Inspection on 16/04/08 for The Lilacs

This inspection was carried out on 16th April 2008.

CSCI found this care home to be providing an Excellent 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 18/08/09

The Lilacs 17/04/07

The Lilacs 20/04/06

The Lilacs 15/11/05

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 The Lilacs 121 Chalkwell Avenue Westcliff On Sea Essex SS0 8NL Lead Inspector Sarah Hannington Unannounced Inspection 16th April 2008 09:00 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 The Lilacs DS0000015447.V362263.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. The Lilacs DS0000015447.V362263.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Lilacs 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 bwatersbassa@aol.com 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 The Lilacs DS0000015447.V362263.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th April 2007 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. All prospective residents are provided with a Statement of Purpose and Service User Guide that supplies them with up to date information on the home. Fees range from £360.00 to £450.00 and there are additional charges for hairdressing, chiropodist, papers, and toiletries. The registered manager and registered person are closely involved in the daily management of the home. Both have experience of residential care. The Lilacs DS0000015447.V362263.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 3 Star. This means the people who use this service experience excellent quality outcomes. The site visit took place over six hours and was carried out as part of the annual inspection programme for this home. This visit was conducted with assistance from the manager. As part of the process a number of records relating to residents, care staff and the general running of the home were examined. The site visit also focused on any requirements and recommendations from the last key inspection. Prior to this site visit CSCI (Commission for Social Care Inspection) sent out surveys to all interested parties, however at the time of writing this report only three have been returned, however these comments from relatives will form part of this report. A number of residents and staff were spoken with during the site inspection and a tour of the building was undertaken. Additionally the manager was sent an (AQAA) Annual Quality Assurance Assessment form. This is a self-assessment that homes are required by law to complete, that asked how well the home is meeting the needs of the people who live at the Lilacs. What the service does well: There is a well-established staff team in place and turn over is low. If there has been a gap, recruitment has been successful and carried out to a good standard that protects the residents. The manager is keen to find out the latest practice and has been to a ‘care homes’ exhibition that will help overall to improve the quality of care given to the residents by providing the latest guidance and ideas. A professional who regularly visits the care home gave praise for the good quality of care given to all residents. The quality assurance annual assessment is to a good standard that reflects residents’ views, their satisfaction or any issues they wanted to raise. Local MPs were invited into the home while canvassing and had a chat with the residents, this enabled them to keep abreast with current affairs and to participate in the local community. The pre-admission assessments care Plans and risk assessments are to a good standard that reflect residents’ views. The Lilacs DS0000015447.V362263.R01.S.doc Version 5.2 Page 6 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. The Lilacs DS0000015447.V362263.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 The Lilacs DS0000015447.V362263.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): 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A robust pre-admission process reassures residents that their needs will be met before they move to the home. EVIDENCE: The manager reviewed the Service User Guide in January 2008 and contains up to date information on the services that the home provides. The care files of four new residents were looked at in terms of their preassessments prior to admission and information provided for people regarding the home. This showed us that prospective residents have enough information about the services offered and are given opportunities to visit the home. Good information on pre-assessments included personal preferences, general health care, and emotional, social and physical needs. The manager states on the AQAA that, ‘ We have candid discussions with families prior to admission as to expected outcomes and the service we can offer.’ The Lilacs DS0000015447.V362263.R01.S.doc Version 5.2 Page 9 Documentation showed that consultation had been undertaken with residents and their families. Surveys returned and relatives and residents spoken with on the site inspection stated, ‘my daughter looked around for me and I had a couple of visits prior to me moving in.’ ‘ I love living here it is like a family environment.’ ‘ The home informed us after a number of visits by us and assessment of my relative that the staff and home could of provide for my relative. I did get a letter to confirm this.’ The Lilacs does not provide intermediate care. The Lilacs DS0000015447.V362263.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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are successful in delivering appropriate care for all residents. EVIDENCE: The manager states on the AQAA that, ‘level of assistance required is documented within care plans.’ ‘ We encourage residents to be as independent as possible.’ In four of the care plans inspected there was sufficient evidence to show that they are all to a good standard and are reviewed regularly. The care plan highlights residents’ routines, their activities, nighttime preferences or that is specifically important to them. Recording of appointments, district nurses visiting and general sharing of information amongst the team is to a good standard. Risk assessments reflect what is written in the care plans. Discussion with the team around involvement of residents in everyday routines showed us that staff actively encourage residents to retain skills. Observation showed that staff are patient in encouraging individuals to retain skills and maintain independence. The daily notes informed us that staff recorded well. Daily notes The Lilacs DS0000015447.V362263.R01.S.doc Version 5.2 Page 11 showed good staff interaction. Many of the residents informed us that the staff were very good at carrying out activities of their choosing and staff observed during the site inspection, gave individuals a chance to carry out activities. A medical professional on sight reported that the team are very good at following any guidance given and are preventative in their practice. Relative comments stated, ‘ The Lilacs respect people as individuals and treat them appropriately without violating their rights.’ ‘ My relative has been in care for about 2 years and I can give nothing but praise for her care and treatment which has always been to a high standard.’ ‘The lilacs is a warm and comfortable home, the staff are kind and caring and other than my relatives own home, I couldn’t wish for them to be anywhere else.’ Residents stated, ‘‘ The staff give a very high standard of care and I am always informed of what is being done.’ ‘ The staff here are very friendly and look after me well.’’ Since moving in my weight has increased and I am very pleased.’ My mobility had improved and the proprietor had gave me the confidence to walk again, as prior to moving in I was scared to do this due to a fall incident in the past.’ Staff never rush me when I am walking but encourage me.’ Policy and procedures are in place for the correct receipt, recording, storage and handling, administration and disposal of medications. Any medication changes had been recorded accurately. All MAR record sheets had been correctly recorded, signed for and there were no gaps in vital information needed. The administration records are maintained in accordance with agreed procedures and the royal pharmaceutical legislation. Evidence of documentation, training, and no incidents around medication issues or practice would suggest that medication is kept to a strict protocol and is maintained consistently to a good standard. A Monitored medication dosage system is in place for each resident. Medication is stored in a lockable cabinet. The Lilacs DS0000015447.V362263.R01.S.doc Version 5.2 Page 12 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. Opportunities for residents to participate in activities, which are suited to their needs and wishes, are available. EVIDENCE: Observation showed that staff interaction with residents was positive, very relaxed and had a natural rapport. When the manager and proprietor arrived they brought in with them an atmosphere of energy and humour which residents obviously responded to well and encouraged residents to interact with each other, for example when asking about what they wanted for lunch there was much banter and residents started to chat and laugh and clearly enjoyed the company of the manager and proprietor. The manager states on the AQAA that, ‘ we have regular activities with residents.’ Speaking with one of the seniors who carries out regular activities they were able to give a good account of what they did on a day-to-day basis and the individual knowledge they had about people who live there. The Lilacs DS0000015447.V362263.R01.S.doc Version 5.2 Page 13 Lunchtime was observed to be a relaxed unrushed interactive environment. The food smelt good and was home cooked. A resident informed me that if a meal did not appeal to one of them, then an alternative meal would be provided. Staff observed during the lunchtime period gave individuals a chance to be independent as much as possible. Prior to the meal being cooked, staff checked with people what they wanted. Observation showed that residents were listened to in terms of quality and dislikes of food. For example when an individual was talking about the meal proposed to be cooked for the day, they commented that the last type of liver used is not what they liked. This person was reassured by the proprietor that a different type of liver had been bought. This not only showed that people were listened to and their views taken on board, but that they felt they could complain freely. To back this up further in the complaints book many concerns such as these were noted down and actioned. Speaking with residents they all felt that they were able to make suggestions around menus and have meals provided which they had requested and would enjoy. The Lilacs DS0000015447.V362263.R01.S.doc Version 5.2 Page 14 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 excellent. This judgement has been made using available evidence including a visit to this service. There are systems in place to ensure that peoples views are listened to, acted upon and support residents to be protected from abuse. EVIDENCE: The manager states on the AQAA that, ‘We act on Complaints in a timely fashion effectively.’ The complaints procedure is thorough and keeps account of residents concerns. It was nice to see that day to day things residents had brought to the attention of staff were noted and actions taken. For example one concern was that the water supplied at lunchtime did not taste nice’, ‘there was too much salt in my sandwich today.’ These concerns also documented that they were resolved and signed off. A relative stated, ‘ I have had concerns and they have been taken seriously and resolved, however trivial they may seem to others, not only resolved but the manger genuinely wanted to make things right.’ Residents spoken with stated, ‘if I have something to say that I am not happy about then I know it will be put right.’ ‘ I feel it is easy talking to any of the staff about any concerns that I have.’ The Lilacs DS0000015447.V362263.R01.S.doc Version 5.2 Page 15 All staff have attended safe guarding (protection of vulnerable adults) training. Speaking with staff they a good awareness around these issues. Safe guarding training forms part of the induction process for all new staff. The Lilacs DS0000015447.V362263.R01.S.doc Version 5.2 Page 16 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 adequate. This judgement has been made using available evidence including a visit to this service. People live in a clean safe environment. EVIDENCE: The manager states on the AQAA that, ‘We regularly Clean all areas.’ There is a good cleaning programme in place. On the day of inspection the home was observed to be clean, tidy and odour free. Individual’s rooms were clean and personalised. Since the last key inspection improvement to the inside and outside environment has been achieved, however this is still on going. Some of the achievements have been, replacements of both boilers, a new call bell system, repainting of the outside of the house, redecoration of the corridor and The Lilacs DS0000015447.V362263.R01.S.doc Version 5.2 Page 17 replacement of the lounge ceiling. New chairs have been bought for the garden and new chairs are on order for the dining room. The repairs highlighted in the last key inspection have all been achieved. The management have a good maintenance plan in place. Overall the home environment present no health and safety issues, the environment was homely comfortable and practical for the use of residents at the Lilacs. The Lilacs DS0000015447.V362263.R01.S.doc Version 5.2 Page 18 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. Residents are protected by good staff recruitment, induction and training. EVIDENCE: The manager states on the AQAA that, ‘ We have caring friendly staff who enjoy their work.’ A training matrix evidenced clearly showed that the staff had completed courses. Training opportunities are good and include manual handling, health and safety, first aid, fire awareness, safeguarding and infection control. The registered provider advised that 4 member of staff have attained NVQ Level 3 (3 staff members still awaiting certificates) and 4 staff, are currently undertaking NVQ Level 3. Staff spoken with reflected that courses undertaken had developed a better understanding of the residents that they worked with. Staff receive good support through induction, handover’s, staff meetings, supervision, annual appraisals and training. Induction for staff is to a good standard. The manager maintains robust recruitment procedure. The most recent staff file was sampled, all had the required information available. Pova 1st checks and CRB are in place before a contract of employment and start date was offered to staff. Supervision notes were present within folders and speaking with staff and the manager it was apparent that these were regular. The Lilacs DS0000015447.V362263.R01.S.doc Version 5.2 Page 19 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 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home is stable which ensures the health, safety and welfare of all residents. EVIDENCE: The manager states on the AQAA that, ‘ we have the interests of the residents as paramount. They are in a safe environment, they feel safe and looked after and are generally happy with their surroundings. We deliver a high standard in End of life Care especially with whose who have Dementia and support their families during this process.’ The Lilacs DS0000015447.V362263.R01.S.doc Version 5.2 Page 20 The manager is knowledgeable, has good experience of the resident group she works with and is highly organised and efficient in her role. There is clear accountability of roles amongst the team. The policy, procedures, supports both the residents and staff which maintains that their health, safety and welfare. The manager leads by example and encourages the staff team to practice in terms of a residents rights and empowerment. Practice is continually changing and adapting according to individual and group need which in turn moulds the service provided. Policy, procedures and documentation evidence that resident finances are protected. All health and safety checks that were inspected are up to date. Within the fire records looked at were found to be to a good standard. The AQAA that was sent by CSCI was completed to a basic standard. The manager needs to develop the next AQAA by covering all of the outcome areas required. Quality Assurance is to a good standard and includes views of residents and their representatives. The Lilacs DS0000015447.V362263.R01.S.doc Version 5.2 Page 21 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 3 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 4 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 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 3 The Lilacs DS0000015447.V362263.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP37 Good Practice Recommendations That the annual AQAA is filled out fully so that CSCI can fully evaluate the quality of service provided as part of the inspection process. The Lilacs DS0000015447.V362263.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 The Lilacs DS0000015447.V362263.R01.S.doc Version 5.2 Page 24 - 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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