Care Home: Lillibet Lodge

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What the care home does well The home had maintained good outcomes for people who use the service. The staff has maintained good working relations with the people who use the service and their family members, and relevant professionals who had been useful for appropriate care delivery. It was observed during the interaction with the people who use the service on this inspection that, they were neatly dressed and appeared clean. During the inspection we spoke to 3 visitors to the home, whom have said they were happy with the staff and care provided by the home. The premises were clean and tidy throughout and all of the people who use this service appeared to enjoy the variety of meals. What has improved since the last inspection? Since the last inspection a lot of redecoration and refurbishment has taken place this includes the bathroom/ shower, the laundry and the hairdressing and chiropody rooms. New chairs and commodes have been supplied. Also a stair lift has been fitted. CARE HOMES FOR OLDER PEOPLE Lillibet Lodge 6 Rothsay Road Bedford Bedfordshire MK40 3PW Lead Inspector Mr Pursotamraj Hirekar Unannounced Inspection 5th August 2008 12:55 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 Lodge DS0000014928.V369686.R03.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 Lodge DS0000014928.V369686.R03.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lillibet Lodge Address 6 Rothsay Road Bedford Bedfordshire MK40 3PW 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) 01234 340712 01234 344929 christina@lillibetlodge.wannadoo.com Mrs Charlotte Chesyre Vacant Care Home 25 Category(ies) of Dementia - over 65 years of age (25), Old age, registration, with number not falling within any other category (25), of places Physical disability over 65 years of age (25) Lillibet Lodge DS0000014928.V369686.R03.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is permitted to accommodate up to four service users in the category DE in the age range 55 -64 years. Date of last inspection Brief Description of the Service: The home is situated in a nice, quiet area of Bedford, not far from the town centre and with easy access to the riverside. The building provides accommodation in a homely environment, a large lounge accommodated a large number of service users who enjoyed company and there were, in addition, two smaller lounges for privacy for those who wanted a quiet corner. The home had a lift connecting the upper lounge and floors. A lower lounge was accessible down four small steps, chair lift or by walking through the garden. The garden was mainly paved and is used by service users even in colder weather. Lillibet Lodge cared for 25 service users with dementia and general age related problems. The minimum fee is £457 and the maximum was £595. Lillibet Lodge DS0000014928.V369686.R03.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 2 stars. This means the people who use this service experience good quality outcomes. This is the report of the unannounced inspection carried out on 05/08/08 over 7 hours 35 minutes by Pursotamraj Hirekar. The registered provider and senior carer coordinated the inspection. The method of inspection included study of care plans, risk assessments, staff recruitment records, staff deployment duty rota, relevant care delivery documents, discussions with registered provider, staffs on duty, 3 visitors of people using the service, conversation with people using the service and partial tour of the building. The pre – inspection survey of people who use this service and staff. The annual quality assurance assessment (AQAA) – provider’s self-assessment and in response to the inspection feedback session, the documentary evidence sent in by the registered provider, post this inspection is included for analysis and preparation of this report as well. What the service does well: What has improved since the last inspection? What they could do better: Lillibet Lodge DS0000014928.V369686.R03.S.doc Version 5.2 Page 6 The registered provider must notify CSCI under regulation 37 of any injury to people using the service. The provider must ensure that the medication storage is maintained with right temperature and records maintained. The registered provider must update and always make available and keep all the staff recruitment records at the home. The manager should update her knowledge of the requirement to notify accidents under regulation 37 to protect people using the service from potential risk of harm. The registered provider should evidence that the staff are regularly supervised as required to improve their capacity and quality of care delivery in the best interest of people who use the service. The registered provider should always ensure that the home’s policies and procedures were regularly updated and staff are made aware of the changes that impact upon the care provision and delivery. The registered provider should ensure that the broken cot is replaced for people who use the service without delay. The registered provider should ensure that the staff have clear guidance on how much to give, when and why for the medicine labelled ‘as required’ or when necessary’. The registered provider should ensure that each individual’s care plan was written with sufficient details including scoring of special risk factors and guidance for staff to understand and provide appropriate care. 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 Lodge DS0000014928.V369686.R03.