Inspection on 11/03/08 for The Lilacs

This inspection was carried out on 11th March 2008.

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

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

The Lilacs 31/08/06

The Lilacs 12/12/05

The Lilacs 08/06/05

The Lilacs 03/02/05

The Lilacs 26/05/04

The Lilacs 28/01/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Lilacs (The) 2a Lickhill Road Calne Wiltshire SN11 9DD Lead Inspector Malcolm Kippax Key Unannounced Inspection 11th March 2008 09:25 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 Lilacs (The) DS0000028354.V351713.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. Lilacs (The) DS0000028354.V351713.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lilacs (The) Address 2a Lickhill Road Calne Wiltshire SN11 9DD 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) 01249 821422 Mr Ronald Michael Taylor Ms Trudy Jane Taylor Care Home 9 Category(ies) of Old age, not falling within any other category registration, with number (9) of places Lilacs (The) DS0000028354.V351713.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: N/A Date of last inspection 31st August 2006 Brief Description of the Service: The Lilacs is a family run care home for up to nine people. It is situated in a residential area of Calne, approximately ten minutes walk from the town centre. The Lilacs is a detached property with a large garden. The Lilacs was purpose built as a care home by the current owner. There are five single bedrooms and one double room on the ground floor. There is a staircase to two single bedrooms on the first floor, where the home’s owner and the manager also have their accommodation. Each bedroom has an en-suite toilet and wash hand basin. One of the bedrooms also has its own bathroom. On the ground floor there is a bathroom with an assisted bath for use by all the residents. The communal space consists of an open plan lounge and dining room. The manager, Ms Taylor, is closely involved in people’s day to day care. Other family members are regularly involved and they work in conjunction with the carers and ancillary staff who make up the staff team. Fees at the time of this inspection ranged from £364 - £450 per week, depending upon the level of care that a person needs and the type of accommodation. A copy of the last inspection report is available in the home. Inspection reports are also available through the Commission’s website at: www.csci.org.uk Lilacs (The) DS0000028354.V351713.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. We made an unannounced visit to The Lilacs on 11th March 2008. The home had six residents at the time. During the visit we spent time with the residents and met with Mr Taylor, the home’s owner. We also spoke to two members of the staff team. We made a second visit to the home on 26th March 2008 in order to meet with Ms Taylor, the manager, and to complete the inspection. We looked at records during both the visits. We have taken other events into account as part of this inspection. • • We have reviewed the information that we have received about the home since the last inspection. We have received an Annual Quality Assurance Assessment (referred to as the AQAA), which was completed by Ms Taylor. The AQAA is the provider’s own assessment of how well they are performing. It also provides us with information about what has happened during the last 12 months. We sent surveys to the home and asked for these to be distributed to residents, their relatives, staff, GPs and other healthcare professionals. We received surveys back from five residents, four relatives, four staff members, two GPs and two other health care professionals. • The judgements contained in this report have been made from all the evidence gathered during the inspection, including the visits. What the service does well: The manager assesses people’s needs before they move in, so that a decision can be made about whether the home will be suitable for them. The assessments provide good information about the new residents’ care needs. The care that people require is well recorded in individual care plans, which helps to ensure that staff know how people should be supported. People feel that they are being well cared for and treated with respect. They are well supported with their healthcare and medication. One person commented that Ms Taylor took care of all their health appointments, which they were pleased about. A relative who visits the home described the atmosphere as ‘very caring and friendly’. A health care professional reported that the manager was prompt in seeking advice about people’s health needs and acted upon this. Lilacs (The) DS0000028354.V351713.R01.S.doc Version 5.2 Page 6 People generally enjoy their meals and have these in pleasant surroundings. They keep in touch with their families and receive support with their individual interests. One person said that Ms Taylor accompanied them on trips to the local library. Another person told us ‘I’m free to come and go as I wish, which I much appreciate’. People are aware of how to make a complaint, but have not felt it necessary to complain. Staff members receive guidance and training that helps to protect people from being harmed. The accommodation is homely and is meeting people’s needs. People told us that the home is always kept fresh and clean. The home has an experienced manager who develops her skills and is readily on hand to deal with any issues or concerns. This provides continuity and reassurance for the residents and their relatives. What has improved since the last inspection? What they could do better: People are given information about the home in a statement of purpose, a service user’s guide and a brochure. This information could be simplified to avoid duplication and to make it easier to read. The brochure lists some services, such as hairdressing and shopping trips, which are available, although it does not specify whether these items are included in the fee or would involve an additional charge. This information needs to be included, so that there can be no misunderstandings about what the fees cover. The décor and use of the bathroom (as a storage area) could be improved, in order to create a more homely and domestic environment for the residents. Lilacs (The) DS0000028354.V351713.R01.S.doc Version 5.2 Page 7 Information obtained in respect of a new staff member needs to include a statement as to their mental and physical health. We have also recommended that advice is obtained about equal opportunities monitoring and suitable formats for staff application forms. This is to ensure that good information is received from applicants, particularly about their experience and previous employment. 