Inspection on 12/12/05 for The Lilacs

This inspection was carried out on 12th December 2005.

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

The Lilacs 11/03/08

The Lilacs 31/08/06

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 Unannounced Inspection 12th December 2005 9:20 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.V269393.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lilacs (The) DS0000028354.V269393.R01.S.doc Version 5.0 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.V269393.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th June 2005 Brief Description of the Service: The Lilacs is a purpose built care home for up to nine older people. The home is situated in a residential area of Calne, approximately ten minutes walk from the town centre. 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. The rooms have en-suite facilities. The owner, Mr R. Taylor and the manager, Ms T. Taylor, also have their accommodation on the first floor. The communal space consists of a large open plan lounge and dining room. The Lilacs is the service users permanent home for as long as this remains appropriate to their needs and wishes. There is also the opportunity for an older person to have a temporary or respite stay away from their usual home, subject to the availability of a vacant room. Lilacs (The) DS0000028354.V269393.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place between 9.20 am and 4.00 pm. Four service users and one member of staff were met with. The manager, Ms T. Taylor, was available throughout the inspection. The communal areas were looked at and a number of the home’s records were examined. A community nurse was spoken with after she had visited a service user in the home. A pharmacist inspector from the Commission looked at the home’s medication arrangements. Three service users have returned comment cards to the Commission as part of the inspection process. This inspection focussed on a number of key standards that were not looked at during the previous inspection of the home. There were five service users at the time of this inspection. What the service does well: What has improved since the last inspection? What they could do better: Changes need to be made in the storage and administration of medication to ensure the safety of service users. Service users also need to better protected by the home’s procedures. A new member of staff has started without an important check of their suitability. All staff members need to receive training in abuse awareness and adult protection. Risk assessments need to be kept up to date, to ensure that appropriate safety measures are in place. Lilacs (The) DS0000028354.V269393.R01.S.doc Version 5.0 Page 6 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. Lilacs (The) DS0000028354.V269393.R01.S.doc Version 5.0 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 Lilacs (The) DS0000028354.V269393.R01.S.doc Version 5.0 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 the following standard(s): These standards were not looked at on this occasion. (Standards 3 and 5 were inspected at the last inspection. Standard 3 was almost met and standard 5 was met) EVIDENCE: A requirement in respect of standard 3 was identified at the previous inspection of the home. This concerned the need to ensure that a full assessment is undertaken of a new service users needs and for a copy of the assessment to be kept in the home. This requirement could not be followed up as no new service users have moved into the home since the last inspection. Ms Taylor said that she is aware of the action that needs to be taken in the future. Lilacs (The) DS0000028354.V269393.R01.S.doc Version 5.0 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 the following standard(s): 8 and 9 Service users receive the support that they need with their healthcare. Systems are in place for the safe handling of medication, however there are areas which need to be improved to ensure the safety of service users. (Standards 7 and 10 were inspected and met at the last inspection). EVIDENCE: The service user’s personal records included risk assessment forms that had been completed in respect of pressure sores, falls and moving & handling. The assessments had been reviewed in October and November 2005. These assessments appear to be a good way of identifying service users who may be at risk and require intervention from staff. The service users’ care plans included goals that are designed to promote or restore good health. Daily reports showed evidence of service users’ recent appointments with GPs and other health professionals. A ‘GP Visits’ form is used. There was a record of flu vaccines given in November 2005. There was also a record of chiropodist’s appointments in November. Lilacs (The) DS0000028354.V269393.R01.S.doc Version 5.0 Page 10 A community nurse visited a service user during the morning of the inspection. The nurse said that, from her experience, the home was meeting the service users’ healthcare needs and that instructions given about the service users’ nursing needs were being appropriately followed. Medication is stored in three locations in the home, one of these is not secure and a lock is needed on the door if the medicines are to be kept here. Most medicines are supplied in a monitored dosage system, those that are not, are put into boxes by staff. This is secondary dispensing and introduces an extra risk into the process. Staff who administer medicines are trained and this extra procedure is not