Inspection on 08/06/05 for The Lilacs

This inspection was carried out on 8th 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 11/03/08

The Lilacs 31/08/06

The Lilacs 12/12/05

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 Unannounced 8th 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) D51_S28354_LILACS(THE)_V178066_080605Stage0.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Lilacs (The) Address 2a Lickhill Road Calne Wiltshire SN11 9DD 01249 821422 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 Ronald Michael Taylor Ms Trudy Jane Taylor Care Home 9 Category(ies) of OP Old Age (9) registration, with number of places Lilacs (The) D51_S28354_LILACS(THE)_V178066_080605Stage0.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 3rd February 2005 Brief Description of the Service: The Lilacs is a purpose built care home for up to nine older people. The home is situated in a residential area of Calne, approximately ten minutes’ walk from the town centre. There are five single bedrooms and one double room on the ground floor. There is a staircase to two bedrooms on the first floor. The rooms have en-suite facilities. The owner, Mr R. Taylor and the manager, Ms T. Taylor, also have their accommodation on the first floor. The communal space consists of a large open plan lounge and dining room. The Lilacs is the service users’ permanent home for as long as this remains appropriate to their needs and wishes. 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. Lilacs (The) D51_S28354_LILACS(THE)_V178066_080605Stage0.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection started at 10.30am and took place over five hours. There were six service users in the home. Each service user, the manager and a staff member were spoken with. The service users were met with in the lounge and in their own rooms. A relative was visiting during the morning and spoken with. A number of the home’s records were looked at, including three of the service users’ care records. What the service does well: What has improved since the last inspection? What they could do better: There should be a more pro-active approach to staff training and to ensuring that staff members have the information they need about the service users’ needs and preferences. A number of the ‘off the shelf’ type written policies and procedures need to be looked at and made more relevant to the home. Matters relating to the recruitment of new staff need to be fully documented in the home, to ensure that service users are protected. Lilacs (The) D51_S28354_LILACS(THE)_V178066_080605Stage0.doc Version 1.30 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) D51_S28354_LILACS(THE)_V178066_080605_Stage4.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) D51_S28354_LILACS(THE)_V178066_080605_Stage4.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) 3 and 5 The assessment of a new service user does not ensure that all appropriate information is available about that person’s care needs and preferred routines. Prospective service users can visit and spend time in the home before making a decision to stay. EVIDENCE: One service user has moved into the home since the last inspection. An assessment form had been used at the time of the admission. However, some sections of the form, e.g. ‘Elimination’, ‘Sleep’ and Dietary preference’ had not been completed. Information about personal preferences in activities and daily routines was also not recorded. The service user in question was staying in the home for respite care. She had previously visited the home and a decision was shortly to be made about a permanent move. Lilacs (The) D51_S28354_LILACS(THE)_V178066_080605_Stage4.doc Version 1.30 Page 9 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 and 10 The service users’ individual care plans are kept under review, but do not necessarily reflect their current needs. Other guidance for staff gives a more up to date picture of a service user’s physical care needs. Service users are encouraged to participate in the planning of their care and information is readily accessible to service users and staff. Service users’ are treated in a respectful manner and benefit from the home’s ‘code of conduct’ for staff. EVIDENCE: Individual care plans are available in the form of a ‘Service User Plan of Care’ and a second care plan, which focuses on the physical support that is required from staff. Some of the plans were written in 2003. They had been added to following review since then, but the original goals identified in the ‘Service User Plan of Care’ had not been updated. Copies of the ‘Service User Plan of Care’ are kept in the service users’ rooms. The other care plan forms are kept in the office and used to record the areas in which a service user requires physical support. Some of the care plan forms have been replaced by more up to date guidance although there was no clear separation within the files. Lilacs (The) D51_S28354_LILACS(THE)_V178066_080605_Stage4.doc Version 1.30 Page 10 Service users expressed satisfaction with the support that they receive and spoke very positively about their relationships with individual staff. Staff members sign a ‘code of conduct’ when starting in the home and were observed to be responding to service users in a friendly and respectful manner. Lilacs (The) D51_S28354_LILACS(THE)_V178066_080605_Stage4.doc Version 1.30 Page 11 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 and 15 Service users enjoy a relaxed and informal atmosphere, with encouragement to keep in contact with relatives and outside interests. The service users benefit from a staff team which provides support with recreational activities, although the service users’ individual preferences and social needs are not well identified. The meal arrangements are of a good standard and the preparation of special diets has improved since the last inspection. EVIDENCE: 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 service users go to clubs in Calne each week, although attendance at one club was cancelled on the day of the inspection. In the lounge, service users were watching television and two service users were reading newspapers, which are provided by the home. Some service users said they prefer the privacy of their own rooms. A statement about weekly activities has been produced. This includes the provision of afternoon activities such as bingo and sing-a-longs. Given the service users’ different interests and dependency levels, a high priority should Lilacs (The) D51_S28354_LILACS(THE)_V178066_080605_Stage4.doc Version 1.30 Page 12 be given to support with individual activities as part of a service user’s care plan. 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. Food for two service users is separately prepared using a blender. Following discussion at the last inspection, advice has now been obtained from a dietician about these special diets. Service users did not know what was to be served for lunch, but were complimentary about the content of the meals. The weekly menus showed an interesting and varied range of meals being served. Lilacs (The) D51_S28354_LILACS(THE)_V178066_080605_Stage4.