Inspection on 28/06/05 for The Lilacs

This inspection was carried out on 28th June 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 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 18/08/09

The Lilacs 16/04/08

The Lilacs 17/04/07

The Lilacs 20/04/06

The Lilacs 15/11/05

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 Ron Reeves Unannounced 28 June 2005 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 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) v229193 i56 s15447 lilacs v229193 280505 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Lilacs (The) Address 121 Chalkwell Avenue Westcliff-on-Sea Essex SS0 8NL 01702 712457 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Barry Norton Waters Ms. Fazlee Painchun Ms Fazlee Painchun CRH Care Home 17 Category(ies) of DE(E) Dementia-over 65 (17) registration, with number OP Old Age (17) of places Lilacs (The) v229193 i56 s15447 lilacs v229193 280505 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The home may accommodate 17 persons of either sex, who fall into the category of old age and people over 65 years of age with dementia. Date of last inspection 25th January 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. home are accessible by a shaft lift. All areas of the There is limited parking at the front of the home. The garden at the rear of the home is a good size. The registered manager and registered person are closely involved in the daily management of the home. Both have experience of residential care. Lilacs (The) v229193 i56 s15447 lilacs v229193 280505 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection that took place on the 28th June 2005, lasting 7.5 hours. The inspection process included: discussions with the proprietor, the manager, 3 staff, 4 service users, 4 visiting relatives, a visiting District Nurse and Chiropodist. Opportunity was taken to tour the premises, examine a sample of records and policies. Twenty nine of the thirty eight standards were inspected. What the service does well: What has improved since the last inspection? The home has addressed the vast majority of the requirements and recommendations detailed in the previous report. Carpet has been replaced in the entrance hall and stairway and further replacement planned. Individual social care assessments are now in place and the manager has developed reminiscence activities for those service users with dementia. Lilacs (The) v229193 i56 s15447 lilacs v229193 280505 stage 4.doc Version 1.30 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) v229193 i56 s15447 lilacs v229193 280505 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Lilacs (The) v229193 i56 s15447 lilacs v229193 280505 stage 4.doc Version 1.30 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 standard(s) 1-5 The admission process is well managed and residents are given clear information regarding the home. Individual residents needs are being well met by the home. EVIDENCE: The home has amended its statement of purpose and service users guide. The manager described a thorough admission process through which she assessed whether the home could meet individual needs. Three residents files were inspected. There was evidence of a pre-admission assessment, although these would benefit from greater detail. A further assessment form provides additional information on resident’s social history and interests, likes and dislikes. The home has appropriate aids and equipment to meet the care needs of the residents. There was evidence of a good level of staff training and staff spoken with demonstrated a sound knowledge of the residents needs. Lilacs (The) v229193 i56 s15447 lilacs v229193 280505 stage 4.doc Version 1.30 Page 9 Residents and relatives spoken with felt confident in the staff and were happy with the care provided. A visiting District Nurse and Chiropodist expressed their confidence in the staff. Lilacs (The) v229193 i56 s15447 lilacs v229193 280505 stage 4.doc Version 1.30 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 standard(s) 7-10 Residents’ are well looked after in respect of their personnel and health needs. Further development of the home’s care planning system are required. Any medical attention for the residents must be provided to the residents in private. EVIDENCE: Three care files were inspected. Each contained care plans that covered all residents assessed needs. However, instructions provided for the staff to meet the residents needs were not clear and concise with generalisations such as “assist or support” being used. Daily recordings did not fully reflect how the residents spend their day and the progress of the care plans. Residents and relatives spoken with were positive about the way personal care and health needs were being met and felt that staff treated them in a respectful manner. A visiting District Nurse felt that the care provided to the residents was to a good standard and reported that she was always kept up to date with resident’s medical conditions. Lilacs (The) v229193 i56 s15447 lilacs v229193 280505 stage 4.doc Version 1.30 Page 11 Administration of medication was inspected and is considered to be safe. Since the previous inspection, the home has developed its homely remedies policy. Residents privacy was seen to be generally accepted. However, the practice of the Chiropodist treating residents in the main lounge must be discontinued. Lilacs (The) v229193 i56 s15447 lilacs v229193 280505 stage 4.doc Version 1.30 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 standard(s) 12,13,15 Social activities and meals are both well managed and provide daily variation for people living in the home. EVIDENCE: The home’s admission process includes information regarding residents social history, interests, likes and dislikes. The manager has developed activities specifically for residents who have dementia. The home has an open visitors policy. Relatives spoken with said they were always made welcome whatever time they visit. Everyone who commented on the food provided said how good it is. Menus seen appeared varied and well balanced and flexible to accommodate individual choices. Daily nutrition records are well maintained. Lilacs (The) v229193 i56 s15447 lilacs v229193 280505 stage 4.doc Version 1.30 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 standard(s) 16 & 18 Arrangements for the protection of residents and responding to their concerns are satisfactory. EVIDENCE: The home has a clear complaints procedure. Two complaints have been received since the previous inspection. Both were dealt with satisfactorily. Residents and relatives spoken with said they felt comfortable in discussing any concerns with the manager. The home has policies and procedures in