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lillibet Lodge DS0000014928.V369686.R03.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessments were completed to assess the care needs of people considering using the service. EVIDENCE: The statement of purpose is comprehensive and reflects the current services, offered to prospective and existing people who use the service. The process for moving into the home, facilities, and choices is detailed including the complaints process. A copy of the statement of purpose was made available at the reception of the home. On this inspection, 4 people who use the service were case tracked, The care file for the people contained comprehensive assessments that were carried out to ensure the staff are able to meet care and support needs of that individual. Lillibet Lodge DS0000014928.V369686.R03.S.doc Version 5.2 Page 9 The people living in the home have diverse needs and diagnoses, and staff training information matrix presented by the provider showed that the staff team had the necessary skills and qualifications to meet their needs. The contracts for these people were not made available during the inspection. However, during the inspection feedback session with the provider, she said that the contracts have been prepared but was at another home. Post this inspection the provider has written to us with sample evidence of contracts and further stated that one person’s family has refused to sign, as they seems to believe, it makes them liable should the social service funding cease. Intermediate care was not provided in the home at the time of this inspection. However, with regard to one person the discussion between the provider and social services were ongoing to determine the nature of the placement. Lillibet Lodge DS0000014928.V369686.R03.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. 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 using available evidence including a visit to this service. The staff and the people using the service have good working relationship. The health and personal care needs of people who use the service were met as set out in their care plan. EVIDENCE: On this inspection four care plans were chosen at random to be examined and we found that, the home had carried out needs and associated risk assessments and developed care plans that included information on personal hygiene, food, nutrition, mobility, sleeping, elimination, vision, bowels, foot care, skin integrity, history/risk of falls, daily routines, social contacts, likes to do, does not like to do, cultural and spiritual needs as well. However, all the plans were not written in sufficient details there were areas that needed improvement to ensure that anyone working at the home could understand and provide the necessary care. For example one person was scored 5 and Lillibet Lodge DS0000014928.V369686.R03.S.doc Version 5.2 Page 11 another person was scored 13 for special risk factors and it was not clear how these scores have been arrived at and how these scores were used in the preparation of care plans. This was discussed with the provider during the inspection feedback session, the provider confirmed in writing to us that, senior staff have now updated those plans and have included the missing information missing and they have been made aware of the need to ensure that this is an area that is not omitted in future care planning. The care plans have been reviewed and updated to reflect the changing needs of the people who use the service. For example three people were risk assessed for falls and bedrail assessment and appropriate action was taken. It was noted that the Administration of Medication Records (MAR) were well kept and clearly provided the necessary audit trail to determine when the medication had been received into the home and when and by whom it had been administered. The MAR sheets for the four people using the service case tracked. We were able to reconcile the medications, including the controlled drugs. The staff that were giving medication had been trained to do so. However, with regard to medicine labelled ‘as required’ or ‘when necessary’ there were no clear instructions on how much to give, when and why. For example a person was administered parecetomol with no clear instructions on how much to give, when and why. And another person’s MAR sheet stated senna tablets 7.5mg take one or two at night when required, but there was no clear instructions on why, and the medicine administered did not match with the bowl movement record of the person. In response to the discussion with the provider during the inspection feedback session, the provider post this inspection confirmed in writing with us that all care plans have been updated to reflect PRN medication requirements and to give care staff clear guidance as to when and why medication is to be given. Also, a refused medication monthly audit is now in place and clear instructions have now been filled in on the back of MAR sheets and cross referenced where necessary with medication care planning for medicated creams as well. We noted that staff treated people living and visiting the home with respect. Personal care was carried out in people’s own bedrooms and all staff knocked before entering a person’s private space. Storage of medication was noted to be in a locked trolley, that was stored on the ground floor of the home and the controlled drug cupboard was on a wall. However, there was