Care Home: Lillibet House

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What the care home does well The home understands the importance of having enough information when choosing a care home. Pre Admission documentation was in place, and was being used effectively for all prospective admissions to the home, to ensure their needs could be met efficiently and effectively in this home. The manager also gives potential residents and their families a welcome pack which contains a selection of the forms that people are expected to complete on admission. This gives them the opportunity to peruse these documents, and where appropriate, discuss and complete them at their own pace, with families, prior to admission. Care plans had been completed in sufficient detail to ensure that staff could provide consistent care. They included personal preferences and had been written in consultation with individuals and their representatives. Medication records were generally in order, contained the required entries and had been signed appropriately by staff. The service has a strong commitment to ensuring residents maintain personal relationships that are important to them. Suitable and meaningful activities are encouraged, and individual`s are assisted and supported to make personal choices. The complaints procedure is supplied to everyone living in the home. Staff working at the home understand the procedures for safeguarding, and know when incidents need to be reported externally. This home provides a clean, comfortable and homely environment for the people who live here. Individual rooms are furnished with personal possessions that reflect their personal life history. The manager has the required qualifications and experience to run this home. She is working continuously to make improvements to systems that may improve the lives of the people who live there. This service is proactive in it`s training, and facilitates staff to undertake external qualifications beyond basic requirements. Key workers have specific time rostered into their working hours to spend time with individuals. An AQAA was completed in August 2008, which recognises areas where improvements could be made. Many of the identified improvements had already been achieved at the time of this inspection. What has improved since the last inspection? The registration process for the manager in this home has recently been completed, and certificates displayed all reflect this appropriately. New wet room facilities are in the process of being installed. Some of which are already completed and in use. Since the last inspection new flooring has been laid throughout the ground floor, new furniture in the lounges and new commodes for the bedrooms have been purchased. The home`s call system has also been improved to include the garden and neck alarms provided for mobile residents. What the care home could do better: Internal auditing of medication could be improved. The manager appreciates the importance of meeting with the residents` relatives and advocates on a regular basis to share information, which may affect the lives of the people who live in the home. This process is not a regular occurrence at present, but the manager is aiming to introduce these meeting on a more regular programme in the near future. The manager in this home monitors the quality assurance, by internal auditing processes and by using questionnaires that are given to the residents and their representatives, and staff to complete. She is in the process of receiving this years completed responses from staff and residents, which will be formulated into a summary report in the near future. We look forward to seeing this. CARE HOMES FOR OLDER PEOPLE Lillibet House Lillibet House 65 De Parys Avenue Bedford Bedfordshire MK40 2TR Lead Inspector Mrs Louise Trainor Unannounced Inspection 19th February 2009 10:00 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 Lillibet House DS0000014927.V374101.R01.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. Lillibet House DS0000014927.V374101.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lillibet House Address Lillibet House 65 De Parys Avenue Bedford Bedfordshire MK40 2TR 01234 272206 01234 345545 member@lillibethouse.wanadoo.co.uk 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) Mrs Charlotte Chesyre Mrs Karen Thompson Care Home 30 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (30), of places Physical disability over 65 years of age (30) Lillibet House DS0000014927.V374101.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Including one resident under the age of 65 years, agreed with the CSCI. 15th November 2006 Date of last inspection Brief Description of the Service: Lillibet house is a residential home for older people situated in a residential street, not far from the centre of Bedford. The home was registered for 30 people users over 65 years of age, but specialised in caring for dementia, Alzheimers disease and minor physical disabilities. The home offers accommodation with 30 single rooms that corresponded to the required size, all with washing facilities. The rooms were fully furnished, but the home encouraged service users to bring in their own personal items, such as items of furniture, TV, music systems, ornaments and pictures. This three-storey building, has 12 rooms on the ground floor, 12 on the first and 6 on the top floor, it also offers pleasant communal areas that created a homely environment. There is a lift to all three floors. There are two steps connecting the new extension to the rest of the building and this does limit the access to this area for the less mobile of the service users. The home has ramps that allowed easy access to the garden for all, including the wheelchair users. The bathrooms and toilets are evenly positioned throughout the home and are equipped with appropriate facilities, rails, raising seats etc. An additional shower room on the ground floor provides choice to service users who preferred to shower rather than use the bath. At the front of the house, there is provision for 3-4 parking spaces. The back garden is secure, there is a brick wall protecting the grassed area in the middle and paving slabs surrounds it. The fees for this service range from £475.00 to £595.00 per week depending on the individual’s needs and funding source. Lillibet House DS0000014927.V374101.