Inspection on 20/04/06 for The Lilacs

This inspection was carried out on 20th April 2006.

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 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 Lilacs (The) 121 Chalkwell Avenue Westcliff On Sea Essex SS0 8NL Lead Inspector Pauline Marshall Key Unannounced Inspection 20th April 2006 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 Lilacs (The) DS0000015447.V290769.R01.S.doc Version 5.1 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.V290769.R01.S.doc Version 5.1 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.V290769.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 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. 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 £370.00 to £410.00 and there are additional charges for hairdressing, chiropodist, papers, sweets and toiletries. 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.V290769.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 20th April 2006; it lasted for five and a half hours. Discussions took place with the owners, the manager, four staff members, nine residents, a visiting district nurse and one relative. After a tour of the home a random sample of staff records, residents records and the homes policies and procedures were inspected. Twenty-three of the thirty-eight standards were inspected on this occasion in addition to the requirements from the last inspection. What the service does well: What has improved since the last inspection? What they could do better: The rota should identify the person in charge of the home on each shift and highlight management hours that are additional to staffing requirements. Lilacs (The) DS0000015447.V290769.R01.S.doc Version 5.1 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) DS0000015447.V290769.R01.S.doc Version 5.1 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.V290769.R01.S.doc Version 5.1 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): 1, 2, 3, 6 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The home carries out a full pre-admission assessment of needs and provides prospective residents with sufficient information to enable them to make an informed choice. EVIDENCE: The home provides prospective residents with a copy of their Statement of Purpose and Service Users Guide prior to admission. Each resident has a written contract/statement of terms and conditions with the home. Care files sampled evidenced that a thorough pre-admission process takes place. Pre-admission assessments included the individual’s social history, their likes and dislikes, their health needs, their social interests and hobbies and their religious and cultural needs. Lilacs (The) DS0000015447.V290769.R01.S.doc Version 5.1 Page 9 Residents spoken with confirmed that information was supplied prior to admission. The Lilacs does not provide intermediate care. Lilacs (The) DS0000015447.V290769.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The homes care plans contain the information required to meet the residents’ needs and are being continually improved to provide clearer guidance to staff. Health care needs are fully met and there is a clear medication policy that is followed by all staff. Residents are treated with respect and their dignity and privacy is upheld. EVIDENCE: The manager is in the process of changing to a new format for the homes care files; this new format shows more clearly the staff intervention needed. Three care files were inspected and all had service user plans that set out each individual’s health, personal and social care needs and how they were to be met. The plans inspected were all reviewed on a regular basis. Residents are encouraged to remain with their own General Practitioner where possible. The home has six different General Practitioners attending to the residents health needs. The District Nursing service is requested whenever required for individual residents. On the day of the inspection the District Lilacs (The) DS0000015447.V290769.R01.S.doc Version 5.1 Page 11 Nurse was visiting and said that although she had not visited the home many times she was made to feel welcome and that staff were friendly and cooperative and that she feels comfortable and that the home has a good atmosphere. The home has a clear medication policy and has a copy of the Royal Pharmaceutical Society of Great Britain Guidelines on Administration of Medicines in Care homes (2003) displayed for staff to refer to. The home uses the NOMAD system of medication administration and all Medication Administration sheets (MARS) inspected were complete. Medication is appropriately stored in a locked metal cabinet. Eight staff have received medication training. Staff addressed residents by their preferred names and was observed to treat them with respect. The visiting District Nurse treated the resident in her own bedroom. Lilacs (The) DS0000015447.V290769.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Residents experience a lifestyle that matches their needs, they are encouraged to maintain contact with family and friends and have as much choice and control over their lives as possible. Residents receive a wholesome appealing balanced diet. EVIDENCE: Residents spoken with said that they were happy at the home and that the food was good. One resident said that she gets everything that she needs and likes her room and that the staff are very nice and always attentive. The home offers a range of activities that include sing-a-longs, reminiscence sessions, manicure, videos and softball. All sessions are scheduled to take place weekly, but are more frequent at the residents’ request. Contact with family and friends are encouraged by the home. A visiting relative said that the home is always friendly and makes her feel welcomed and that staff are nice and that she feels that her relative is well cared for. Residents meetings are held regularly and minutes of these are kept in the home. The home holds small amounts of residents cash, relatives hold larger amounts and requests are made by the proprietor when money is needed. Lilacs (The) DS0000015447.V290769.R01.S.doc Version 5.1 Page 13 Residents’ valuables are not stored at the home; if there are any relatives look after them. All bedrooms contain residents’ personal possessions and one resident spoken with confirmed that she was encouraged to bring small items of furniture if she wished on admission. The dining area is well laid out, clean and bright; the meal was cooked with fresh produce and look wholesome and appealing. Drinks and snacks were available throughout the day; residents spoken with commented on the high quality of the food and confirmed that they chose what to eat. Menus are adapted to meet individual residents requirements when requested. Nutrition records are kept and show the amount of food and drink taken. Lilacs (The) DS0000015447.V290769.