Inspection on 07/12/07 for Lilybank Hamlet

This inspection was carried out on 7th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 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 11/06/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Lilybank Hamlet Chesterfield Road Matlock Derbyshire DE4 3DQ Lead Inspector Angela Kennedy and Rose Veale Unannounced Inspection 7th December 2007 09:50 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.V355182.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.V355182.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 Limited Mrs Patricia Blurton 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.V355182.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. 4th January 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 home had major alterations in 2007. The registration was changed in August 2007 so that the home could provide care for people whose primary care needs was because of dementia and is registered to provide Dementia Care for up to 22 people aged 60 years and over. The home is an older, converted building with accommodation on the ground floor and two upper floors with good views over the surrounding countryside. The provider has upgraded the third floor of the existing building, which was not previously used, to create additional bedrooms and 2 units within the existing care home. The home has a large garden at the rear of the home. The garden is to be extended and landscaped, and new fencing is to be fitted. Work has been carried out to create a temporary garden area, which is safe and meets the needs of people with dementia and old age related illnesses. The fees range from £358 to £396 per week. This information was provided by the registered manager on 07/12/07. Lilybank Hamlet DS0000002062.V355182.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over six hours. Two inspectors undertook this inspection visit. Key inspections take into account a wide range of information and commence before the site visit by examining previous reports and information such as any reported incidents. The site visit is used to see how the service is performing in practice and to meet with the people using the service. The inspection was focused on assessing compliance with defined key National Minimum Standards. Four residents were case tracked. Case tracking is a method used to track the care of individuals from the assessments undertaken before they are admitted to a service through to the care and support they receive on a daily basis. This includes looking at support plans and other documents relating to that persons care, talking to staff regarding the care they provide and if possible talking to the individual. The inspectors were accompanied by an ‘expert by experience’ for part of the inspection visit. An expert by experience is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. The expert by experience spoke to people at the home about the lifestyle in the home and their views of the service. Information from the findings of the expert by experience has been included in the body of this report. Several members of staff were spoken with to gain their views on the service and support provided to the people using the service and the training and support given to staff. For the purposes of this report the Commission for Social Care Inspection is referred to as ‘we’. What the service does well: The service ensured that any health care needs identified were promptly addressed and referred to the relevant professional body. People using the service that were spoken with said that staff treated them respectfully, and from observations it was noted that staff provided a caring approach when providing care and support. Lilybank Hamlet DS0000002062.V355182.R01.S.doc Version 5.2 Page 6 The people using the service generally enjoyed meals and comments made indicated that the staff team made every effort to meet the needs and tastes of individuals. 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.V355182.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lilybank Hamlet DS0000002062.V355182.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The detail provided within the pre admission information was not always completed, which meant that residents could not be assured that their needs could be met by the home. EVIDENCE: The care records of two people living in the Matlock View unit were seen. This unit provides care for people with Dementia. One was for a person who had lived in the home for several years and the other was for a person who had been admitted about six weeks before the inspection visit. Both records included assessment information. The assessment information for the person who had lived at the home for several years had been updated in July 2007 and included brief details of their needs and abilities. The assessment information for the person admitted in 2007 included information from Social Services and a brief assessment carried out by the home prior to admission. Lilybank Hamlet DS0000002062.V355182.R01.S.doc Version 5.2 Page 9 The care records of two people living in the Matlock Hydro unit were seen. This unit is a general unit. One was for a person who had lived in the home for two years and the other person had been admitted to the home in January 2007. Assessment information was in place for both of these people. Although it was noted that the assessment information for the person admitted in 2007 had not been completed on all the needs assessment documents, such as the information provided on the admission checklist and the ‘essential information’ record, and pre-admission assessment. An example of this was in relation to this person’s mobility needs, which had been recorded on their admission checklist and ‘essential information’ record but not on their pre admission assessment of need. The person that had lived at the home since 2005 did have completed needs assessment records in place. This person had a needs assessment that had been undertaken by Social Services and this assessment had been reviewed annually since admission, to ensure any changing needs identified could be met by the service. Lilybank Hamlet DS0000002062.V355182.R01.S.doc Version 5.2 Page 10 