necessary. Medication is taken individually to service users and signed on the medication administration sheet prior to the drugs being taken. The chart must only be signed after administration has occurred to ensure that it accurately reflects the administration or refusal of the medicine. Medication returned to the pharmacy is recorded, but no record is kept of the quantities of medicines received into the home. A printed medication administration record is provided by the pharmacy; written additions are not signed. Currently only two members of staff are trained to administer medication, consideration should be given to increasing this number to allow for sickness and holiday cover. Lilacs (The) DS0000028354.V269393.R01.S.doc Version 5.0 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 the following standard(s): 14 Service users are encouraged to exercise choice and autonomy, with the support of relatives. (Standards 12, 13 and 15 were inspected and met at the last inspection). EVIDENCE: It was evident from conversation with service users that there is no pressure to fit in with a particular routine. Service users can choose where they wish to spend their time. Some service users have a preferred place in the open plan lounge. Another service user who was met with liked to spend most of her time in her own room. This was respected by staff. Some service users had chosen to have breakfast in their own rooms and others in the dining room. When asked, one service user could not think of any rules that apply in the home. Some of the goals within the service users’ care plans were helping to maintain independence and choice. One of the goals was to support a service user with hospital appointments, in conjunction with members of their family. This is a good way of people working together for the service user’s benefit. Lilacs (The) DS0000028354.V269393.R01.S.doc Version 5.0 Page 12 There is information displayed in the front hall which included a leaflet about a local advocacy service and a copy of the home’s inspection report. This was for an inspection that took place in February 2005 although a more recent inspection had taken place in June 2005. Service users have been able to bring items of furniture and personal possessions with them when moving into the home. Lilacs (The) DS0000028354.V269393.R01.S.doc Version 5.0 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 the following standard(s): 18 Not enough is being done to protect service users from abuse. (Standard 16 and 18 were inspected at the last inspection. Standard 16 was met and standard 18 was almost met). EVIDENCE: The home has a policy on the prevention of abuse. This refers to the training of staff in order that abuse can be recognised. Ms Taylor said that a video about adult protection had been bought for this purpose but it had yet to be seen by staff. Staff members have not been given a copy of the ‘No Secrets’ booklet. The policy on abuse includes a contact number for social services, although the number given is for the Commission for Social Care Inspection. A new member of staff had started within the last month without a POVA check having been made (see standard 29). Lilacs (The) DS0000028354.V269393.R01.S.doc Version 5.0 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 the following standard(s): These standards were not looked at on this occasion. (Standards 19 and 26 were inspected at the last inspection. Standard 19 was almost met and standard 26 was met). EVIDENCE: The details of standard 22 were not looked at, although in their comment card, one service has mentioned that access when visiting the home is sometimes difficult for a relative who is a wheelchair user. Lilacs (The) DS0000028354.V269393.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 29 Service users’ needs are being met, with the close involvement of the registered person’s family. The staff team have not yet achieved the level of qualification that is expected. A new staff member has undertaken relevant training although the lack of a POVA check is a significant omission that puts service users at risk. (Standards 29 and 30 were inspected at the last inspection. Standard 29 was almost met and standard 30 was met). EVIDENCE: The minimum staffing level for a home of this size is for two people to be working in the home throughout the day. The records show that either Ms Taylor or Mr Taylor is working in the home at any one time, together with a second person who is usually one of the staff team. This was the case during the inspection. Service users said that Ms Taylor or Mr Taylor were readily on hand to deal with any issues. Ms Taylor’s daughter is also covering a number of shifts in the home. One of the four members of care staff has achieved NVQ at level 2. Ms Taylor said that another member of staff would be enrolling shortly. The staff member met with had been working in the home for approximately two weeks. The staff records showed that she had received training in a range of subjects during the last 18 months, including food hygiene, manual handling, first aid (appointed person), conflict resolution, health & safety and Lilacs (The) DS0000028354.V269393.R01.S.doc Version 5.0 Page 16 infection control. An induction programme was implemented upon starting at The Lilacs. The new staff member had signed agreement to a code of conduct and to confirm receipt of some policies and procedures. The recruitment record for the new member of staff included copies of identity documents and two references from the most