Inspection on 31/08/06 for The Lilacs

This inspection was carried out on 31st August 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 11/03/08

The Lilacs 12/12/05

The Lilacs 08/06/05

The Lilacs 03/02/05

The Lilacs 26/05/04

The Lilacs 28/01/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Lilacs (The) 2a Lickhill Road Calne Wiltshire SN11 9DD Lead Inspector Malcolm Kippax Key Unannounced Inspection 31st August 2006 09:30 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) DS0000028354.V298583.R02.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. Lilacs (The) DS0000028354.V298583.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lilacs (The) Address 2a Lickhill Road Calne Wiltshire SN11 9DD 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) 01249 821422 Mr Ronald Michael Taylor Ms Trudy Jane Taylor Care Home 9 Category(ies) of Old age, not falling within any other category registration, with number (9) of places Lilacs (The) DS0000028354.V298583.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th December 2005 Brief Description of the Service: The Lilacs is a family run care home for up to nine older people. It is situated in a quiet setting in a residential area of Calne, approximately ten minutes walk from the town centre. The Lilacs is a detached property with a large garden. The Lilacs is the service users permanent home for as long as this remains appropriate to their care needs. There is also the opportunity for an older person to have a temporary or respite stay away from their usual home, subject to the availability of a vacant room. The Lilacs was purpose built by the current owner as a care home for older people. There are five single bedrooms and one double room on the ground floor. There is a staircase to two single bedrooms on the first floor, where the home’s owner and the manager also have their accommodation. The communal space consists of a large open plan lounge and dining room. Each bedroom has an en-suite toilet and wash hand basin. One of the bedrooms also has an en-suite bathroom. One the ground floor there is a bathroom with an assisted bath for use by all the service users. The manager, Ms Taylor, is closely involved in the day to day care of the service users. Other family members are regularly involved and work in conjunction with the carers and ancillary staff who make up the staff team. At the time of the inspection, the fees range was from £380 - £400 per week. Lilacs (The) DS0000028354.V298583.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit to the home, which took place on 31 August between 9.30 am and 3.20 pm. A second visit was arranged with the home’s manager in order to complete the inspection and to give feedback. This took place on 14 September between 10.10 am and 12.20 pm. There were four service users at the time of the visit on 31 August. Each service user was met with. The accommodation was seen and time was spent observing routines in the home. There were also individual meetings with the manager and with two members of staff. A number of the home’s records were looked at during the visits. A new service user had moved in at the beginning of September and was met with during the second visit. Other information has been received and taken into account as part of the inspection: • • • The manager completed a pre-inspection questionnaire about the home. Four service users, two with the support of their relatives, completed surveys about what it is like to live at The Lilacs. Comments have been received from a District Nurse who visits the home. The judgements contained in this report have been made from the evidence gathered during the inspection, including the visits to the home. What the service does well: Assessments are carried out providing good information about a service user’s needs and preferences. New service users are well supported with settling into the home. Individual care plans provide up to date information about the service users’ health and care needs. The service users benefit from the support that they receive with their healthcare. They are treated in a respectful manner by the manager and staff. Service users enjoy a relaxed and informal atmosphere within the home. They are well supported in their relationships with family and friends and have the opportunity to participate in some regular social activities. Service users generally enjoy their meals, which are taken in pleasant surroundings. Service users and their relatives are aware of how to make a complaint but have not felt it necessary to do so. Lilacs (The) DS0000028354.V298583.R02.S.doc Version 5.2 Page 6 Staff members receive guidance and have an awareness of abuse that helps to protect service users. Service users live in an environment that is generally homely and is meeting their needs. The layout of the home is convenient for people. The accommodation is kept clean and tidy. The home has an experienced manager who provides continuity and reassurance for service users. Service users are protected by the home’s recruitment practices. A system of quality assurance is being developed. The service users’ financial interests are safeguarded with the involvement of their relatives and outside parties. Service users are protected by the arrangements being made for their health & safety. New risks are being well identified and responded to. What has improved since the last inspection? What they could do better: Objectives have been identified in the service users’ care plans although in some cases it was not clear whether these have been achieved or were no longer relevant. The system of objective setting helps to focus support on agreed areas but a lack of monitoring could result in staff time and support not being used in the most effective way. In their surveys, the service users were mostly very positive about the care and service that they receive in the home. The responses were slightly less favourable in respect of the provision of activities and the quality of meals, indicating that these are areas that the home could improve on. Lilacs (The) DS0000028354.V298583.R02.S.doc Version 5.2 Page 7 The views of service users could be more directly obtained as part of the home’s system of quality assurance. The accommodation is generally very homely although the bathroom would benefit from attention, in order to make it a more comfortable and domestic type environment. Service users would benefit from staff members’ greater involvement in training activities outside the home, rather than an over-reliance on in-house training. 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) DS0000028354.V298583.R02.S.doc Version 5.2 Page 8 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) DS0000028354.V298583.R02.S.doc Version 5.2 Page 9 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): 3 Quality in this outcome area is good. This judgement has been made from evidence gathered before and during the visits to the home. Assessments are carried out, providing good information about a new service user’s needs and preferences. (Standard 6 did not apply to this home). EVIDENCE: The assessment records were looked at for two new service users who had moved into the home since the last inspection. Ms Taylor had carried out a pre-admission assessment with one service user at their previous residence. The other new service user had visited The Lilacs on a number of occasions since June 2006 and a pre-admission assessment form was completed over time. Further information was recorded at the time of admission using a number of assessment pro-formas. These included a general assessment form, which Lilacs (The) DS0000028354.V298583.R02.S.doc Version 5.2 Page 10 had sections for mental and physical health, social needs and the service users’ involvement in domestic tasks. More detailed assessments were completed after admission. The new service users’ personal files contained completed forms for ‘Client Handling’, ‘Personal Client Risk’, ‘Pressure Sore Assessment’ and ‘Falls Risk Assessment’. One service user’s assessments had been reviewed monthly following their admission. The other service user had not been in the home long enough for a review to be needed. Both service users were met with and said that they were settling into the home well. In their surveys, each service user confirmed that they had received a contract and enough information about the home before moving in so they could decide that it was the right place. Lilacs (The) DS0000028354.V298583.R02.S.doc Version 5.2 Page 11 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 and 10 Quality in this outcome area is good. This judgement has been made from evidence gathered before and during the visits to the home. Service users participate in the planning of their care. Their care plans provide good information about the support that is required with health and personal care. The plans are kept under review, although the outcome for service users would be improved by better monitoring of the care plan objectives. Service users benefit from the support that they receive with their health needs. Service users are better protected following changes that have been made in the procedures for dealing with their medication. Service users are treated in a respectful manner. EVIDENCE: Each service user had a ‘Plan of Care’, which reflected a range of needs. Service users also had a separate ‘Service User Plan’, which focused on the physical support that is required from staff. The involvement of the service user was recorded on the plans although they were not written from the service user’s perspective. Lilacs (The) DS0000028354.V298583.R02.S.doc Version 5.2 Page 12 The plans included objectives which covered a variety of areas, such as a service user being able to watch videos in their own room, having a ‘shampoo and set’ every two weeks and receiving encouragement to sit outside on warm days. Comment was made where a review had confirmed the effectiveness of the plan, although progress with meeting the objectives was not consistently recorded. In some cases it was not clear whether an objective had been achieved or was no longer relevant. The system of objective setting helps to focus support on agreed areas but a lack of monitoring could result in staff time and support not being used in the most effective way. The service users’ care plans included other goals that were designed to promote or restore good health. Weight was recorded at the time of admission, which enabled a reduction or increase in weight to be monitored. The service user’s personal records included