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. Lilacs (The) DS0000028354.V351713.R01.S.doc Version 5.2 Page 8 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 Lilacs (The) DS0000028354.V351713.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Standard 6 does not apply to this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have access to information about the home, but would benefit from a change in the way that the information is produced. People’s needs are assessed before they move in, so that a decision can be made about whether the home will be suitable for them. EVIDENCE: Written information about The Lilacs was provided to people in a statement of purpose, a service user’s guide and a brochure. There was some duplication of the information and we agreed with Ms Taylor that the guide and the brochure could be combined into a single document. This would also mean that the information could be produced in a format that was easier to read. The brochure listed some services, such as hairdressing and shopping trips, which were available. However it did not specify whether these items were included in the fee or would involve an additional charge. Lilacs (The) DS0000028354.V351713.R01.S.doc Version 5.2 Page 10 In their surveys, each resident confirmed that they had received enough information before moving in to enable them to decide whether the home was the right place for them. Information was also readily available to people in the home’s front hall. This included a copy of the last inspection report, a complaints procedure and leaflets about some local advocacy and older persons’ services. We looked at some of the residents’ individual files. These included the care records for three people who had moved into the home since the previous inspection. Pre-admission assessment forms had been completed, which gave information about these people’s individual needs. Ms Taylor said that she undertook the assessments, and that the prospective residents and their families were involved as far as possible. The forms did not show who had contributed to the assessments, or the date when the assessments had taken place. Ms Taylor said that in future she would add these details to the assessment forms. The home had received other information about people’s individual needs and circumstances before they moved in. This included hospital transfer letters and the outcome of review meetings. Lilacs (The) DS0000028354.V351713.R01.S.doc Version 5.2 Page 11 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 good. This judgement has been made using available evidence including a visit to this service. People’s health and care needs are met and they are protected by the way that their medicines are managed in the home. EVIDENCE: We looked at the care records for four people. Their individual files each contained a general assessment form, which had been completed at the time of admission. These forms gave information about people’s mental and physical health, social needs and their preferred daily routines. Other assessments forms had been completed for moving and handling and for areas of risk, including falls and pressure sores. Each person had two types of care plan. One plan focussed on the support that people needed with their long term care needs. Another plan covered other areas of need and the objectives to be achieved. Some of the plans were originally written over two years ago but they were being reviewed each month and the outcome of these reviews was recorded. Lilacs (The) DS0000028354.V351713.R01.S.doc Version 5.2 Page 12 We discussed with Ms Taylor the benefits of having these two types of plan, or whether a single plan would reflect a more person centred approach to people’s care. Ms Taylor said that she would consider this further. The people we met during the visits said that they were happy with the care and support that they received. One person said ‘they would recommend the home to anybody’ and that Ms Taylor took care of all their health appointments, which they were pleased about. The responses that we received in their surveys were also positive about the care that people received and the manner in which they were treated by staff. One relative commented that there was a ‘very caring and friendly atmosphere’. A GP reported that they felt that people were treated as individuals and with respect. Another health care professional reported that the manager was prompt in seeking advice about people’s health needs and acted upon this. Staff members received a ‘code of conduct’, which Ms Taylor had produced. This included a number of items relating to maintaining the residents’ dignity and privacy. Daily reports showed evidence that the manager and staff were observant of the residents’ health and welfare, and of changes in well-being that might need to be followed up. A separate ‘Health Visits’ form was used for the recording of all health care matters and the outcome of appointments. The community nurse had visited the home on a number of occasions to support particular residents with their nursing needs. In their surveys, each