Care Home: Lilybank Hamlet

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What the care home does well People told us they were given the care and support they needed, including medical support. They said “I’m well looked after here”. A relative told us “Her needs vary as her dementia progresses. The staff do well in coping with these changes”. People told us their privacy and dignity were respected by the staff. They described staff as “kind”, “patient”, “always polite”, and said “we can have a bit of fun with them”. We observed that staff showed affection and respect for people in the home with a warm and friendly approach. People told us they enjoyed the activities provided at the home. There was an activities coordinator employed for 5 days per week. People told us the home was always clean and fresh. A relative said, “The cleanliness of the home and clean smell when you enter is welcoming”. What has improved since the last inspection? The care plans had been improved by using standard documentation throughout the home and by including more detail about people’s preferred routines, likes and dislikes. The AQAA said that communication with other healthcare professionals had improved in the last 12 months, creating positive working relationships. The activities coordinator was employed for 5 days per week instead of 3 to offer an improved range of activities for people in the home. Staff had received training about the Mental Capacity Act 2005 to ensure they were aware of how to promote people’s rights. The manager had achieved registration with CSCI / CQC since the last key inspection. New laundry equipment had been installed since the last inspection. A new cooker and ventilation system had been installed in the kitchen.Lilybank HamletDS0000002062.V375284.R01.S.docVersion 5.2 What the care home could do better: Care plans should include more detail of how staff are to ensure the privacy and dignity of people in the home are promoted. There should be assessments of the nutritional needs of people in the home, and also of their risk of developing pressure sores. This will help to ensure people’s needs are fully met. The gardens should have safe, easy access and sufficient seating so that people can enjoy sitting outside and using the gardens. Key inspection report CARE HOMES FOR OLDER PEOPLE Lilybank Hamlet Chesterfield Road Matlock Derbyshire DE4 3DQ Lead Inspector Rose Moffatt Key Unannounced Inspection 6th May 2009 09:20 DS0000002062.V375284.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Lilybank Hamlet DS0000002062.V375284.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Lilybank Hamlet DS0000002062.V375284.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lilybank Hamlet Address Chesterfield Road Matlock Derbyshire DE4 3DQ 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) 01629 580919 01629 760019 lilybank@btconnect.com Progressive Care (Derbyshire) Ltd Miss Julie Ann Gallagher Care Home 57 Category(ies) of Dementia (57), Learning disability (57), Old age, registration, with number not falling within any other category (57) of places Lilybank Hamlet DS0000002062.V375284.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered persons may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission are within the following category: Old age, not falling within any other category - Code OP Dementia - Code DE Learning Disability - Code LD The maximum number of service users who can be accommodated is 57 11th June 2008 2. Date of last inspection Brief Description of the Service: Lilybank Hamlet is situated in the town of Matlock. There is a range of facilities in the town, including shops, pubs, restaurants and public transport. The home provides personal care for up to 57 people. The registration was changed in 2007 so that the home could provide care for people whose primary care need was because of dementia. The registration was changed again in 2008 so that the home could provide care and support for people with learning disabilities The home is in an older building, at one time a hotel, and still has many original features and the character of a period property. The home has accommodation on the ground, first and second floors with good views over the surrounding countryside. The home had major alterations in 2007. The provider has upgraded the top floor, which was not previously used, to create additional bedrooms. The home has a large garden at the rear of the home and car parking space at the front. The fees range from £358 to £403 per week, depending on the level of care required and the size, location and facilities provided in the person’s bedroom. This information was provided by the manager on 6th May 2009. Lilybank Hamlet DS0000002062.V375284.R01.S.doc Version 5.2 Page 5 Information about the home, including CSCI inspection reports, is available from the home. The last inspection report is included in the Service User Guide given to all people living in the home. Lilybank Hamlet DS0000002062.V375284.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use the service experience good quality outcomes. The focus of our inspection is on outcomes for people who live in the home and their views on the service provided. The inspection process looks at the providers ability to meet regulatory requirements and national minimum standards. Our inspections also focus on aspects of the service that need further development. We looked at all the information we have received, or asked for, since the last key inspection or annual service review. This included: • the annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also has some numerical information about the service. • surveys returned to us by people using the service and from other people with an interest in the service • information we have about how the service has managed any complaints • what the service has told us about things