau disclosure had been obtained. However, the employee was working under the supervision of another member of staff and was not involved in the personal care of residents. Records seen contained all the required information except for proof of identity including a recent photograph. Lilybank Hydro C52-C02 S2062 Lilybank Hydro V240210 190705 Stage 4.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 and 36 Management arrangements in the home needed to be clarified for the reassurance of residents, relatives and staff. Staff in the home were supported by regular supervision. EVIDENCE: The acting manager had been working at the home for several years and had been working as the deputy manager until the recent takeover by a new provider. She had therefore only been acting manager for a short time and expressed some concerns about her new role, although she felt well supported by the staff team. Residents, relatives and staff spoken with had confidence in the abilities and competence of the acting manager. Relatives spoken with felt that it would be useful if the new providers could meet with residents and their representatives. The operations manager for the new provider was visiting the home on the day of the inspection and said that it was intended that a new manager would be recruited as soon as possible. Lilybank Hydro C52-C02 S2062 Lilybank Hydro V240210 190705 Stage 4.doc Version 1.40 Page 18 The staff files seen contained records of supervision sessions carried out every two months. Staff spoken with confirmed that they had taken part in supervision and had found it useful. Lilybank Hydro C52-C02 S2062 Lilybank Hydro V240210 190705 Stage 4.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 3 x x x 3 x x STAFFING Standard No Score 27 2 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 2 x x x x 3 x x Lilybank Hydro C52-C02 S2062 Lilybank Hydro V240210 190705 Stage 4.doc Version 1.40 Page 20 NO 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. 1. 2. Standard 19 19 Regulation 23(2) (b) (d) 13(4) Requirement The first floor bathroom must be in a good state of repair and reasonably decorated Risk assessments must be completed in relation to the radiators identified as a potential hazard in bedrooms Fire doors must not be wedged open The care staff hours provided must take into account the supernumerary time required by the acting manager Staff records must contain all the required information, inlcuding proof of identification and a recent photograph CSCI must be informed of the menagement arrangements for the home Timescale for action 31/10/05 31/08/05 3. 4. 19 27 23(4) 18(1)(a) 31/08/05 31/08/05 5. 29 19(1)(b) 30/09/05 6. 31 8 31/08/05 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. Refer to Standard 15 Good Practice Recommendations A choice of main meals should be included on the written C52-C02 S2062 Lilybank Hydro V240210 190705 Stage 4.doc Version 1.40 Page 21 Lilybank Hydro 2. 19 menus The provider should consider fitting fire alarm activated closure devices to fire doors so that the doors can be safely left open if required. Lilybank Hydro C52-C02 S2062 Lilybank Hydro V240210 190705 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection South Point Cardinal Square Nottingham Road Derby DE1 3QT 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. Extracts may not be used or reproduced without the express permission of CSCI Lilybank Hydro C52-C02 S2062 Lilybank Hydro V240210 190705 Stage 4.doc Version 1.40 Page 23 - 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!