no maintenance of temperature for the medicine and controlled drugs as well. This was brought to the attention of the provider, who said that, this would be looked into and appropriate records maintained. The provider has confirmed in writing with us post this inspection that the temperature now monitored and recorded daily. Lillibet Lodge DS0000014928.V369686.R03.S.doc Version 5.2 Page 12 All of the four files of the people we case tracked, indicated that they had seen various health care professionals such as doctors and community nurses and had access to opticians, chiropodists and dentists as needed. However, a family member of a person reported that the hearing aid of their relative was broken and they were without it for 10 days, they had to make an appointment themselves with the hospital to get the hearing aid fixed. The home has told us that they had taken the hearing aid in for repair but the hospital had not carried out the repair until the relative had taken the person to the hospital themselves. Another visiting family member said that, in their opinion, sometimes there seems not to be enough staff on duty. The home has reassessed the staffing levels and has told us that they have increased them. It was noted that the people were dressed in clean clothes and that they were treated as individuals. Throughout the inspection staff were seen talking to people and treating them with dignity; this was particularly noticeable at mealtimes, leisure activity and medication times. One of the visiting family member said ‘this is a clean place, staff are good’ and another visiting family member said ‘they are nice people, they look after him well’ and the people who use the service said ‘ nice place I am happy’. Lillibet Lodge DS0000014928.V369686.R03.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is committed to and promotes good relationships with people who use this service. The menu was varied and staff are sensitive to the needs of those people who find it difficult to eat and give assistance with feeding. EVIDENCE: On the day of the inspection, the activity coordinator had organised activities, which were specific to individual needs. The activity coordinator appeared to have the appropriate skills to involve people who found it difficult to concentrate in something that stimulated them, both mentally and physically. Two people using the services were actively engaged and appeared to have enjoyed the activity. A couple of others were engaged in the hairdressing. People using the service had the opportunity to meet with their visitors in the lounge or in their own rooms. Visitors reported that they were welcomed into the home, could come and go as they pleased and felt part of the home. During the inspection 3 visitors (families) were spoken to. A daughter visit Lillibet Lodge DS0000014928.V369686.R03.S.doc Version 5.2 Page 14 every day to see her mother and said ‘it is a clean place, staff are good, this home is a better home than the previous one, but need more staff to attend people all the time’. The other two visitors have echoed the same feeling and satisfaction as well. People were able to make choices about, when they got up and what they ate. For example on person choose not to go to bed before 8.00pm and two people were supported to attend church. Staff spoken to have confirmed that the people are encouraged to have their choices. Observation of the lunchtime meal showed it to be unrushed and enjoyed by the people using the service. Nutritional risk assessments were seen within the people’s care records. The menu plan appeared to provide people with a balance nutritious diet, drinks were served with the meal, and people were encouraged to eat in the dining room and lounge as well. Staffs are sensitive to the needs of those people who find it difficult to eat and give assistance with feeding. The people expressed satisfaction with the quality, quantity, and presentation. For example one person, using the service spoken to, have said that ‘lunch has been always good, staff are polite and feed the people who cannot eat on their own’. Lillibet Lodge DS0000014928.V369686.R03.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 and 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home’s complaints policy and procedure ensured the people who use the service were protected from abuse. EVIDENCE: The service had a complaints procedure. It gave simple guidance on how to make a complaint and gave timescales in which the home would respond to a complainant. People using the service spoken to knew how to put across a view or a concern to staff. One person using the service said, “I am happy here, staff are good”. Another person said ‘I have not experienced any problems or had any concerns about living at the home’. Staff demonstrated a good awareness of their role, responsibility, and procedures they are required to follow in relation to any allegation or suspicion of abuse. Staff training records also showed that staff at the home had received training in this area. Staff were confident to whistle-blow on bad practice and confirmed that the manager or the provider is available at all times should any concerns arise. The manager was not available to discuss her understanding in this area and that was aware of the local guidance in reporting procedures. The home has had several incidents / accidents involving people using the services with regard to falls and a couple of these falls also had interventions from the nurse but were not notified to the commission. Lillibet Lodge DS0000014928.V369686.R03.S.doc Version 5.2 Page 16 However, the home has carried out risk assessments and had developed appropriate action plan. For example, bed rails were provided for one person and for another person bed sides and cot sides were provided. The registered provider stated that the home had not received any complaints since the last inspection. This was further mentioned in the annual assessment document received from the provider prior to the inspection. Lillibet Lodge DS0000014928.V369686.R03.