risk assessment forms that had been completed in respect of pressure sores, falls and moving & handling. The assessments were reviewed monthly. These assessments appear to be a good way of identifying service users who may be at risk and require intervention from staff. Daily reports showed evidence of service users’ recent appointments with GPs and other health professionals. A ‘GP Visits’ form was used for the recording of all health care matters. Service users had received flu vaccines within the last year. In their surveys, each service user confirmed that they always receive the care and medical support that they need. One person commented that the manager is very good at getting the doctor and podiatrist to visit when needed. District nurses were supporting service users with their short term nursing care needs. One district nurse commented that from her experience, the home was meeting the service users’ healthcare needs and that instructions given about the service users’ nursing needs were being well followed up. Service users were receiving support with the administration and safekeeping of their medication. The procedures and the practical arrangements had improved since the last inspection. The requirements made at the last inspection had been met. The administration of medication records were up to date and medication was kept securely. There was a recommendation at the last inspection that sufficient staff should be trained to administer medication to ensure adequate cover for holidays and sickness. This has not yet happened (see standard 27). Each service user had their own room in which they could receive care in private. Service users said that they were treated with respect. Ms Taylor had Lilacs (The) DS0000028354.V298583.R02.S.doc Version 5.2 Page 13 produced a ‘code of conduct’ for staff, which included a number of items relating to maintaining service users’ dignity and privacy. Staff members had signed a sheet to confirm that they had received the code of conduct on their first day of work. Lilacs (The) DS0000028354.V298583.R02.S.doc Version 5.2 Page 14 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 and 15 Quality in this outcome area is good. This judgement has been made from evidence gathered before and during the visits to the home. Service users enjoy a relaxed and informal atmosphere. They are well supported in their relationships with family and friends. Service users have the opportunity to participate in some regular social and recreational activities. They would benefit from an activities programme that is more geared to their individual needs. Service users are encouraged to exercise choice and autonomy, with the support of relatives. Service users generally enjoy their meals, which are taken in pleasant surroundings. EVIDENCE: Upon arrival at the home on 31 August, two service users were finishing their breakfast in the dining area, one service user was reading in the lounge and another person was in their bedroom. It was evident from conversation with service users that they could choose where they wished to spend their time Lilacs (The) DS0000028354.V298583.R02.S.doc Version 5.2 Page 15 and that the getting up and breakfast routines were geared around their individual preferences. One service user had their own daily newspapers delivered to the home and various magazines were available to all service users. Information displayed in the front hall included a leaflet about a local advocacy service and a copy of the home’s last inspection report. There was a small library of books that service users could choose from. Service users spoke about their different interests and the contact that they have with friends and visitors. One relative said that she was made to feel welcome and that she was kept well informed about events. Some activities, such as bingo, sing-a-longs and board games took place on weekday afternoons. Staff members said that they assist with these activities although not all the service users choose to participate. The service users’ assessment forms included information about more individual interests. Unlike the group activities, specific time was not identified for when service users would receive support with these. Some preferred routines and activities were recorded in the care plans. For example, it was recorded in a new service user’s care plan that they wished to have their breakfast by 8 am and that they would receive assistance with having a lift to Church. The care records showed that the manager liaises with relatives to ensure that service users receive the support that they need with hospital appointments and going out. In some cases there was a comment on the care plans to show that a relative had contributed to the reviews. Service users have been able to bring items of furniture and personal possessions with them when moving into the home. A religious service is held in the home each month. Some service users go to clubs in Calne each week. Entertainers visit the home on an occasional basis. Five service users had lunch together in the dining room and one person had chosen to eat in her own room. A three-course meal of soup, followed by roast turkey, with gateau for a sweet course, was freshly prepared and well presented. The weekly menus showed an interesting