that have happened - these are called notifications and are a legal requirement • the previous key inspection and the results of any other visits we have made to the service in the last 12 months • relevant information from other organisations • what other people have told us about the service. We carried out a random unannounced inspection in December 2008 in response to concerns raised about the home. Relevant information from that inspection is included in the body of this report. For this report, we carried out an unannounced inspection visit that took place over 7 hours on 6th May 2009. The inspection visit focused on assessing compliance with requirements made at the previous inspection and assessing all the key standards. We sent out 10 surveys to people living in the home, but did not receive any responses. We sent out 10 surveys to the relatives or representatives of people living in the home and received 1 completed response. We sent out 10 surveys to staff employed at the home and received 4 completed responses. There were 28 people accommodated in the home on the day of the inspection visit. People who live in the home, visitors and staff were spoken with during the visit. The manager was available and helpful throughout the inspection visit. Some people were unable to contribute directly to the inspection process Lilybank Hamlet DS0000002062.V375284.R01.S.doc Version 5.2 Page 7 because of communication difficulties, but they were observed during the visit to see how well their needs were met by staff. Case tracking was used during the inspection visit to look at the quality of care received by people living in the home. 4 people were selected and the quality of the care they received was assessed by speaking to them and / or their relatives, observation, reading their records, and talking to staff. What the service does well: People told us they were given the care and support they needed, including medical support. They said “I’m well looked after here”. A relative told us “Her needs vary as her dementia progresses. The staff do well in coping with these changes”. People told us their privacy and dignity were respected by the staff. They described staff as “kind”, “patient”, “always polite”, and said “we can have a bit of fun with them”. We observed that staff showed affection and respect for people in the home with a warm and friendly approach. People told us they enjoyed the activities provided at the home. There was an activities coordinator employed for 5 days per week. People told us the home was always clean and fresh. A relative said, “The cleanliness of the home and clean smell when you enter is welcoming”. What has improved since the last inspection? The care plans had been improved by using standard documentation throughout the home and by including more detail about people’s preferred routines, likes and dislikes. The AQAA said that communication with other healthcare professionals had improved in the last 12 months, creating positive working relationships. The activities coordinator was employed for 5 days per week instead of 3 to offer an improved range of activities for people in the home. Staff had received training about the Mental Capacity Act 2005 to ensure they were aware of how to promote people’s rights. The manager had achieved registration with CSCI / CQC since the last key inspection. New laundry equipment had been installed since the last inspection. A new cooker and ventilation system had been installed in the kitchen. Lilybank Hamlet DS0000002062.V375284.R01.S.doc Version 5.2 Page 8 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Lilybank Hamlet DS0000002062.V375284.R01.S.doc Version 5.2 Page 9 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 Lilybank Hamlet DS0000002062.V375284.R01.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There was a thorough assessment process so that people were confident the home could meet their needs. EVIDENCE: At the random inspection in December 2008, we found that the Statement of Purpose did not include all the required information. At this inspection, we found that the Statement of Purpose had been appropriately revised and updated. People told us their needs were met at the home. One person said, “I’m well looked after here”. Lilybank Hamlet DS0000002062.V375284.R01.S.doc Version 5.2 Page 11 We looked at the care records of 4 people in the home. Each had an assessment carried out by staff from the home before the person was admitted. The assessments covered all of the person’s needs and abilities. There was also assessment information by social services and hospital staff. The AQAA said that people who are interested in coming to live in the home are offered the opportunity to visit the home and have lunch there before making a decision. Standard 6 did not apply as there were no people receiving intermediate care in the home. Lilybank Hamlet DS0000002062.V375284.R01.S.doc Version 5.2 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements had been made in care planning so there was a consistent and thorough approach to ensure people’s needs were met. EVIDENCE: People told us they were given the care and support they needed, including medical support. A relative told us “Her needs vary as her dementia progresses. The staff do well in coping with these changes”. The care records we looked at all had an individual care plan. Since the previous inspection the care plans had been improved by using standard documentation throughout the home and by including more detail. The care plans covered all of the assessed needs of each person and included details of their personal preferences. The care plans had been reviewed monthly and had Lilybank Hamlet DS0000002062.V375284.R01.S.doc Version 5.2 Page 13 been signed by the person or their relative to indicate their involvement and agreement. The records showed that people had access to