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 stars. This means the people who use this service experience excellent quality outcomes. This inspection was carried out in accordance with the Commission for Social Care Inspection’s (CSCI) policy and methodologies, which require review of the key standards for the provision of a care home for older people that takes account of service users’ views and information received about the service since the last inspection has been used and judgements made within the main body of the report include information from this visit. This was the first Key Inspection for this service since November 2006, when the home was rated a good service. It was carried out by Regulatory Inspector Louise Trainor on the 19th of February 2009, between the hours of 10:00 and 16:00 hours. During this inspection two of the people who live in this home were picked at random by the inspector to track. This involved examination of all documentation relating to their care, observations of care delivery and interactions with staff, and communication with the individuals themselves. A tour of the premises, and documentation relating to staff recruitment, training and supervision, medication administration, complaints and quality assurance were also examined during this inspection. The inspector also had the opportunity to speak informally with some of the staff on duty. The home manager, Karen Thompson, who had been appointed into post and registered since the last inspection, was present throughout the day, and all observations and findings were fed back to her periodically throughout the inspection, and on completion, when the Responsible Individual Mrs Charlotte Chesyre was also present. The inspectors would like to thank everyone involve for their assistance and support during this inspection. Lillibet House DS0000014927.V374101.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Lillibet House DS0000014927.V374101.R01.S.doc Version 5.2 Page 7 The registration process for the manager in this home has recently been completed, and certificates displayed all reflect this appropriately. New wet room facilities are in the process of being installed. Some of which are already completed and in use. Since the last inspection new flooring has been laid throughout the ground floor, new furniture in the lounges and new commodes for the bedrooms have been purchased. The home’s call system has also been improved to include the garden and neck alarms provided for mobile residents. 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. The summary of this inspection report can be made available in other formats on request. Lillibet House DS0000014927.V374101.R01.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 Lillibet House DS0000014927.V374101.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, 6 People who use this service experience good quality outcomes in this area. The home understands the importance of having enough information when choosing a care home. Pre Admission documentation was in place, and was being used effectively for all prospective admissions to the home, to ensure their needs could be met efficiently and effectively in this home. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: Information documents for this home are detailed, and reviewed on a regular basis. These are on display in the home and easily accessible by all residents and visitors to the home. During this inspection we viewed the pre admission assessments of two residents that are due to be admitted to the home within the next few days. Lillibet House DS0000014927.V374101.R01.S.doc Version 5.2 Page 10 These documents were clearly dated and signed, so it was very clear when these had been carried out, and by whom. These documents contained detailed information relating to individuals’ specific needs, and were then used to generate initial care plans following admission. We also looked at the files of three residents presently living in this home. Contracts of terms and conditions, which were clearly signed and dated, were present in all these files. Residents are very welcome to visit the home prior to making a decision about admission, however when this is not possible, families are encouraged to do so on their behalf. The manager also gives potential residents and their families a welcome pack which contains a selection of the forms that people are expected to complete on admission. This gives them the opportunity to peruse these documents, and where appropriate, discuss and complete them at their own pace, with families, prior to admission. People are encouraged to ask as many questions as they wish, and families are encouraged to become involved with the planning of care for their loved ones from these very early stages. The manager has previously worked with domiciliary care services, which has given her an invaluable insight into the problems and concerns people face when leaving their own homes and coming into residential care. Lillibet House DS0000014927.V374101.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 People who use this service experience good quality outcomes in this area. Care plans had been completed in sufficient detail to ensure that staff could provide consistent care. They included personal preferences and had been written in consultation with individuals and their representatives. Medication records were generally in order, contained the required entries and had been signed appropriately by staff. Internal auditing could be improved. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: During this inspection we asked to look at the care plans of four residents. Two were in relation to specific needs; one was for an indwelling catheter, and the second for the care of a resident being ‘nursed on bed rest’. The other two were relating to a variety of general aspects of daily living. Lillibet House DS0000014927.V374101.R01.S.doc Version 5.2 Page 12 The care documentation for the first resident, who had the catheter in situ, did identify this need, and a risk assessment was in place, however because the district nurse attends this resident on a daily basis, the need for the home to have their own ‘catheter care plan’ had not been recognised. However this had been addressed and put in place before we left this inspection. The care plan for the resident on bed rest was specific in detail. It was being reviewed regularly in line with GP visits, and included information about turning the resident, mouth care, and swallowing difficulties, as well as the use of bedrails, accompanied by an appropriate risk assessment. The other two files that we examined had numerous care plans in each. These ranged from personal care and activities to maintaining independence. Detail was very specific instructing staff how much assistance was required by the individual for each ‘need’ to be met. These were being reviewed on a regular basis to reflect any changes, and were detailed with information relating to individuals personal preferences, wishes and needs, Each file also contained numerous risk assessments, including moving and handling, nutrition, falls and mobility, leaving the home premises, smoking, and a variety of other potential hazards. Dependency rating scales were completed for each individual, as were Mental Capacity assessments and mini mental assessments. Since the previous inspection the call system had been improved to include the garden and neck alarms provided for mobile residents. There was also evidence in the files that we looked at, to suggest that residents and their relatives were involved in the information gathering and care planning processes, in particular providing life history information, which enables staff to, understand the individual and personalise these documents. We examined the Medication Administration Record (MAR) sheets for ten of the residents presently living in the home. These were generally well completed with signatures and omission codes where necessary. We did however find some of the medication that was supplied in boxes and not in the blister packs somewhat difficult to reconcile. Through discussion with the home manager, we believe the carrying forward of medication from month to month may be partially the cause of this problem. The manager had addressed reviewing this process before we left this inspection, and also agreed that the auditing process was in need of review. We are confident this will happen with immediate effect. Controlled drugs (CD)s were stored appropriately in this home, and remaining stocks and records of CD’s reconciled accurately. Lillibet House DS0000014927.V374101.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 People who use this service experience excellent quality outcomes in this area. The service has a strong commitment to ensuring residents maintain personal relationships that are important to them. Suitable and meaningful activities are encouraged, and individual’s are assisted and supported to make personal choices. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: When residents are admitted to this home, families are encourage to write a brief resume of the individuals life history. The ones that we looked at included details of previous careers and lifestyles. Loved ones and ‘lost ones’, and any life events that may have had an impact on the individual either in a positive or negative way. The staff then use this information to help build a profile of social interactions or activities that the individual may particularly enjoy or benefit from. Lillibet House DS0000014927.V374101.R01.S.doc Version 5.2 Page 14 There is an activity programme situated in the main corridor, this identifies what activities are available each day of the month. It included group activities such as bingo and board games, a library visit, various music and movement sessions, quizzes, a Tai Chi class, a visiting pianist and outings to events such as tea dances and war celebration evenings in the local town centre. On the day of the inspection there was a movie afternoon planned. The home has recently purchased a large projector and screen, which, when set up, and the lights dimmed creates the atmosphere of a cinema. This was far more effective than putting a DVD on the television. Healthcare sessions such as chiropody visits, optical testing, hairdressing and hand and nail care are also integrated into this programme. We visited the kitchen area. The fridge / freezers and the pantry were all well stocked with both fresh and dry store produce. The cook told us that she orders the stores in the home, including, a green grocery delivery three times a week, a butchers order at least once a week, and a regular fresh fish delivery. This home offers a variety of nutritious meals that are presented and served in an appetising way. On the day of the inspection there was a choice of beef burgers in onion gravy or spam salad followed by a fruit salad and cream or yogurt. There is presently a four week rolling menu plan in place. This home has an open visiting policy, which allows relatives and visitors to call in at any time they like. The manager advised us that there are occasions when a relative may stay for a meal with their loved one, however this is not a regular event. Lillibet House DS0000014927.V374101.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 People who use this service experience good quality outcomes in this area. The complaints procedure is supplied to everyone living in the home. Staff working at the home understand the procedures for safeguarding, and know when incidents need to be reported externally. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: This home has a complaints policy, which is on display and easily accessible to residents and visitors to the home. This document details expected timescales for responses, and guidance for any complainant that remains dissatisfied with investigatory outcomes. We spoke to the Responsible Individual about complaints in the home, and she advised us that they had not received anything in writing which required investigating since the previous inspection. Safeguarding issues were also clearly recorded, and reported appropriately. There had been one referral made since our last visit, which we were already aware of. This had been managed appropriately. Lillibet House DS0000014927.V374101.R01.S.doc Version 5.2 Page 16 Documentation indicates that the manager liaises with the safeguarding team as and when necessary, and the home is also embracing the Mental Capacity Act including the Deprivation of Liberty. The whistle blowing procedure is also clearly displayed. Lillibet House DS0000014927.V374101.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 People who use this service experience good quality outcomes in this area. This home provides a clean, comfortable and homely environment for the people who live here. Individual rooms are furnished with personal possessions that reflect their personal life history. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: This home provides a clean, comfortable and safe environment for the people who live here. On the day of the inspection the home was warm and homely, and generally free from offensive odours. Lillibet House DS0000014927.V374101.R01.S.doc Version 5.2 Page 18 The reception of the home is welcoming, with information leaflets, posters of forthcoming social events, menus, and friendship / advocacy organisation details to name but a few. Since the last inspection new flooring has been laid throughout the ground floor, new furniture in the lounges and new commodes for the bedrooms have been purchased. Corridors display photograph collages of past events, and in house craftwork. There are also plants and ornamental displays on shelves throughout the building. Communal lounge / dining areas, on the ground floor are spacious and comfortable, with ample seating for those residents who wish to use this facility. Alternatively residents are free to spend time in their rooms or utilise the quiet lounge on the upper floor if they prefer. Individual rooms are decorated according to individual resident’s taste, and furnished with photographs and personal assets that reflect their life history to some degree. Bathing facilities were clean and well maintained, and new wet room facilities are in the process of being installed. Some of which are already completed and in use. The gardens to the rear of this property are mainly laid to lawn. They are accessible to wheelchair users; therefore in the better weather all residents will have the opportunity to benefit from this facility. Lillibet House DS0000014927.V374101.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 People who use this service experience excellent quality outcomes in this area. This service is proactive in it’s training, and facilitates staff to undertake external qualifications beyond basic requirements. Key workers have specific time rostered into their working hours to spend time with individuals. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: This home is fully staffed, and the Responsible Individual informed us that “In the eight years that the registered provider has owned Lillibet House, the home has been fully supported by its’ staff and there has not been a need to employ agency staff for any reason”. Staffing levels in this home are good. With five staff plus the manager on duty during the day, and three staff plus a senior on call during the night. The home operates a ‘clocking in’ system, for staff coming on duty, and also provides a monitoring system for half hourly checks, carried out throughout the home during the night shift. Lillibet House DS0000014927.V374101.R01.S.doc Version 5.2 Page 20 The level of staff retention in this home is good, with over 70 of staff having worked in the home for more than twelve months, and more than 50 for more than two years. During this inspection we looked at the files of three staff, two of which had been appointed since the previous inspection. Each file contained fully completed application forms, appropriate references, Criminal Record Bureau (CRB) checks, various forms of identification and contracts of terms and conditions of employment. There were also letters in files, relating to issues, which needed to be addressed with individual members of staff. This clearly indicated that the manager takes the staff conduct and responsibilities very seriously, and manages them efficiently and effectively. Evidence in each file indicated that all staff attend an induction programme when they commence employment with this company, and their practices are then monitored by periodic spot checks, whilst carrying out specific tasks of care. Staff training is monitored very closely in this home. The manager has an electronic spreadsheet, which is updated each month. This identifies what training each member of staff has done, training that is due for a refresher course and when future courses are booked for each individual, allowing the manager to monitor this process at a glance and ensure training needs are fulfilled. The home has recently introduced an in house training programme, whereby one particular subject is offered each month, with sufficient sessions for all staff to attend. External trainers are being invited into the home to deliver this programme. On the day of the inspection, one of the Falls Awareness sessions was taking place. This was the chosen topic for February, and it was hoped that by the end of the month everyone would have attended. At present 80 of staff have either completed or are working towards NVQ levels 2/3. The Responsible Individual told us that training is viewed with such importance by the provider, that they pay staff to attend all training days, which presently stands at twelve subjects. Lillibet House DS0000014927.V374101.