and varied range of meals being served. Service users generally spoke positively about the meals. One person commented that she had ‘plenty of milk with the cornflakes – just as I like it’. Another person said that sometimes a cooked dished was not as hot as she would like. In their surveys, each service user said that they ‘usually’ like the meals. One person stated that at tea-time there is a choice of whatever she wants and that staff know what her favourite meals are. Lilacs (The) DS0000028354.V298583.R02.S.doc Version 5.2 Page 16 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 and 18 Quality in this outcome area is good. This judgement has been made from evidence gathered before and during the visits to the home. Service users and their relatives are aware of how to make a complaint but have not felt it necessary to do so. Staff members receive guidance and have an awareness of abuse that helps to protect service users. EVIDENCE: The home’s complaints procedure was displayed in the front hall, where a suggestions box was also available. There was a ‘record of complaints’ file in the office, although no complaints had been reported during the last year. In their surveys, each service user stated that they know how to make a complaint, know who to speak to if they are not happy, and that staff always listen and act on what they say. The home had a policy on the prevention of abuse. This referred to the training of staff in order that abuse can be recognised. A video about adult protection had been bought for this purpose, which staff members said they had watched. Staff members had also been given the ‘No Secrets’ booklet and copies of the most recent version were available in the office. Lilacs (The) DS0000028354.V298583.R02.S.doc Version 5.2 Page 17 Abuse awareness was included in the induction programme that new staff members undertake. The opportunity for staff to develop further knowledge and understanding in the area of protection was discussed with Ms Taylor. Ms Taylor acknowledged that it would be useful for staff to participate in some external events, such as learning more about the local Vulnerable Adults Unit. Lilacs (The) DS0000028354.V298583.R02.S.doc Version 5.2 Page 18 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 and 26 Quality in this outcome area is good. This judgement has been made from evidence gathered before and during the visits to the home. Service users live in an environment that is generally homely and is meeting their needs. The bathroom would benefit from attention, in order to make it a more comfortable and domestic type environment. The layout of the home is convenient for service users. The accommodation is kept clean and tidy. EVIDENCE: The Lilacs was purpose built as a care home and has a layout and facilities that are helpful to older people. There is level access to the home. Most of the accommodation is on the ground floor and the service users’ rooms are close to the communal areas and other facilities. The rooms are off a spacious hall, which allows plenty of room for people who use zimmer frames and other aids Lilacs (The) DS0000028354.V298583.R02.S.doc Version 5.2 Page 19 to get about. However, handrails were not fitted in all locations and the need for these should be kept under review. There is one communal room, which was light, homely and well furnished, with views of the garden. The dining area at one end of the room had a door directly onto the kitchen, which helps with the serving of meals. Each service user had an en-suite toilet and wash hand basin attached to their rooms. One bedroom also had an en-suite bath. Other service users shared a bathroom on the ground floor. This is a spacious room, but unlike other areas of the home looked functional, rather than homely. It was used for the storage of various items such as commodes and ‘wet floor’ warning signs. There were notices for staff giving guidance about hygiene and personal care, which added to the institutional feel. The gardens were varied with a mix of shrubs and lawned areas. There was a patio at the front of the home, which can be reached from the lounge. An environmental health officer had visited the home in April 2006. The report of the visit was seen and there were no requirements or recommendations made. The home looked clean and there were no unpleasant odours. In their surveys, each service user stated that the home is always kept fresh and clean. Lilacs (The) DS0000028354.V298583.R02.S.doc Version 5.2 Page 20 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 and 30 Quality in this outcome area is adequate and improving. This judgement has been made from evidence gathered before and during the visits to the home. The manager and staff team are meeting the service users’ needs. The presence of the manager provides continuity and reassurance for service users. The roles and responsibilities of staff could be further developed. Service users are protected by the home’s recruitment practices. Service users would benefit from staff members’ greater involvement in training activities outside the home. EVIDENCE: The minimum staffing level for a home of this size is for two people to be working in the home throughout the day. The names of people working each day were recorded in a desk dairy, although this