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 adequate. This judgement has been made using available evidence including a visit to this service. Gaps in care plans indicated that resident’s needs were not always fully met. The medication practices in place did not always protect resident’s welfare, and this potentially put residents at risk. EVIDENCE: For the two people case tracked within Matlock View, the care plans in the records seen did not cover all the assessed needs of the person and did not include enough detail about their individual needs and preferences. For example, one person had diabetes but there was no mention of this in the care plan; one person needed help with mobility but there was no detail about the kind of help needed and no mention that the person used a walking frame. Neither of the care plans covered the social and spiritual needs of the person. For the two people case tracked within Matlock Hydro, the care plans seen provided good detail, but as within the care plans seen in Matlock View the care plans did not cover all the assessed needs of the individual, such as one resident whose health care needs meant that they would sometimes refuse Lilybank Hamlet DS0000002062.V355182.R01.S.doc Version 5.2 Page 11 their medication or refuse to eat or drink. There was no care plan in place regarding these needs. Daily records also demonstrated that this person received treatment from the district nurse for a wound on their leg. However there was no care plan in place regarding this. Neither of the care plans seen in Matlock Hydro covered the social and spiritual needs of the person. However there was information regarding the religious needs of one of the residents on their needs assessment, but this had not been transferred to their care plan. On speaking to staff it was stated that this person no longer expressed an interest in their religion, due to their failing health needs. This information therefore should be transferred to their care plan and reviewed regularly. The pro-forma for the care plans did not allow much space for staff to write details of the help needed. None of the care plans seen had been signed by the person or their representative to indicate their involvement and agreement. All care plans seen had been reviewed regularly and partly updated. The review documentation seen did not always match the care plans. Two people were self-funding and so had no reviews by a Social Services care manager. There was no procedure in place at the home for people who were self-funding to have a similar review to those who were funded by the local authority. The daily logs for each of the people case tracked were informative and showed that in general people were referred promptly to GPs and other healthcare professionals when necessary. It was noted however that one person had not been seen by a GP for nearly a year. There were records of the visits and input of the GP, District Nurse, chiropodist, and dentist. The medication administration records (MARs) seen were in general correctly completed. However, one person had been prescribed a variable dose of medication, and it was not clear what dose they were receiving, as staff had not always recorded to dose given on the record. A pharmacy audit had taken place at the home on the 22 November 07 and a recommendation was left at this audit that the dosage be recorded when administering variable dose prescriptions. It was noted that one MAR showed a drug out of stock for one person for the previous 2 weeks. It was not clear that any action had been taken to re-order the medication. The medication reference book in use was several years out of date. The medication trolley on the third floor was being stored in a spare/unused bedroom. The manager confirmed that this was a temporary arrangement until the trolley could be fixed to the wall. The manager confirmed that this Lilybank Hamlet DS0000002062.V355182.R01.S.doc Version 5.2 Page 12 bedroom door was kept locked whilst the medication trolley was stored there, and this room was noted to be locked during the inspection visit. Medication training was provided to staff by an external training agency and staff had received training to administer insulin by the district nurse. There were few references to promoting privacy and dignity in the care records seen. Interaction between people living in the home and staff was observed to be kind and friendly. One person living in the home said, “They’re very good here, they look after us”. Staff were observed to knock on bedroom doors before entering. The expert by experience observed one resident being transferred by a hoist into a chair in the lounge area of the third floor and stated “…I felt that a blanket should have been put over this ladies knees before hoisting her, to try to avoid showing her underwear. However, the member of staff who did this had a very caring manner and talked to the residents while she was working”. One of the people living at the home told the expert by experience that they felt they were treated with dignity and respect and said, “The staff do what they can.” For instance, this person said that if they missed their cup of tea in the afternoon because they was having a bath, staff always asked them if they wanted one afterwards. That morning, because they told the staff member that they liked their tea weak, they brought them a jug of hot water, so that they could have their tea just the way they liked it, which pleased them. Lilybank Hamlet DS0000002062.V355182.R01.S.doc Version 5.2 Page 13 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 adequate. This judgement has been made using available evidence including a visit to this service. The lifestyle preferences of the people living at Lilybank Hamlet could not always be met, as activities were not provided on a regular scheduled basis. Individual meal tastes and preferences were provided, therefore meals were generally enjoyed. EVIDENCE: In the Matlock View unit there was a weekly activity plan displayed. There were records of activities in the individual care records. There were few entries in the records after August 2007. There was no activities coordinator, although the home was actively trying to recruit for