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, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service was clean, tidy, and free of any offensive odours. The environment is well maintained for the people who use the service to live in. EVIDENCE: A tour of the premises was undertaken all the communal areas were found to be clean, tidy, and free of any offensive odours. People’s rooms that were seen contained personal items, photographs, pictures, and furniture. Grab rails were also in place to assist with their mobility. The rooms were clean and tidy and no odours were detected. Lillibet Lodge DS0000014928.V369686.R03.S.doc Version 5.2 Page 18 One person’s bed leg was broken and was temporarily supported by container box. This was discussed with the provider during the inspection feedback session. The provider had confirmed in writing to us, post this inspection that the bed has been ordered for replacement. Information received from the provider prior to the inspection stated that the home has a rolling programme of maintenance and decoration of the bedrooms and communal areas. The information further stated that the home complies with all the health and safety requirements, including fire safety as well. For example, the bathroom, laundry room, hairdressing, chiropody, and showers were refurbished and stair lift fitted since the previous inspection. Lillibet Lodge DS0000014928.V369686.R03.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 and 30 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Between them, the staff had the necessary training and experience to meet the assessed needs of the people living in the home. However, the service needs to make sure that all the required staff records are made available at the home at all times for inspection. EVIDENCE: The staff are deployed to satisfactory levels and the staff rota reflected this. However, a couple of visitors spoken to during this inspection said that sometimes staff was not available when required. This was discussed with the provider during the inspection feedback session and the provider has confirmed with us in writing post this inspection that staffing levels have been reviewed and increased on all day shifts. There will be a 3 month review to further assess resident care and pressure on staff within the home and the need, if any, of a further increase. The interaction of staff with the service users was good, showed there was a good rapport both verbal and non-verbal communication used and a good understanding. During this inspection six staff members’ profiles were seen and we found that, the home’s recruitment procedure appeared inadequate from the records that Lillibet Lodge DS0000014928.V369686.R03.S.doc Version 5.2 Page 20 were made available on the inspection, with regard to their statutory checks prior to employment. These findings were discussed with the provider during the inspection feed back session. The provider stated that all the necessary recruitment procedures have been followed and some of the documentation was at the organisations head office in St Albans where she was in the process of carrying out an audit. She has since confirmed this in writing and that the documents are now available at the home and a sample of them have been sent to us for verification. She further confirmed that this would be continued to be reviewed as part of the internal audit. The information received from the provider before this inspection stated that the service had the required percentage of staff with NVQ level 2 or above qualification. Staff training records showed that staffs have attended a variety of training that included dementia awareness, infection control, medication, safeguarding, first aid, food hygiene, moving and handling, and fire safety. Staff confirmed that the home supported, them to attend training courses. Lillibet Lodge DS0000014928.V369686.R03.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): 31,33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered provider is available at the service for ongoing monitoring of care provision and delivery that promote the quality of life of people using this service. EVIDENCE: The home does not have a registered manager. The information received prior to the inspection stated that the current manager has over 2 years of management experience in a care setting, holds 8 units towards her NVQ 4 and is studying for her registered manager’s award. The current manager’s application for registered manager is in progress. We were not able to meet with the current manager on this inspection as she was on leave. The Lillibet Lodge DS0000014928.V369686.R03.S.doc Version 5.2 Page 22 registered provider was in control of the management of the service with the support of the senior staff. Staff supervision appeared irregular from the records that were made available by the home. In response to the inspection feedback session, the provider