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 and 18 Service users and their representatives have information about what to do if they have complaint and they are encouraged to raise any concerns on an informal basis. The home’s policies and procedures provide some safeguards for service users although they do not give staff information about the local arrangements for the protection of vulnerable people. EVIDENCE: A complaints procedure is on display in the home and a suggestions box is available. A ‘record of complaints’ file is kept in the office and there were no reports of any complaints being made during the last year. The service users spoken with had not had reason to make a complaint. They felt that issues could be readily raised with the manager if needed. There was a written statement for staff about the importance of responding to concerns about abuse and what to do if abuse is suspected. This was taken from a care home management pack and does not reflect the arrangements that are made locally for the protection of vulnerable adults. The statement was not included in the information that is given to staff members. A new staff member said that abuse awareness was included in the T.O.P.S.S. induction programme that she was currently undertaking. Lilacs (The) D51_S28354_LILACS(THE)_V178066_080605_Stage4.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 and 26 Service users appreciate their surroundings, both internal and external. Service users benefit from the layout of the home and the attention that is given to maintaining a comfortable and well maintained environment. However a delay in the fitting of radiator covers is a matter of concern. EVIDENCE: Most of the accommodation is on the ground floor and the service users’ rooms are in close proximity to the communal rooms and other facilities. There is a spacious hall, which allows plenty of room for zimmer frames. However, handrails are not fitted and the need for these should be kept under review. Radiators are uncovered. The covers have been bought but not yet installed. A timescale (by 31.05.05) that was identified in the provider’s action plan following the last inspection has not been met. A new timescale was confirmed in an immediate requirement notice. Service users were using the patio chairs that are provided in the garden and there is convenient access from the home. The home looked clean and there were no unpleasant odours. Lilacs (The) D51_S28354_LILACS(THE)_V178066_080605_Stage4.doc Version 1.30 Page 15 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) 29 and 30 Service users benefit from the induction that new staff members receive. However, a lack of clarity about the recruitment arrangements raises concerns about how well the service users are protected. Training activities are arranged which help staff to support service users in accordance with good practice, although a more pro-active approach to training would be beneficial. EVIDENCE: Three staff members came on duty at different times and were met with. Staff members are mostly part-time and work alongside the manager. Service users said that staff were friendly and there were compliments about the mature approach of individual staff members. A new member of staff described her induction, which included working alongside the manager and undertaking a T.O.P.S.S. accredited induction / foundation programme. The records for two new staff members showed that two written references and proof of identity had been obtained. An outside body is used for the carrying out of P.O.V.A. and C.R.B. checks. The manager said that P.O.V.A. checks had been processed and were satisfactory for the two new staff members, although their C.R.B. disclosures had not yet been received. There was no documentation available in the home about this or the decision made that the staff members could start working under these circumstances. An immediate requirement notice was issued in connection with this. Lilacs (The) D51_S28354_LILACS(THE)_V178066_080605_Stage4.doc Version 1.30 Page 16 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 and 37 Service users benefit from the manager’s personal commitment to training and to developing her skills in the running of the home. The approach of the manager is promoting good relationships within the home. A more pro-active and timely response is needed to matters arising out of inspections. EVIDENCE: The manager is near to completing NVQ level 4 in care and has arranged to follow this with attendance on the Registered Managers Award course. There has been a dependence on ‘off the shelf’ type written policies and procedures. These should be personalised for use in the home and the manager is making gradual progress with this process. Following previous inspections, the manager and registered provider have not, within the identified timescale, provided the Commission with an action plan in response to the inspection requirements and recommendations. Lilacs (The) D51_S28354_LILACS(THE)_V178066_080605_Stage4.doc Version 1.30 Page 17 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 x x 2 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 x 28 x 29 2 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 x 3 x x x 2 x Lilacs (The) D51_S28354_LILACS(THE)_V178066_080605_Stage4.doc Version 1.30 Page 18 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 3 Regulation 14 Requirement A full assessment must be undertaken of a new service users needs and a copy of the assessment kept in the home The homes policies and procedures on abuse must include information about the local arrangements for the protection of vulneralbe adults and the appropriate contact details. Each member of staff must be aware of this information Covers must be fitted to radiators A record must be kept in the home of the P.O.V.A. and C.R.B. checks that have been carried out in respect of staff. Any decision made about a member of staff being able to start without a C.R.B. disclosure must be fully documented in the home Timescale for action FROM 09/06/05 BY 30/06/05 2. 18 13(6) 3. 4. 19 29 13(4) 19 BY 30/06/05 BY 15/06/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Lilacs (The) D51_S28354_LILACS(THE)_V178066_080605_Stage4.doc Version 1.30 Page 19 No. 1. 2. Refer to Standard 7 12 Good Practice Recommendations That the service users care plans are rewritten at least annually That the service users individual preferences and social needs are clearly identified in their care plans and that this information is used to develop a new and more individual programme of weekly activities That service users are informed of the days menu and given the opportunity to choose an alternative dish to that on the set menu That work continues on the development of written policies and procedures that are relevant to the home and provide appropriate guidance for staff 3. 4. 15 37 Lilacs (The) D51_S28354_LILACS(THE)_V178066_080605_Stage4.doc Version 1.30 Page 20 Commission for Social Care Inspection 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) D51_S28354_LILACS(THE)_V178066_080605_Stage4.doc Version 1.30 Page 21 - 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!