person confirmed that they always received the medical support that they needed. The health care professionals who returned surveys had no concerns in this area. One person chose to look after their own medication. Ms Taylor had assessed the safety of this and was keeping the arrangements under review. Other people received support with the administration of their medication. There were suitable storage arrangements. There were no controlled drugs being administered, although a new cabinet had recently been bought for their storage, if needed. We advised Ms Taylor to check that the cabinet complied with the current standards. The medication records were up to date. One resident was being administered an anti-coagulant medicine. Ms Taylor was aware of recent changes in how this should be monitored and was keeping the appropriate records. We have recommended at previous inspections that additional staff are trained to administer medication to ensure adequate cover if Ms Taylor was absent from the home. This has received attention and some more staff having attended a course on medication. Ms Taylor said that the home’s owner, Mr Taylor would also be attending a course. Lilacs (The) DS0000028354.V351713.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People enjoy their meals and the lifestyle in the home meets their expectations. EVIDENCE: People were spending their time in different ways when we arrived at the home on 11th March. Somebody was finishing their breakfast in the dining room and other people were using the lounge or their own rooms. One person had a daily newspaper delivered to the home. Some people were watching television or reading in their own rooms. The people we met said that they received the support that they needed with activities and with following their interests. Ms Taylor said that the small numbers meant that it was sometimes difficult to arrange group activities. Some activities such as board games were arranged during the afternoons, although the main aim was to support people with their individual interests. One person said that Ms Taylor accompanied them on trips to the local library, which they enjoyed. Arrangements had been made for two residents to attend a social club and day centre in Calne, as they had expressed a wish to do this. One person had chosen to look after a cat in the home. Lilacs (The) DS0000028354.V351713.R01.S.doc Version 5.2 Page 14 In their surveys, the residents confirmed that the staff listened to them and acted on what they said. One person commented ‘I’m free to come and go as I wish, which I much appreciate’. Relatives reported in their surveys that they felt that the home met people’s different needs and helped them to keep in touch with them. Information was received in the AQAA about diversity and people’s individual cultural and spiritual needs. Ms Taylor felt that the current arrangements in the home reflected people’s backgrounds and current needs. A Christian service was being held in the home once a month. Ms Taylor said that these services originally started at the bequest of former residents, and were now a well established part of life in the home. Ms Taylor said that residents of other faiths, or with no faith, were welcome in the home and would also receive the support that they needed. Information received from the residents in their surveys indicated that there were no unmet needs at the current time. The residents’ assessment forms included information about their individual interests and preferred routines. The care records showed that Ms Taylor was in close contact with relatives to ensure that people were supported with appointments and with going out. One person commented that their relative in the home was treated as an individual and that the home did well in coping with their very special needs. On 11th March 2008 we saw that most people had lunch together in the dining room. One person chose to eat in their own room. The meal had three courses. We looked at copies of the weekly menus and saw that lunch was always three courses, usually with soup as the starter. Roasts were served twice a week and there was fish at least once a week. Tea was a lighter meal, which included dishes such as quiche and salmon salad. In their surveys, three people reported that they always liked the meals and two people that they usually did. A relative commented that staff were very good at knowing what their relative in the home liked to eat and provided a choice at teatime of ‘whatever they fancied’. Lilacs (The) DS0000028354.V351713.R01.S.doc Version 5.2 Page 15 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. People are listened to and there are procedures being followed that help to protect them from harm. EVIDENCE: The home’s complaints procedure was displayed in the front hall. Contact details for the Commission were included in the procedure and these were up to date. A suggestions box was also available in the front hall. A ‘Record of complaints’ file was kept in the office, although we saw that the home had not received any complaints during the last year. The residents confirmed in their surveys that they knew how to make a complaint. One person added the comment ‘Never needed to in six years!’ They also knew who to speak to if not happy and reported that staff listened and acted on what they said. Other information available in the hall included leaflets about ‘Elder Abuse’ and how people could follow up any concerns. The home had a policy about the prevention of abuse. This referred to the training of staff, so that they could recognise any signs of abuse. There were training materials in the home, including a video about adult protection. A staff member told us that they had also attended an outside course about safeguarding vulnerable adults and had received a copy of the ‘No Secrets’ booklet, which summarised the local procedures. Lilacs (The) DS0000028354.V351713.R01.S.doc Version 5.2 Page 16 The staff members confirmed in their surveys that they knew what to do if somebody had concerns about the home. It was reported in the AQAA that the home had not received any complaints in the last 12 months and there had been no safeguarding adults referrals during this time. Ms Taylor had attended a conference on adult protection since the last inspection. Lilacs (The) DS0000028354.V351713.R01.S.doc Version 5.2 Page 17 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. People live in homely and clean surroundings. EVIDENCE: The Lilacs was purpose built as a care home and has a layout and facilities that are helpful to older people. The gardens were varied, with a mix of shrubs and lawned areas. There was a patio at the front of the home, which could be reached from the lounge. There was a temporary ramp to the home so that people in a wheelchair could manage the step up to the front door. Ms Taylor reported in the AQAA that there were plans to replace this with a permanent sloped concrete area. Most of the accommodation was on the ground floor. The two rooms on the first floor were not being used at the time of this inspection. Lilacs (The) DS0000028354.V351713.R01.S.doc Version 5.2 Page 18 The residents’ rooms had en-suites and those on the ground floor were close to the communal areas and other facilities. The rooms were off a spacious hall, which allowed plenty of room for people who used walking frames and other aids to get about. There was one large communal room, which was light, homely and well furnished, with views of the garden. The dining area at one end of the room had a door directly onto the kitchen, which helped with the serving of meals. One of the bedrooms on the first floor had an en-suite bathroom. There was a bathroom on the ground floor with an assisted bath, which was used by all the residents. This was a spacious room. However, unlike other areas of the home the room looked functional, rather than homely. It was also used for the storage of various items such as commodes. We had recommended at the last inspection that the décor and the use of the bathroom is changed in order to create a more homely and domestic environment. We discussed this again with Ms Taylor who said that she intended to look at ways in which the bathroom could be enhanced. One option was to create a new storage area in the utility room, which was next to the bathroom. Ms Taylor said that she would also like to look at installing a shower in the bathroom. Residents told us in the surveys that the home was always kept fresh and clean. We found this to be the case when we went around the home. There were no unpleasant odours. The accommodation looked well decorated and maintained. Staff had completed a distance-learning course in infection control, which was arranged from a local college. There were policies for the control of infection, which included the safe handling and disposal of clinical waste and the provision of protective clothing. Lilacs (The) DS0000028354.V351713.R01.S.doc Version 5.2 Page 19 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. People’s needs are being met by competent and trained staff. People are generally well protected by the home’s recruitment procedure, although some changes are needed. EVIDENCE: The staffing records showed that there was a minimum of two people working in the home throughout the day. Ms Taylor or Mr Taylor covered most of the main shifts, usually working alongside one of the staff team. The manager’s daughter also covered duties in the home. The names of staff working each day were recorded, together with their starting and finishing times. Residents commented positively about their dealings with staff. They told us in the surveys that staff were available when needed and that they received the care and support from staff that they required. Relatives felt that the home gave people the support that they expected and that staff had the right skills and experience to look after people properly. One person commented, ‘everyone seems cheerful, competent and efficient’. The staff members who completed surveys also told us that there were enough staff to meet people’s individual needs. Lilacs (The) DS0000028354.V351713.R01.S.doc Version 5.2 Page 20 The staff we met during the visits told us about the training that they had received. This included training in a range of areas such as Health & Safety, Moving & Handling, Infection Control, First Aid, Food Hygiene, Medication and Adult Protection. Details of the training were being maintained in individual records. Ms Taylor also kept another training record, which gave an overview of the training that staff had received. Different types of training were being arranged, including distance-learning courses, in-house videos and events run by outside trainers. Some training events had been arranged in conjunction with another care home in the area. Staff members reported in their surveys that their induction had covered everything very well. They also confirmed that they received training that was relevant to their role and kept them up to date with new ways of working. Ms Taylor had arranged for individual staff members to attend some specialist training courses in areas which included nutrition and dementia care. Since the last inspection, one carer has completed a National Vocational Qualification (NVQ) at level 2 in Health and Social Care. This meant that over 50 of the staff team had obtained an NVQ. One staff member had also completed an NVQ in business administration. Customer service was one of the topics that had been covered in a distance-learning course during the year. Plans were also being made for one staff member to do a NVQ in Customer Service. Staff members told us in their surveys that they their employer had carried out checks, such as CRBs (Criminal Record Bureau disclosures) and references, before they started