Inspection on 15/11/05 for The Lilacs

This inspection was carried out on 15th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Lilacs 18/08/09

The Lilacs 16/04/08

The Lilacs 17/04/07

The Lilacs 20/04/06

The Lilacs 28/06/05

The Lilacs 25/01/05

The Lilacs 19/08/04

The Lilacs 03/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Lilacs (The) 121 Chalkwell Avenue Westcliff On Sea Essex SS0 8NL Lead Inspector Pauline Marshall Unannounced Inspection 15th November 2005 08:35 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) DS0000015447.V258997.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) DS0000015447.V258997.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Lilacs (The) Address 121 Chalkwell Avenue Westcliff On Sea Essex SS0 8NL 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) 01702 712457 Mr Barry Norton Waters Ms Fazlee Painchun Ms Fazlee Painchun Care Home 17 Category(ies) of Dementia - over 65 years of age (17), Old age, registration, with number not falling within any other category (17) of places Lilacs (The) DS0000015447.V258997.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th June 2005 Brief Description of the Service: The Lilacs provides care and accommodation for up to seventeen older people who may also have dementia. The home is situated in a residential area close to the sea front and a short distance from Chalkwell railway station. The home is a large residential style home on three levels. All areas of the home are accessible by a shaft lift. There is limited parking at the front of the home. There is a good sized garden at the rear of the home. The registered manager and registered person are closely involved in the daily management of the home. Both have experience of residential care. Lilacs (The) DS0000015447.V258997.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 15th November 2005, it lasted 7.5 hours. Discussions took place with the proprietor, the manager, 5 staff, 7 residents and 1 visiting relative. After a tour of the home, a sample of 3 staff records, 3 residents’ records and the homes’ policies and procedures were inspected. 22 of the 38 standards were inspected on this occasion in addition to the requirements and recommendations of the last inspection. Review of the care plans take place monthly and is agreed and signed by the resident and staff. There are on-going improvements being made to the care plan documents to ensure that staff are clear on care instructions. What the service does well: What has improved since the last inspection? Replacement carpets have been purchased in the lounge and dining area; constant updating of furnishings and decorations has taken place. The new care plan format that has been designed is a good improvement on the current one in use and includes more detailed information for staff to follow. Two further staff have begun their NVQ 2 training. The home now has dog visits, which residents enjoy. Lilacs (The) DS0000015447.V258997.R01.S.doc Version 5.0 Page 6 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. Lilacs (The) DS0000015447.V258997.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) DS0000015447.V258997.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): 2,4,6 Residents’ needs are being met by the home and there is a well managed admission process. EVIDENCE: Each resident has a written contract/statement of terms and conditions with the home. Care files evidenced that a pre-admission process is in place, further assessment forms show each resident’s likes and dislikes, interests and social history. The manager has devised a more detailed comprehensive care plan format and intends to put this into practice once agreed by the staff team. Staff spoken with demonstrated a good knowledge of the residents needs. There is clear evidence of staff training; copies of certificates are displayed in the hallway and in staff files. Residents said that they felt confident in the staff and were happy with the care provided. One relative spoken with said that she was happy with the care and that the home was recommended to her. The Lilacs does not provide intermediate care. Lilacs (The) DS0000015447.V258997.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): 7, 8, 10, 11 There are care plans in place; however they do not give staff clear instructions and need to be developed to include all aspects of care as described in the above outcomes. EVIDENCE: Three care files were inspected; these covered all the residents’ assessed needs. The new format for care plans that is being developed gives clearer instructions to staff and describes the way in which support and assistance is to be given. Daily notes inspected were appropriate and included how the resident had spent their day. A notice board in the lounge area displays the activities offered by the home, these include soft ball, manicure, videos, sing-a-longs and reminiscence sessions. Sessions are scheduled weekly, but are more frequent if requested by residents. Residents’ meetings are held regularly and minutes of these are kept in the home. Monthly review of the care plan takes place and on the three care files inspected these had been signed as agreed, by staff and resident. Lilacs (The) DS0000015447.V258997.R01.S.doc Version 5.0 Page 10 Health charts showing medical visits were seen to be fully completed and detailed. Bathroom scales have been purchased and are in use. Visiting chiropodist now provides treatment in resident’s rooms to ensure privacy. There was no evidence on the care files inspected of residents wishes concerning terminal care and arrangements after death. The manager has included this issue on the new care plan document that will be put in to practice once agreed by the staff team. Lilacs (The) DS0000015447.V258997.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, 15 Residents are helped to exercise as much choice and control over their lives as possible. Residents are offered a well balanced diet in clean pleasant surroundings and alternative choices are made available on request. EVIDENCE: Small amounts of residents’ cash are kept in the home, appropriate records are kept. Two records and cash were checked at random and were correct. Relatives hold larger amounts and requests are made by the proprietor when money is needed, usually in the form of a bill. A Solicitor holds one resident’s money and the proprietor makes requests when cash is required. Residents’ valuables are kept by relatives and not stored at the home. There are currently no residents at the home that are able to keep and administer their own medication. The menu does not show a choice, however the manager stated that choices are made by the residents’ a week in advance and the menu is adapted accordingly. The manager will show the choices on the menu when it is next Lilacs (The) DS0000015447.V258997.R01.S.doc Version 5.0 Page 12 reviewed. Residents meetings show that choices are made on a regular basis and residents spoken with confirmed this. Nutrition records are kept separate from the care plans, all residents’ are shown on the same form, amounts of food and drink taken are written in a code; there is a key to explain what each code means. Prior to 2004 the manager kept separate nutrition records but as a result of a Council Monitoring Officers visit, these were changed. Residents spoken with said that “food is really good”. Lilacs (The) DS0000015447.V258997.