confirmed with us in writing post this inspection that those staff who have been in place 3 or more months have been supervised but the records for this have not been updated. This has now been addressed with senior care staff that has been made aware of the need and those staff not supervised in the last 3 months would be supervised immediately. Staff said that they could speak to the senior carer or the manager at any time. The manager has not maintained her knowledge of the requirement for notification to us under regulation 37 for example, the home has had several incidents / accidents involving people using the services with regard to falls and a couple of these falls also had interventions from the nurse but were not notified to the commission. This was discussed with the registered provider during the inspection feedback session, who then confirmed with us in writing post this inspection that retrospective notification of accidents and the manager absence have been completed and forwarded to us. All future possible regulation 37 notifications to be analysed and actioned if required weekly at senior staff meeting. The home had an internal quality assurance system and procedure, to ensure that the quality of care provision and delivery is of always-high standard and the people who use this service; their quality of life goals are addressed. However, this was not clearly recorded and provided on this inspection. In response to the inspection feedback session, the provider has confirmed in writing with us that the questionnaires were issued to families at the beginning of August and responses are due to be analysed in September. The improvement plan will be set out and made available in the public area of the home to encourage further feedback. The provider aims to achieve this by end of October 2008. The moving and handling techniques observed during the inspection were good, with appropriate use of slings, and the use of footrests on wheelchairs to avoid injury to staff and people who use the service. The information received from the manager before the inspection confirmed, there is a programme of servicing and testing of equipment, maintenance, and fire detection and emergency equipment. Risk assessments are in place for the home, people who use the service, and staff. The hot water temperatures checks were regularly carried out. Staff and their training records confirmed that they had been trained in a variety of Health and Safety areas including moving and handling and food hygiene. Lillibet Lodge DS0000014928.V369686.R03.S.doc Version 5.2 Page 23 The home’s various policy and procedures records did not include the updated version. This was brought to the attention of the provider during the inspection feedback session, who then has confirmed with us in writing post this inspection that the policy and procedure material that was supplied to the home has been now included in the records and the senior staff and manager made aware of its importance of inserting updates as they are received. The people, who use the service spoken to, said that the staff are good and all felt that they were very easy to talk to and that they trusted them. The home does not manage any money of people living at the home. Lillibet Lodge DS0000014928.V369686.R03.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 X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 2 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 Lillibet Lodge DS0000014928.V369686.R03.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. 1. Standard OP18 Regulation 37 Requirement Timescale for action 01/09/08 2. OP9 13 (2) 3. OP29 17 (2) The registered provider must notify CSCI under regulation 37 of any injury to people using the service. The provider must ensure that 01/09/08 the medication storage is maintained with right temperature and records maintained. The registered provider must 01/09/08 update and always make available and keep all the staff recruitment records at the home. 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 OP18 Good Practice Recommendations The manager should update her knowledge of the requirement to notify accidents under regulation 37 to protect people using the service from potential risk of harm. DS0000014928.V369686.R03.S.doc Version 5.2 Page 26 Lillibet Lodge 2. OP36 The registered provider should evidence that the staff are regularly supervised as required to improve their capacity and quality of care delivery in the best interest of people who use the service. 3. OP38 The registered provider should always ensure that the home’s policies and procedures were regularly updated and staff are made aware of the changes that impact upon the care provision and delivery. The registered provider should ensure that the broken bed is replaced for people who use the service without delay. The registered provider should ensure that the staff have clear guidance on how much to give, when and why for the medicine labelled ‘as required’ or when necessary’. The registered provider should ensure that each individual’s care plan was written with sufficient details including scoring of special risk factors and guidance for staff to understand and provide appropriate care. 4. 5. 6. OP24 OP9 OP7 Lillibet Lodge DS0000014928.V369686.R03.S.doc Version 5.2 Page 27 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 Lodge DS0000014928.V369686.R03.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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