did not always show their start and finishing times. Service users said that Ms Taylor or Mr Taylor were readily on hand to deal with any issues. Ms Taylor’s daughter was also covering a number of shifts in the home. In their surveys, each service user said that staff are always available when needed. Lilacs (The) DS0000028354.V298583.R02.S.doc Version 5.2 Page 21 One member of care staff has achieved a National Vocational Qualification (NVQ) at level 2 or above and another person had recently started their NVQ. The staff members met with said that they had received training in a range of areas including Health & Safety, Moving & Handling, Infection Control, First Aid, Food Hygiene and Adult Protection. This was shown in their individual training records. Some of this training had taken place ‘in-house’, using videos and workbooks; other training had been provided through distance learning courses. The latter included Occupational Health & Safety and Intermediate Food Hygiene. First aid training for staff had been provided through the use of a video and workbook. One staff member also had a current first aid certificate and it was agreed with Ms Taylor that arrangements would be made for all staff to attend a certificated course. Ms Taylor had arranged for individual staff members to attend some outside courses. These had included Positive Dementia Care, Certificate in Health & Nutrition and Moving & Handling. One member of staff had left and one person started since the last inspection. The new staff member’s employment file was looked at and the recruitment process discussed with Ms Taylor. This area has improved since the last inspection. An application form was completed and two written references obtained. A check with the Criminal Records Bureau was completed prior to the staff member starting work. The staff member undertook a T.O.P.S.S. accredited programme of induction and had signed the induction workbook to confirm the items covered. As part of their induction the new staff member had also signed agreement to a code of conduct and to confirm receipt of some written policies and procedures. The staff member’s file also included a record of supervision that she had received from Ms Taylor. Ms Taylor said that either she or Mr Taylor takes the lead when on duty. The records showed that Ms Taylor or Mr Taylor cover all the main shifts, working alongside one of the staff team. This was the case at the time of the visits and meant that staff members had limited responsibilities when on duty. It was recommended at the last inspection that other staff should be trained to administer medication to ensure adequate cover for holidays and sickness. Ms Taylor said that two staff members were being prepared for this. It was also the intention to provide more opportunities for staff development and for individual staff to take further responsibilities in the home. The staff team were not meeting together on a regular basis and it was recommended to Ms Taylor that such meetings would help to develop the staff team and the staff members’ individual roles. Lilacs (The) DS0000028354.V298583.R02.S.doc Version 5.2 Page 22 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 and 38 Quality in this outcome area is good, however a requirement has been identified to ensure that the Commission is appropriately notified of certain events. This judgement has been made from evidence gathered before, during and after the visits to the home. Service users benefit from a manager who has undertaken relevant qualifications and who is closely involved in meeting their needs. A system of quality assurance is being developed. Service users would benefit further by being able to contribute more directly within this system. The service users’ financial interests are safeguarded with the involvement of their relatives and outside parties. Service users are protected by the arrangements being made for their health & safety. New risks are being identified and responded to. Lilacs (The) DS0000028354.V298583.R02.S.doc Version 5.2 Page 23 EVIDENCE: Since the last inspection, Ms Taylor has completed NVQ at Level 4 in Care and also the Registered Managers Award course. Ms Taylor was waiting to receive her RMA certificate. Ms Taylor has been involved with The Lilacs since it opened and gained experience in the day to day business whilst the home was managed by her mother. Ms Taylor has now had several years’ experience of running the home in her own right and managing the on-going care of the service users. Ms Taylor completed two Regulation 37 reports at the time of the inspection. These related to events that had taken place in recent months and the Commission had not been notified within the required timescale. In the service users’ surveys, the relative of one service user said that their general impression is that The Lilacs is a pleasant, well-run establishment. Another person said that Ms Taylor keeps them well up to date with what is going on. There was a file kept with feedback from relatives, such as thank you cards and compliments. Ms Taylor said that the daughter of a deceased service user sent flowers to the home each year on her mother’s birthday. New service users and their relatives were asked to complete a ‘Client Satisfaction’ questionnaire within two