this post. On the morning of the inspection visit, it was seen that there was little interaction between staff and people living in the Matlock View Unit and no organised activities taking place. Staff spoken with said that some staff were more confident at providing activities and interacting with people and so it would depend which staff were on duty. In Matlock Hydro a record of social and leisure activities was in place within the two individuals care records. However as in Matlock View there were few entries in these records since August 2007. Lilybank Hamlet DS0000002062.V355182.R01.S.doc Version 5.2 Page 14 One member of staff was observed providing nail care to one individual and this included painting their nails with nail polish. No other activities were noted. However the two staff that were on duty within the Matlock Hydro unit were seen on a few occasions chatting with residents, and demonstrated a caring and friendly approach. Several of the people living at Lilybank Hamlet and some of their visitors spoke with the expert by experience regarding the activities they took part in and their routines. One resident said there were not many activities and they did not think there were any outings, and stated, “ I would have gone if there were any outings”. This person confirmed that they went into the garden when the weather was good. Two other people living at the home confirmed that the home was short of an activities person and confirmed that on the previous day, four of the people living at the home had played dominoes. They stated that two people had needed help and so a member of staff had to leave her other job to help them. The expert by experience asked some of the people living at the home if they were able to get up and go to bed when they wanted. Comments made included, “They get me up when they are ready. They have plenty to do.” Another person living at the home stated that although they could choose when to go to bed, the staff usually brought their breakfast to them at 8am, this person stated that they required assistance with dressing and indicated that this was the reason why they didn’t have so much choice in getting up. One person told the expert by experience that they chose to get up at 5.30am each morning, they stated they had always got up at this time, and confirmed they were still able to do this. Visiting was open and visitors spoken with confirmed that they are allowed to visit at any time and they were given tea and biscuits. They also stated that they could visit their friend in their room if they wanted to talk to them privately. The comments regarding the meals available was generally very positive and all of the people spoken with confirmed there was a sufficient quantity of food provided to them. Not all of the people spoken with were sure if there were alternative choices available. Two people who spoke to the expert by experience said they thought the food was “ usually quite good.” “We have our dislikes, but everyone does. They try to accommodate us.” For instance, one person did not like mashed potatoes Lilybank Hamlet DS0000002062.V355182.R01.S.doc Version 5.2 Page 15 and the regular staff left their potatoes whole. One person had a milk allergy and regular staff were aware, but “it does not work the same when agency staff are in because they do not know us. There is always the alternative of fresh fruit and yoghurt.” Lilybank Hamlet DS0000002062.V355182.R01.S.doc Version 5.2 Page 16 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. This judgement has been made using available evidence including a visit to this service. Complaints were effectively dealt with, which ensured the people using the service and their representatives, could be confident that their complaints would be addressed. The practices in place and staff awareness enhanced the protection of the people living at the home. EVIDENCE: There were records of complaints at the home that showed the action taken. Complaints appeared to be dealt with appropriately. Since the home was divided into 2 units in August 2007, separate meetings were being held on each unit for people living in the home and/or their relatives. The meeting for the Matlock View unit was due to take place the day after the inspection visit. Relatives had been asked to write with any issues they wanted raising if they could not attend the meeting. There were two complaints received by us about the home in May and October 2007. One complaint was about the lift being out of action and other regarding the consequences of the building work carried out at the home in the early summer time. The other complaint was about insufficient staffing and the use of agency staff, and the lack of activities for people living in the home. Both complaints were referred to the provider to investigate and respond. Appropriate responses were received within the given timescales. Lilybank Hamlet DS0000002062.V355182.R01.S.doc Version 5.2 Page 17 The expert by experience spoke with some of the people living at the home about what they would do if they had any concerns or complaints and they confirmed that they would speak with the manager. Staff at the home had received training about safeguarding vulnerable adults. There had been two incidents of alleged abuse since the last inspection and both were referred to Social Services for investigation. Neither incident was notified by the home to us as required. Lilybank Hamlet DS0000002062.V355182.R01.S.doc Version 5.2 Page 18 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): 19,20,22,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was generally well maintained so that residents lived in comfortable, clean and pleasant environment. The temporary garden area meant that the people living at the home did not have full access to the grounds of the home, which limited their choices when accessing outdoor facilities. EVIDENCE: The home had major alterations in 2007. The registration was changed in August 2007 so that the home could provide care for people whose primary care needs was because of dementia. A tour of the building was undertaken this included viewing areas of the home that had been refurbished during 2007, such as some of the bedrooms, the