recent employers. There was documentation in respect of a C.R.B. disclosure that had been issued in 2004 and Ms Taylor said that her previous employer had receives a more recent disclosure. The staff member had started without a new C.R.B. disclosure and without a POVA check having been made. This was discussed with Ms Taylor, who then acted on an immediate requirement that was issued at the time. There has been correspondence between the Commission and the registered person about this since the inspection. C.R.B. disclosures had been obtained in respect of other members of the staff team and this documentation was included in their individual files. Lilacs (The) DS0000028354.V269393.R01.S.doc Version 5.0 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 and 38 The service users’ financial interests are safeguarded with the support of people outside the home. Service users benefit from a tidy and well maintained home although a lack of up to date assessments may put service users at risk. (Standards 31, 33 and 37 were inspected at the last inspection. Standards 31 and 33 were met and standard 37 was almost met). EVIDENCE: Ms Taylor said that the home had no involvement in the service users’ personal money. Relatives are reported to support those service users who cannot manage their own affairs. Relatives are billed for certain expenditures that are not covered by the fees. Some service users in the lounge were reading their own daily newspapers that are delivered to the home. Lilacs (The) DS0000028354.V269393.R01.S.doc Version 5.0 Page 18 The accommodation looked well kept and in a good state of repair. Checks of the home’s fire precaution systems and facilities were up to date, as recorded in the fire log book. The date on which staff members receive fire instruction needs to be included in the instruction record. A fire risk assessment had been undertaken in May 2003, but had not been reviewed since. A programme is underway for the fitting of radiator covers. Ms Taylor said that radiators in the service users’ en-suites have been completed since the previous inspection. Covers have not been fitted in the main areas of the rooms and risk assessments were carried out about this in 2002. These assessments have not been reviewed, although the occupants of the rooms have changed. An immediate requirement was issued concerning the need to assess the risk of hot radiator surfaces. Ms Taylor said that covers were due to be fitted during the coming year. There has been a pro-active approach to safety in some areas. The manager has expressed concerns to the local authority about the condition of a road outside the home. A record is kept each month of any new hazards that have been identified. The condition of the garden and the risk of slippery surfaces have also been looked at. Lilacs (The) DS0000028354.V269393.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X X X X X X X X STAFFING Standard No Score 27 3 28 3 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 2 Lilacs (The) DS0000028354.V269393.R01.S.doc Version 5.0 Page 20 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 OP9 Regulation 13(2), 13(4)(a) Requirement All medication must be stored securely at all times; untrained staff, visitors and service users must not have access to general medicine storage. Medication must not be transferred from the original dispensed container prior to the administration process. Medicines must be administered from correctly labelled containers. A record must be kept of all medicines received into the home from the pharmacy, hospital or service user’s own home. The medication administration record must be completed at the time of administration, not before, to ensure that it accurately reflects the administration, refusal or other action of the service user. Staff members must receive training in adult protection and abuse awareness. Staff members must receive guidance on the local DS0000028354.V269393.R01.S.doc Timescale for action 01/01/06 2 OP9 13(2) 01/01/06 3 OP9 13(2) 01/01/06 4 OP9 13(2) 19/12/05 5 6 OP18 OP18 13(6) 13(6) 31/01/06 31/01/06 Lilacs (The) Version 5.0 Page 21 7. OP29 19 8 9 10 OP29 OP38 OP38 19 23(4) 13(4) arrangements for the protection of vulnerable adults. A record must be kept in the home of the P.O.V.A. and C.R.B. checks that have been carried out in respect of staff. Any decision made about a member of staff being able to start without a C.R.B. disclosure must be fully documented in the home. (This requirement is outstanding in part from the last inspection). A POVA check must be completed before a staff member starts working in the home. The fire risk assessment must be reviewed. Risk assessments in respect of radiators and hot surfaces must be undertaken for individual service users. 13/12/05 13/12/05 19/12/05 19/12/05 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 2 3 Refer to Standard OP9 OP9 OP22 Good Practice Recommendations Written additions and alterations to the medication administration record should be signed, dated and checked by two members of staff. Sufficient staff should be trained to administer medication to ensure adequate cover for holidays and sickness. That the difficulties reported in access by a wheelchair user are followed up and improvements are made where practicable. Lilacs (The) DS0000028354.V269393.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Lilacs (The) DS0000028354.V269393.R01.S.doc Version 5.0 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. 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