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): 17, 18 Staff training, and the policies and procedures within the home ensure that residents’ legal rights are protected and they are protected from abuse. EVIDENCE: Currently there are no residents using an advocacy service; however the proprietor was aware of the availability of them and how to make contact if required. Residents spoken with were aware of their right to vote and confirmed that they had done so in the past. A policy on physical restraint dated August 2005 is now in place. All staff have attended training for the protection of vulnerable adults. There have been no complaints since the last inspection. There is a Whistle blowing policy in place at the home and staff spoken with had a good understanding of the procedure. Lilacs (The) DS0000015447.V258997.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): 19, 21, 22, 23, 24, 26 The home provides a comfortable, clean and safe standard of accommodation that meets the needs of the residents. EVIDENCE: The garden area is untidy; there is old and broken items of garden furniture that needs to be disposed of. The home has three bathrooms, one bath is an assisted bath that is also used as a shower, and most residents say that they prefer to use this. There are four toilets and six rooms with en-suite facilities. There are no wheelchair users in the home at present; however one resident has brought her wheelchair, which she uses for going out only. There is a hoist available if needed, this is regularly serviced. Lilacs (The) DS0000015447.V258997.R01.S.doc Version 5.0 Page 15 All bedrooms are personalised, although a little small, they suit the needs of the residents. Three residents spoken with said how they liked their rooms and they had everything they need in them. One resident spoken with said they like to sit in their room and look out of the window and that it is homely and clean and the staff are kind. There were no paper towels or liquid soap in the communal bathrooms, bar soap and cotton towels were in place in some. Their use could cause a spread of infection and should be discontinued immediately to prevent this potential risk. Lilacs (The) DS0000015447.V258997.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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, 29 Staff are well trained and there is the right skill mix to meet the needs of the residents. Recruitment procedures need to be more robust to ensure that residents are supported and protected. EVIDENCE: The home has a stable staff group, many of the staff have worked at the home for some years, there is a low staff turnover and agency staff are rarely used. Four staff have achieved NVQ 2 in Care and 2 further staff are currently undertaking the award. A good range of mandatory and additional training is provided as well as NVQs. The manager is a registered nurse who has recently completed NVQ level 4 Registered Managers Award. Staff confirmed that agreed staffing levels are being maintained and if there are shortages due to staff sickness at the last minute, the proprietor or manager would work the shift. The rota shows three care staff during the day and one a wake and one sleep-in carer throughout the night. Cleaning hours are in addition to care hours. The proprietor carries out the cooking duties. The current weeks rota was the only one available on the day of the inspection, this identified who was on each shift and who the seniors were, however it did not show who was in charge or who was cooking on Wednesday Lilacs (The) DS0000015447.V258997.R01.S.doc Version 5.0 Page 17 and Thursday. It was not clear from the rota which shifts were supernumery for the manager. Three staff files were inspected, there was evidence of induction on all three, and all had CRB checks, which are stored in a separate folder. Of the three files inspected two contained one reference only. Staff records must contain all the relevant documents as stated in schedule 2 of the Care Homes Regulations. Lilacs (The) DS0000015447.V258997.R01.S.doc Version 5.0 Page 18 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): 33, 34, 35 The accounting and financial procedures of the home ensure that the residents financial interests are safeguarded. EVIDENCE: The quality assurance scheme is underway and the proprietor produced copies of several survey questionnaires completed by various people. The proprietor will send a report to CSCI when all information is collated. A current certificate of employers’ liability is in place and displayed on hallway wall. The lounge carpet has been replaced since the last inspection and there is evidence of good financial record keeping. All transactions for residents’ cash were entered appropriately and receipts kept. Residents’ cash is stored in individual coin bags and kept in the safe. Lilacs (The) DS0000015447.V258997.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 3 X 3 X N/A HEALTH AND PERSONAL CARE Standard No 7 8 9 10 11 Score 2 X 2 3 3 3 X 2 2 3 X 3 2 STAFFING Standard No Score 27 3 28 X 29 2 30 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 3 3 X X X Lilacs (The) DS0000015447.V258997.R01.S.doc Version 5.0 Page 20 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 OP26 Regulation 13 (3) Timescale for action The registered person will ensure 31/12/05 that paper towels and liquid soap are available in all communal bathrooms to reduce the risk of spreading infection. The registered person will ensure 30/11/05 that all information required under schedule 2 of the Care Homes Regulations is collected and made available for inspection. Immediate and on-going. Requirement 2. OP29 19 (1)(b)(i) 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 OP7 OP11 OP19 Good Practice Recommendations Care plans to give clear written instructions to staff on all aspects of care needs. As far as possible service users wishes concerning terminal care and arrangements after death are discussed and recorded. The garden area should be tidied and old and broken DS0000015447.V258997.R01.S.doc Version 5.0 Page 21 Lilacs (The) 4. 5. OP21 OP27 furniture disposed of. Consideration should be given for one of the existing baths to be converted to an assisted bath or shower to meet residents’ needs. The rota needs to show the person in charge of the home and the amount of hours allocated as supernumery for the manager to complete management tasks. Lilacs (The) DS0000015447.V258997.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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) DS0000015447.V258997.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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