lounges, dining room, and bathrooms. During the tour it was however noted that two fire extinguishers, one in a bathroom and one in a corridor were free Lilybank Hamlet DS0000002062.V355182.R01.S.doc Version 5.2 Page 19 standing on the floor. The manager was unsure of the reason for this, and confirmed that these should be fixed in place on brackets. The laundry and kitchen was also seen. The home was clean throughout, free from offensive odours, and appeared generally well-maintained and provided attractive views of the surrounding countryside. The home had suitable equipment to meet the needs of residents, such as hoists and wheelchairs. However safe practices were not in place regarding the use of some of this equipment. (See standards 31-38 for further information) It was noted when touring the kitchen that cupboards and freezers were locked. This was discussed with the manager who stated that this had been put in place following a theft of the homes provisions. It was confirmed by the manager that sufficient supplies were left out for staff to provide drinks or snacks throughout the night to anyone living at the home that may require them. A large window within the main kitchen was noted to have no opening light and staff confirmed that the fan situated in this window did not work and hadn’t done so for some time. Further discussions confirmed that a requirement had been made by environmental health at a recent visit, regarding this window and the need for ventilation to be fitted, and then consequently a fly screen to be put in place. At a CSCI visit in August 2007 it was noted, “The home has a large garden at the rear of the home. The company has confirmed in writing that the garden will be extended and landscaped within the next 6 months, and new fencing will be fitted. Work has been carried out to create a temporary garden area, which is safe and meets the needs of people with dementia and old age related illnesses. Temporary fencing has been provided. The provider accepts that the current garden facilities are not ideal for residents; it has been agreed that a member of staff will supervise residents wishing to go into the garden.” It was found at this inspection visit that the work to landscape the garden had not been carried out and the temporary fencing remained in place. It was found that the garden had rarely been used by people living in the home in the last few months. The laundry room was seen. Within the laundry three washing machines were in place, however one was a coin-operated machine, which the manager stated had not been in use for as long as she could remember. Another machine was also out of order. This left one machine for the laundering of all clothing, bedding and other items. A built in sluicing facility was incorporated within this washing machine. One large tumble dryer was also in place within the laundry, on discussions with the manager it was stated that the member of staff employed to undertake laundry duties had not requested an additional tumble dryer but had stated that it was difficult to maintain the washing of items with only one machine in use. Lilybank Hamlet DS0000002062.V355182.R01.S.doc Version 5.2 Page 20 One person living at the home told the expert by experience they had been upset when they sent things to the laundry and did not get their own things back. The manager did state that relatives and the representatives of the people living at the home had been asked to provide nametags in clothing. Signs had been provided to indicate the way to the dining room and lounge. There were no signs appropriate for people with dementia on the doors of toilets and bathrooms. There were coded locks to the external doors and a gate had been installed in the main entrance area to give extra security for people who might be at risk if they left the home unescorted. Lilybank Hamlet DS0000002062.V355182.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 adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels were not always sufficient to ensure residents’ needs could be properly met. EVIDENCE: At the time of a complaint about staffing levels made to us in October 2007, the manager was asked to send copies of the current staff rotas. These rotas and the rotas seen during the inspection visit showed that the home relied significantly on agency staff to cover shifts. For some shifts, it was seen that there were more agency staff on duty than the permanent staff employed by the home. It was seen on 2 shifts that there appeared to be only 1 care assistant on duty for the top floor unit, where there should have been 2. The information provided by the service following this inspection visit confirmed that in the last three months, temporary or agency staff had been used on 180 shifts. This equates to over 64 of shifts within the last three months. Discussions took place with the manager regarding the staffing levels in place on the top floor unit, as it was noted that one person living on this unit required the use of a hoist to assist them with transfers. As two staff are required to assist with transfers involving hoists. This would mean that during Lilybank Hamlet DS0000002062.V355182.R01.S.doc Version 5.2 Page 22 these practices none of the other people living on this floor could receive support from the staff on duty in this unit. The expert by experience observed one of the people living on the top floor having difficulty manoeuvring their walking frame, when in the lounge area. They stated that the other people sitting in the lounge were very helpful to this person, but noted that no staff were in the lounge at this time. Staff spoken with were positive regarding the training provided to them, but did indicate their concerns regarding the staffing levels in place, especially within the general unit, situated on the top floor. Staff were observed in their interactions with the people living on the top floor unit and appeared relaxed and friendly. Since the last inspection, a new induction programme had been introduced that met the Skills For Care standards. Individual records were seen of completion of the induction programme. Of the fourteen permanent care staff employed, seven of these had achieved a National Vocational Qualification in care at level 2 or above. Staff training records showed that staff had received the required training, such as manual handling and fire safety. Staff had also received training about dementia. Lilybank Hamlet DS0000002062.V355182.