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Complaints are acted upon swiftly and all issues are taken seriously by the home. Residents are protected from abuse. EVIDENCE: There is a complaints policy in place that is dated October 2003, this is in the process of being reviewed to ensure that it meets with current requirements. The proprietors are at the home on a daily basis and minor complaints are dealt with immediately, more serious issues are recorded on the homes complaints form and dealt with according to the homes policy. The proprietor will be compiling a new complaints book where all complaints forms will be logged. There have been no complaints since the last inspection. The home has a policy on physical restraint and Adult Protection and all staff have attended training for the protection of vulnerable adults. There is a Whistle blowing policy in place at the home and staff spoken with had a good understanding of the procedure. The policy is dated October 2003 and needs to be reviewed to ensure it meets current requirements. Lilacs (The) DS0000015447.V290769.R01.S.doc Version 5.1 Page 15 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, 26 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Residents live in a safe well-maintained environment that is clean, pleasant and hygienic. EVIDENCE: The home is comfortable and the furniture and fittings well maintained, there are handrails fitted around the home. Residents have their own walking aids and the home provides a hoist that is regularly serviced. There are paper towels and liquid soap in all communal bathrooms and toilets. Three bedrooms and one toilet have been redecorated since the last inspection. All safety certificates are in place and fire drills carried out regularly. The garden has been improved since the last inspection and flowers and shrubs have been planted. Lilacs (The) DS0000015447.V290769.R01.S.doc Version 5.1 Page 16 The home has policies on infection control and disposal of clinical waste and staff were observed working to the procedures. The home was clean, hygienic and odour free. Lilacs (The) DS0000015447.V290769.R01.S.doc Version 5.1 Page 17 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, 29, 30 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Staff are well trained, competent and supplied in sufficient quantities to meet residents needs. The homes recruitment policy and practice supports and protects the residents. 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. Since the last inspection one staff member has left to open her own care home. The staff rota did not indicate who was in charge of the shift and it did not highlight any management hours. The rota needs to indicate who is the person in charge of each shift and highlight any additional hours that are allocated for management duties. Four staff have achieved NVQ level 2 in Care and two staff are currently undertaking the award. The manager is a registered nurse and has an NVQ level 4 Registered Managers Award. Three staff records were inspected and they contained all the relevant documents as required in schedule 2 of the Care Homes Regulations. The newest member of staff began work two days prior to the inspection and is working under supervision whilst on her induction. Lilacs (The) DS0000015447.V290769.R01.S.doc Version 5.1 Page 18 Staff are well trained and there is a good range of mandatory and service specific training provided by the home. Lilacs (The) DS0000015447.V290769.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The home is well managed and run in the best interests of the residents and their financial interests are safeguarded. The health, safety and welfare of the residents is promoted and protected. EVIDENCE: The manager is one of the proprietors and is a Registered Nurse who has undertaken the NVQ level 4 Registered Managers Award in addition to all the mandatory training required. The proprietors have undertaken dementia, Parkinson’s disease and difficult behaviour training. Lilacs (The) DS0000015447.V290769.R01.S.doc Version 5.1 Page 20 Regular residents meetings take place and the discussions are recorded. The proprietor undertook a quality assurance audit in September 2005 and supplied the CSCI with a copy of the findings. Residents cash is kept in the safe, all transactions are entered appropriately and receipts kept. All safety certificates are in place and policies and procedures for health and safety are up to date and followed by staff. Regular fire drills have taken place and the outcomes recorded. Lilacs (The) DS0000015447.V290769.R01.S.doc Version 5.1 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Lilacs (The) DS0000015447.V290769.R01.S.doc Version 5.1 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 OP27 Good Practice Recommendations The rota needs to show the person in charge of the home and the amount of hours allocated as supernumerary for the manager to complete management tasks. Lilacs (The) DS0000015447.V290769.R01.S.doc Version 5.1 Page 23 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.V290769.R01.S.doc Version 5.1 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. 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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