work. We looked at the employment files for two staff members who had started since the last inspection. CRB and Protection of Vulnerable Adults (POVA) checks had been undertaken before they had started working in the home. Written references and proof of identity had been obtained. Application forms had been completed. We discussed the content of the forms with Ms Taylor and recommended ways in which the forms could be improved, in order to obtain better information from the applicants. We also confirmed with Ms Taylor that the applicants needed to provide a statement as to their mental and physical health. The employment files included records of the staff members’ induction and the completion of induction workbooks. As part of their induction, new staff members signed agreement to a code of conduct and confirmed receipt of some written policies and procedures. Information about the General Social Care Council was available to people in the home’s front hall. Lilacs (The) DS0000028354.V351713.R01.S.doc Version 5.2 Page 21 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 good. This judgement has been made using available evidence including a visit to this service. People benefit from a well run home. EVIDENCE: Ms Taylor has been involved with The Lilacs since it opened in 1990. Ms Taylor first gained experience in the day to day business when the home was being managed by her mother. Ms Taylor has now had several years’ experience of running the home in her own right. Ms Taylor has completed the Registered Managers Award course and obtained other care related qualifications. Ms Taylor said that she was now developing her skills and knowledge by undertaking a NVQ at level 4 in Customer Service. Lilacs (The) DS0000028354.V351713.R01.S.doc Version 5.2 Page 22 The people who completed surveys responded positively about how the home was being run and the service that residents received. Relatives said that they were kept well informed of developments. In response to the question, ‘What does the home do well’, one relative commented ‘always finding time to talk on the telephone, or personally’. Other people mentioned a homely atmosphere, clean surroundings, and the individual attention that people received. Ms Taylor has produced a policy for quality assurance. Feedback from residents and other parties was being obtained in a number of ways, both formal and informal. These included the use of satisfaction surveys. We looked at the most recent Annual Development Plan for the home. This covered the period January 2008 – January 2009. The plan highlighted the home’s strengths and also identified areas that could be improved further. Ms Taylor said that the residents managed their own money, with support from family members. There was no involvement in the residents’ financial affairs, other than in respect of one person, whose relative received an invoice for the hairdresser’s visits. Staff members signed a form to confirm that they had received a copy of the home’s policy on accepting gifts from residents. We looked at the home’s fire log book and saw that the fire precaution systems were being checked regularly. Staff members had received fire instruction and taken part in a drill during January 2008. Risk assessments had been undertaken in respect of environmental hazards and activities involving individual residents. The outcome of the assessments was being reviewed regularly and checks made to help identify new hazards, for example in respect of the weather and the condition of the garden. The home looked well maintained when we had a look around. Devices had been fitted to residents’ bedroom doors, so that the doors could be left open safely. One person said that they liked to be able to keep their door open. Records were being kept in the kitchen, which showed that the refrigerator and freezer were operating at a safe temperature. We saw labels on the electric plugs and the bath hoist, which showed that these had been checked for safety in the last few months. The hot water outlets used by residents had been fitted with temperature control valves. Radiator covers have been fitted in the en-suite areas of people’s bedrooms, but not on the radiators in the main areas of the rooms. Risk assessments had been undertaken in respect of these radiators, although Ms Taylor confirmed that it was the intention to fit covers. Two covers were already waiting to be fitted and Ms Taylor said that the work would be completed within two months. Lilacs (The) DS0000028354.V351713.R01.S.doc Version 5.2 Page 23 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Lilacs (The) DS0000028354.V351713.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 5 (1) Requirement The Service User’s guide must included details of charges and of how any additional services are paid for. Information obtained in respect of a new staff member must include a statement as to their mental and physical health. Timescale for action 31/05/08 2 OP29 19 27/03/08 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. 3. Refer to Standard OP1 OP19 OP29 Good Practice Recommendations That the way in which information about the home is produced is reviewed. This is so that the information is clearly set out and is in a user-friendlier format. That the décor and the use of the bathroom is changed, in order to create a more homely and domestic environment. That advice is obtained from an appropriate source about equal opportunities monitoring and suitable formats for staff application forms. This is to ensure that good information is received from applicants, particularly in respect of their experience and previous employment. Lilacs (The) DS0000028354.V351713.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection South West Regional Office Colston 33 33 Colston Avenue Bristol BS1 4UA 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. 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