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): 31,33,35,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some of the practices in place regarding moving and handling, did not promote safe working practice and therefore put both the staff and people using the service at risk. EVIDENCE: The manager has been in post since November 2006. She achieved registration with us in March 2007, and has the registered managers award. The quality assurance systems in place were being further developed following the major alterations to the service. The manager stated that separate meetings were now being held for the dementia unit and the general unit. Lilybank Hamlet DS0000002062.V355182.R01.S.doc Version 5.2 Page 24 It was confirmed that a meeting for the people living on the general unit and their representatives, had been held the week prior to this inspection visit. A meeting was planned for the people living on the dementia unit and their representatives, the weekend following this inspection visit. Minutes of meetings held were looked at, and it was noted that feedback from previous meetings was not included in the minutes, such as the actions taken from any issues or matters raised. This was discussed with the manager and operations manager. It was confirmed that satisfaction questionnaires were sent out to residents, their representatives and visiting professionals. It was stated that questionnaires for 2007 had not been sent out at the time of this inspection visit. It was confirmed that the information received in these questionnaires would be collated and sent to the operations manager, who would look at any further action required. Staff meetings were usually held on a monthly basis and evidence of meetings held was seen. The personal monies and records held for the four people case tracked were seen. The monies held corresponded with the records and all transactions had two signatures. Notifications about allegations of abuse were not sent to us as required by law. Although suitable equipment was in place to meet the needs of residents such as hoists and wheelchairs, the expert by experience observed a single member of staff transferring a person into a chair using the hoist. This is not safe working practice and has the potential to cause harm to the person being hoisted and the member of staff working alone during this manoeuvre. Health and safety records were sampled and in general were satisfactory. It was however noted that weekly fire checks had not been undertaken since August 2007, which potentially puts the people living at the home, staff and visitors at risk. The information received from the home following this inspection visit indicated that policies were not in place regarding continence promotion, pressure area care and missing service users. As neither the registered manager or operations manager were available to discuss this with, this will be followed up with them in the near future. Lilybank Hamlet DS0000002062.V355182.R01.S.doc Version 5.2 Page 25 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 2 X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 1 Lilybank Hamlet DS0000002062.V355182.R01.S.doc Version 5.2 Page 26 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 OP3 Regulation 14 Requirement Health, personal care and social needs must be fully assessed prior to admission and recorded on the needs assessment to demonstrate this, and inform the care plan documents. 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. (Previous timescale of 31/01/07 not met) Medication must be available to administer as prescribed to ensure people receive the correct levels of medication. Staff must record the dosage of medication administered for variable dose prescriptions to ensure people receive the correct levels of medication Staff must ensure that each person’s dignity is maintained when providing support in moving and handling practices. People using the service must be consulted about the programme DS0000002062.V355182.R01.S.doc Timescale for action 07/04/08 2. OP7 15 07/04/08 3. OP9 13.2 20/01/08 4 OP9 13.2 20/01/08 5 OP10 12 (4) (a) 20/01/08 6 OP12 16 (2) (n) 07/04/08 Lilybank Hamlet Version 5.2 Page 27 7 OP19 16 (e) (f) of activities arranged, having regard to their needs and preferences. The second washing machine must be repaired or replaced to ensure adequate facilities for laundry are in place. External grounds must be accessible, suitable for and safe for use by the people using the service. Grounds must be appropriately maintained. An assessment must be carried out of staffing levels appropriate to the needs of residents, taking into the mobility needs of people using the service, and the design of the building. Notifications about allegations of abuse must be sent to the CSCI Staff must not work alone when undertaking moving and handling practices such as hoisting individuals. This is to ensure the safety of the person being hoisted and the staff undertaking this procedure from injury and harm. Weekly fire tests must be undertaken to ensure the fire alarm systems and fire doors are operating correctly. 07/04/08 8 OP20 23 (2) (o) 07/04/08 9 OP27 18(1)(a) 20/01/08 10 11 OP37 OP38 17 13 (5) 20/01/08 20/01/08 12 OP38 23 (4) 20/01/08 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 OP9 OP27 Good Practice Recommendations The medication administration trolley should be securely attached to a solid fixture such as a wall, when not in use. The Residential Forum care staffing tool should be used to DS0000002062.V355182.R01.S.doc Version 5.2 Page 28 Lilybank Hamlet provide guidelines for the staffing levels required to meet the assessed needs of residents. 3. 4. OP19 OP33 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. Lilybank Hamlet DS0000002062.V355182.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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.V355182.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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