weeks of admission. The most recent questionnaire included the comment that the service user was ‘very happy’ and had ‘settled in well’. During 2005, service users had been given another questionnaire and a ‘Quality Questionnaire’ was sent out to GPs, District Nurses and other health care professionals. Positive comments were received about the home’s atmosphere and the helpfulness of staff. There was an Annual Development Plan for the period January 2005 – January 2006. A plan for the current year had not been produced. Ms Taylor said that it was the intention to do this, although there was no policy and procedure for quality assurance and improvement, setting out how and when this would be implemented in the home. Ms Taylor was also recommended to use the feedback gained from service users on a daily basis, in addition to other means such as the questionnaires. Ms Taylor said that the home had no involvement in the service users’ finances and personal money and that the service users receive support from their relatives with all their financial affairs. Relatives were billed for certain expenditures that are not covered by the fees, such as newspapers, hairdressing and chiropody. Lilacs (The) DS0000028354.V298583.R02.S.doc Version 5.2 Page 24 Staff members had signed a form to confirm that they had received a copy of the home’s policy on accepting gifts from service users. The home’s fire precaution systems were being regularly tested. Staff members had last received fire instruction during the period July – September 2006, although the actual date needed to be recorded on the instruction form in the fire log book. The home’s fire risk assessment had been reviewed during the last year. The hot water outlets used by service users had been fitted with temperature control valves. Radiator covers have been fitted in the en-suite areas of the service users’ rooms and in other locations where indicated by risk assessment. Assessments had also been undertaken in response to some recent hazards that could present a risk to service users. In June 2006 Ms Taylor had assessed the affect of hot weather on service users. The assessment had been reviewed following an increase in temperature in July and some further safety measures identified. Ms Taylor was regularly assessing the home environment. A record was kept each month of any new hazards that have been identified. This has included such things as the condition of the garden and the risk of slippery surfaces. One accident had been recorded during the last year. Ms Taylor had assessed a new service user’s use of bed rails, with guidance produced about their safety. The risk assessment recording format did not clearly state whether the risk was acceptable, or whether further safety measures were needed. Ms Taylor has confirmed the dates on which various facilities and items of equipment were last serviced. There was a contract in place for the disposal of clinical waste. Lilacs (The) DS0000028354.V298583.R02.S.doc Version 5.2 Page 25 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 x 3 x x x 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 2 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) DS0000028354.V298583.R02.S.doc Version 5.2 Page 26 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 OP30 Regulation 13(4) Requirement Each staff member must attend a certificated course in first aid Notifications made under Regulation 37 must be received by the Commission without delay Timescale for action 30/11/06 2. OP31 37 01/09/06 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 OP7 Good Practice Recommendations That the service users’ progress with meeting their objectives is better monitored and recorded on their personal files That the service users’ care plans better reflect the views of the service users and how they wish their care to be provided 2. OP7 Lilacs (The) DS0000028354.V298583.R02.S.doc Version 5.2 Page 27 3. OP9 That sufficient staff are trained to administer medication to ensure adequate cover for holidays and sickness. (Recommendation outstanding from the previous inspection). That a more individual approach is taken in the provision of activities within the home That the décor and the use of the bathroom is changed in order to create a more homely and domestic environment That the starting and finishing times of staff duties are consistently recorded That staff members are given the opportunity and training necessary to take further responsibilities in the home That staff meetings are held on a regular basis That staff members are given the opportunity to participate in more external training events That a policy and procedure on quality assurance is produced That the feedback gained from service users on a daily basis contributes to the home’s system of quality assurance That the risk assessment forms clearly state whether the risk is acceptable or whether further safety measures are needed 4. OP12 5. OP19 6. OP27 7. OP27 8. 9. OP27 OP30 10. OP33 11. OP33 12. OP38 Lilacs (The) DS0000028354.V298583.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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) DS0000028354.V298583.R02.S.doc Version 5.2 Page 29 - 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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