Random inspection report
Care homes for older people
Name: Address: The Lilacs 121 Chalkwell Avenue Westcliff On Sea Essex SS0 8NL three star excellent service The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Sarah Axam Date: 1 8 0 8 2 0 0 9 Information about the care home
Name of care home: Address: The Lilacs 121 Chalkwell Avenue Westcliff On Sea Essex SS0 8NL 01702712457 Telephone number: Fax number: Email address: Provider web address: bwatersbassa@aol.com Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Mr Barry Norton Waters,Ms Fazlee Painchun care home 17 Number of places (if applicable): Under 65 Over 65 17 17 dementia old age, not falling within any other category Conditions of registration: Date of last inspection Brief description of the care home 0 0 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. Care Homes for Older People Page 2 of 10 Brief description of the care home Care Homes for Older People Page 3 of 10 What we found:
This was a unannounced random inspection carried out on the 18th August 2009 to look at four specific aspects of care and was undertaken as a result of concerns raised via safeguarding of vulnerable adults and a complaint received by the commission. The last key inspection was carried out on 8th April 2008. The four specific areas looked at were, Residents contracts, care plans, environment and complaints. We looked at the documentation around the area of contracts. Contracts (by the home)were not included in two out of the three files looked at. The one contract that was in place was not signed by both the provider or manager, so were invalid. The manager and provider told us that this would be an area that they would look into and discussed some of the difficulties they had been having around contracts with us. When we visited the service we saw that in three peoples information that they have a good access to other health professionals such as GPs, consultants, nurses and social workers. When we looked at care plans for two of the residents living in the home, we found that risk assessments, care plans and guidelines given to staff, did not reflect fully what the initial assessments told us. For example, one person had written in their risk assessment that they liked to use a specialised chair and we saw by meeting this person that they were bed bound and therefore the care plan and risk assessments were out of date. In both files looked at they lacked appropriate risk assessment.s, regular monthly review.s and vital information needed (information used if someone needed urgent medical attention and was taken into hospital, missing person.s profile) to keep all people safe best as possible. We looked at the documentation around complaint.s. The provider told us that there is a policy and procedure for dealing with complaint.s, which we looked through. He also told us that the home has an open door policy where people are encouraged to come and raise any concerns they may have. He told us that as part of the homes complaints procedure all complaints would be investigated by him or the manager. The manager told us that most residents living in the home would be capable of making a verbal complaint or that they would have some form of a representative if they couldnt. Since the last inspection there have been three outside complaints that we have been informed of (two from the same relative and one from another relative). Records examined did not contain any information about the three complaints (from outside of the home) as these had not been recorded onto the homes complaint system. On the other hand residents complaints were recorded and showed us that the home knew how to deal with any concerns or complaints that were raised well. The manager told us that there would be systems in place to ensure that all peoples views are listened to acted upon and support residents to be protected from abuse. Additionally that they would review the complaints policy and procedure which would include the timescales as stated in the regulations and the update of CQC names, address and telephone numbers, as well as our role within the complaints procedure. We carried out a tour of all rooms within the house, including all of the residents bedrooms. We saw that these rooms were bright, clean and reflected each persons
Care Homes for Older People Page 4 of 10 individual taste. The manager told us that in each bedroom were a nurse call point which was in easy reach for each person to use, these were also provided in all toilets, bathrooms, lounges and the dining room. This was seen by us when a tour of the building was undertaken. We saw that the home was in some places poorly maintained in certain areas such as, the front room had odour issues which may have stemmed from a nearby toilet which was off from the lounge. The main downstairs toilet had no paper towels, the toilet bowl needed a good clean and had an open bin that contained soiled waste. The downstairs bathroom needed a clean, removal of clutter, a rail full of drying clothes was present, a chromed open framed stand kept all peoples prescribed creams in and communal toiletries. These were easily accessible to all people within the home. The bathroom flooring needed repairing as it was a slip hazard. (It had a big square in front of the bath cut out). Some people had rugs in their rooms in front of the sink, which were curling up and could lead someone to have a fall. Some peoples bedroom doors were left open and had no fire guards attached (protection to close doors automatically if a fire broke out). An old hoist and a wheelchair were stored in the first floor lobby that had restricted space. On one persons commode chair, and on a wardrobe, there was a note for staff giving instruction and other information, this did not protect this persons privacy or dignity. The provider produced paperwork for us to look at which showed us that cleaning checks were carried out regularly. The manager carried out monthly environmental checks, that included equipment checks, such as, hoists, kitchen equipment, call systems, lift, stairs, fire doors, toilets, walking aids, commodes and wheelchairs. We saw that there were procedures in place and that staff had training to promote and to reduce the risk of infection. During a tour of the building and the outside of the home we saw that many of the communal areas were also in some areas of need of re carpeting, repainting and redecoration. Additionally the access to the back garden could be improved upon so that all residents could access this area independent of staff and maintain safety. The garden itself was maintained well, pleasant and provided plenty of space. One resident informed us that they often used the garden and enjoyed this use of their time. Speaking with the provider he told us that a maintenance plan is underway and would be addressing these issues raised by us. The provider reported that in the last six months the cleaner had left which they had found hard to replace. This post was presently being recruited for. The provider stated that it hadnt been easy to recruit for that post and had taken time. The provider had interviewed someone and potentially they looked like a good candidate for this role. Meanwhile staff had been carrying out these duties among their busy schedule of other usual tasks .As a result the environment had suffered, as they could not carry out this role consistently due to other demands made upon them. What the care home does well: What they could do better:
Care Homes for Older People Page 5 of 10 The provider and manager should ensure that all peoples contracts are in place. And that all care plans, risk assessments are in place and regularly reviewed. This will ensure that staff can support all people in the correct way. The recording of complaints need to contain any outside complaint made and the complaints policy needs to be updated to reflect better the commissions role, details and time scale criteria expected and stated within the care standards act 2000 regulations. The provider should provide an outside area to the back garden that is easily accessible for all residents so that they can use the garden freely and have a choice to do so. Additionally many parts of the communal areas of the home are worn and in need of a bit of attention to them and attention needs to be paid to the cleanliness of the home so that they continue in the future to provide a pleasant environment for all people. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 6 of 10 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 7 of 10 Requirements and recommendations from this inspection:
Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours.
No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action 1 2 5 The manager needs to ensure that all residents receive a contract. This is because two out of the three residents information looked at did not include contracts and the third had a contract but unsigned by the manager and provider. 31/12/2009 2 7 15 All care plans are to be 31/12/2009 regularly reviewed and all relevant care needs are updated and have a risk assessment if need be. This is to ensure that vital information needed to keep people safe and to instruct staff to support people is in place and fully reflects the needs of people. 3 16 22 All complaints received from all people are Statutory requirements. These requirements set out what the registered person must do to meet the Care 30/09/2009 Care Homes for Older People Page 8 of 10 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. This is to ensure that all complaints received are dealt with appropriately. 4 19 23 The environment needs to be kept clean and reasonably decorated. This is to ensure that people live in a clean, safe home. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No Refer to Standard Good Practice Recommendations 31/03/2010 Care Homes for Older People Page 9 of 10 Reader Information
Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 10 of 10 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