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 People who use this service experience excellent quality outcomes in this area. The manager has the required qualifications and experience to run this home. She is working continuously to make improvements to systems that may improve the lives of the people who live there. The home has a comprehensive range of policies and procedures to promote and protect the residents and the employees’ health and safety. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: Lillibet House DS0000014927.V374101.R01.S.doc Version 5.2 Page 22 The registration process for the manager in this home has recently been completed, and certificates displayed all reflect this appropriately. She is enthusiastic and confident in her role, she is an experienced manager and has worked hard since coming into post to maintain and improve standards and systems throughout the home, and the staff appear to have supported her. She is quick to address any issues identified, which are in need of action. For example during this inspection we indicated that the auditing process for MAR sheets was not robust enough. By the end of the inspection she had already identified how this was could to be addressed. We also identified the need for one particular care plan relating to a catheter, and this was being written as we completed the inspection. Since this inspection took place, we have received a copy of a letter sent to the Provider from Bedford Social Service Quality Assurance Review Manager. This was commending, Karen Thompson, the home manager, on her quick response to suggestions and the introduction of new ideas of improvement in the home, such as the introduction of Afro Caribbean meals, and a ‘friend for life’ visitor scheme. An AQAA was completed in August 2008, which recognises areas where improvements could be made. Many of the identified improvements had already been achieved at the time of this inspection. She appreciates the importance of meeting with relatives and advocates on a regular basis to share information or forthcoming changes, which may affect the lives of the people who live in the home. This process is not a regular occurrence at present, but the manager is presently working to introduce these meetings on a more regular programme, however initial attempts have not been welcomed as enthusiastically as had been hoped. We looked at health and safety documentation, including the fire log and maintenance records. There was evidence to indicate that fire call points and the emergency lighting were being tested on a regular basis and water temperatures tested and recorded throughout the home on a monthly basis monthly, and in the kitchen daily to ensure legionella prevention. Fire drills are also ‘timed’ on a regular basis, and when the weather improves a full evacuation will be monitored. Maintenance issues are being addressed in a timely fashion. Supervision records were examined, and indicated that staff are receiving regular 1:1 sessions with a senior line manager. The manager has involved her senior carers in this process, by allocating them a team of staff to supervise. The seniors are issued with a supervision guidance pack, which helps to ensure that all have the same approach to this process. Staff meetings are also seen as an important means of information sharing amongst the team, and an opportunity for staff to share ideas, and discuss areas where they would like to see change. Lillibet House DS0000014927.V374101.R01.S.doc Version 5.2 Page 23 Accidents and incidents are being recorded and reported appropriately, and where necessary safeguarding referrals are being submitted. The manager in this home monitors the quality assurance, by internal auditing processes and by using questionnaires that are given to the residents and their representatives, and staff to complete. She is in the process of receiving this years completed responses from staff and residents, which will be formulated into a summary report in the near future. The Responsible Individual is also the owner of this home. She spends a lot of time at the home, and is generally visible and accessible to staff, residents and relatives. To date, because her visits to the home are so regular, these have not been recorded in a formal report. However following a discussion on this matter, she has agreed to keep a file, which reflects any findings from her visits. This will remain in the home and be available for inspection. This home does not hold the role of appointee for any of its’ residents, however small amounts of ‘pocket money’ are held in safe keeping for about ten of the residents. We looked at the records for four of these personal expenditure accounts. Funds remaining all corresponded correctly with the account records, and all transactions were clearly signed and dated appropriately. Receipts were present for all those purchases and transactions that we checked. Lillibet House DS0000014927.V374101.R01.S.doc Version 5.2 Page 24 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 4 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 4 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 X 3 4 3 3 Lillibet House DS0000014927.V374101.R01.S.doc Version 5.2 Page 25 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. 2. Refer to Standard OP9 OP14 Good Practice Recommendations The home should consider reviewing the auditing process for their medication system. The home should consider alternative ways of offering choices to residents with more severe cognitive impairment. Lillibet House DS0000014927.V374101.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Lillibet House DS0000014927.V374101.R01.S.doc Version 5.2 Page 27 - 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. 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