place for the protection of vulnerable adults and all staff have attended training. Policies and procedures are in place for the management of physical and verbal aggression, however it was noted at the previous inspection further development is required. This has yet to be addressed by the home. Lilacs (The) v229193 i56 s15447 lilacs v229193 280505 stage 4.doc Version 1.30 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 standard(s) 19-21,24-26 A comfortable and safe standard of accommodation is provided for the residents. EVIDENCE: In general the home is well maintained and suited to residents needs, although there are corridor areas that would benefit from redecoration. A new carpet has been fitted to the entrance hallway and the stairs. Further carpet renewal is planned. The residents’ bedrooms were seen to be homely and residents had been able to bring some of their possessions with them. Residents spoken with said they were happy with their rooms. Not all rooms have lockable storage. The home has 3 bathrooms of which only one has a specialist bath. The proprietor said he would be redesigning one of the bathrooms in the near future. The main kitchen is being improved with a new work surface fitted. Communal areas are sufficient to meet residents needs, however the main lounge would benefit from improving the natural light. The provision of an additional window was discussed with the proprietor. Lilacs (The) v229193 i56 s15447 lilacs v229193 280505 stage 4.doc Version 1.30 Page 15 The laundry contained a washing machine with a sluice cycle and tumble dryer. There is a large garden to the rear which should be developed to make it more attractive and accessible for the residents. Lilacs (The) v229193 i56 s15447 lilacs v229193 280505 stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,30 Staff at the home are well trained, supported and employed in sufficient numbers to meet the residents needs. EVIDENCE: The home has a relatively stable core group of staff with a comparatively low staff turnover. Many of the staff have worked in the home for many years. Agency staff are not used. Service users spoken with said the staff were very good, kind and treated them well. Staff spoken with agreed staffing levels are being maintained by the home, as three staff on duty during the day and one awake and one sleeping in at nights. In addition the home has a domestic. Cooking is carried out by the proprietor. The staff rota did not clearly identify who was in charge of each shift, what periods the manager was supernumery and what duties the proprietor was undertaking. Three staff have currently achieved NVQ2 and three staff are currently training to achieve NVQ2. A good range of mandatory training and additional training is provided. Lilacs (The) v229193 i56 s15447 lilacs v229193 280505 stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31-33-36-38 The home is managed effectively by the manager with support from the joint provider. Records required to protect service users were generally well maintained and stored securely. EVIDENCE: There was evidence of good day to day contact between the manager and staff. The manager has a hands on approach to managing the home and frequently works alongside care staff and through this contact any issues identified are dealt with as they arise. Staff meetings and handovers provided additional opportunities for group supervision. The relatively stable staff group and the daily presence of one or both of the proprietors promotes a friendly atmosphere. The registered manager is a qualified nurse and has achieved the Registered Managers award and has managed the home since registration in 2000. Quality assurance procedures are in their infancy. These need further development. Lilacs (The) v229193 i56 s15447 lilacs v229193 280505 stage 4.doc Version 1.30 Page 18 Staff supervision is now taking place on a regular basis. Records required by regulation have been randomly sampled during the inspection. Those seen were generally well maintained and stored appropriately. The home is generally run in a safe and effective manner. Health and safety policies were in place and staff have received refresher training in moving and handling current safety certificates for systems and equipment were seen to be in place. Lilacs (The) v229193 i56 s15447 lilacs v229193 280505 stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 2 x x 3 3 3 STAFFING Standard No Score 27 2 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 3 3 x x 3 3 3 Lilacs (The) v229193 i56 s15447 lilacs v229193 280505 stage 4.doc Version 1.30 Page 20 YES Are there any outstanding requirements from the last inspection? 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 18 Regulation 13(6) Requirement Timescale for action 31/07/05 2. 21 23(2)(a)( b) 3. 7 12 The homes policies and procedures relating to the management of physical and verbal aggression must include reference to the use of physical intervention and restraint. Bathroom facilities at the home 1/11/04 must be suitable to meet the needs of service users, and be well maintained. This is a repeat requirement from the previous inspection The home must make suitable 28/05/05 arrangements to ensure the privacy and dignity of service users. This includes service users receiving medical treatment in private. 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 8 Good Practice Recommendations The home should consider the purchasing of weighing scales suitable for use by all service users. v229193 i56 s15447 lilacs v229193 280505 stage 4.doc Version 1.30 Page 21 Lilacs (The) 2. 10 (This was not inspected on this occasion). Visitors should be offered the option of going somewhere private when visiting their relatives/friends. (This was not inspected on this occasion). As far as possible service users wishes concerning terminal care and arrangements after death are discussed and carried out. (This was not inspected on this occasion). Service users should be provided with a lockable storage area in their rooms. Service users should be made aware of their options in relation to standard 24 and, where possible, their choices sought and recorded. The home should continue to develop their quality assurance strategies. Daily records maintained for residents should be developed ro reflect the welfare of the residents how they spend their day and the progress of the care plans. The garden area should be improved to make it more atractiveand accessible to the residents. 3. 11 4. 24 5. 6. 7. 33 7 19 Lilacs (The) v229193 i56 s15447 lilacs v229193 280505 stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Kingdwood 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. 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