healthcare services, such as their GP, District Nurse, chiropodist, dentist, and optician. Daily records showed that people were referred promptly for medical help. People told us they could see their GP as necessary. Each person had an assessment of their manual handling needs and any associated risks, also an assessment of their risk of falls. Nutritional needs were included in care plans, though there was no separate risk assessment seen. The care plans included any action needed to reduce the risk of pressure sores, but no separate risk assessments were seen. Appropriate aids and equipment were provided – such as special mattresses to reduce the risk of developing pressure sores, lifting hoists, and handrails. The care records included details of the person’s medication and the assistance they required. The care plans included any medication prescribed ‘as required’, though there was no detail of any alternative action for staff to try before offering the medication. Medication was stored securely and there were appropriate systems in place to ensure safe handling and administration. People told us their privacy and dignity were respected by the staff. They described staff as “kind”, “patient”, “always polite”, and said “we can have a bit of fun with them”. We observed that staff showed affection and respect for people in the home with a warm and friendly approach. The care plans included some references to maintaining people’s privacy and dignity, though more detail was needed in some. The AQAA said that communication with other healthcare professionals had improved in the last 12 months, creating positive working relationships. Lilybank Hamlet DS0000002062.V375284.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There was a good range of activities, reasonably flexible routines, and an acceptable choice of food so that the lifestyle in the home met the needs and preferences of people living there. EVIDENCE: People told us they enjoyed the activities provided at the home, including gentle exercise to music, a recent trip out to Chatsworth, and a visiting organist. On the day of the inspection visit people were enjoying a game of skittles, a sing-along, and a gentle exercise session. A visitor said there was “usually something going on” and said the activities coordinator was good at involving people. We saw records of activities offered to each person, including their response to the activity. There was a regular church service in the home and visitors from the local church. There was a full-time activities coordinator working at the home. The manager said they were currently trying to recruit an activities assistant so that the Lilybank Hamlet DS0000002062.V375284.R01.S.doc Version 5.2 Page 15 range of activities could be increased, and activities could be offered on 7 days a week. People told us they could follow their preferred routines. Some people liked to spend their day in the ground floor conservatory, others preferred to be in the top floor lounge. People said they could get up and go to bed when they wanted to. There was a board in the main hallway with details of the activities and menu for the day. Visitors told us they could visit at any reasonable time and were always made welcome. They said they were kept informed of any concerns about the person in the home. We saw records of meetings held for people in the home and their relatives to express their views and raise any issues. The manager said the meetings were not usually well attended. People were encouraged to bring in their own possessions to personalise their bedrooms. People told us they usually enjoyed the meals provided. The dining rooms were bright and pleasant. The tables looked attractive with cloths, flowers and menus. The carpets in both dining rooms appeared stained and marked. The AQAA said the home had improved in the last 12 months by having an activities coordinator for 5 days per week instead of 3 and by increasing the range of activities offered. There was also a monthly newsletter with information about life in the home, activities and forthcoming events. Lilybank Hamlet DS0000002062.V375284.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There were satisfactory systems in place so that people were protected and their complaints were effectively dealt with. EVIDENCE: The complaints procedure was displayed in the main hallway of the home and was also included in the Service User Guide. We saw records of complaints with details of the action taken and the outcome. People told us they knew how to make a complaint and they were confident that staff would take the appropriate action to address any concerns. The AQAA said the home wanted to “continue to encourage open communication so not to create a blame culture, where residents feel comfortable in complaining and active solutions are sought without cause for written complaint”. In December 2008 we received concerns about the home and information about safeguarding allegations. We carried out a random inspection in December 2008 to look at some of the issues raised. (Other issues were referred to social services for further investigation). We found that some concerns were substantiated, and we also found other areas of concern. Lilybank Hamlet DS0000002062.V375284.R01.S.doc Version 5.2 Page 17 Following the random inspection, appropriate action was taken by the providers to address the concerns and comply with requirements made. Most staff had received training about safeguarding vulnerable adults. Staff told us they knew what to do if anyone had any concerns about the home. Staff knew the correct procedures to follow if abuse was alleged or suspected. There was information about the Mental Capacity Act 2005 available in the home and most staff had received relevant training. Lilybank Hamlet DS0000002062.V375284.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was suitably equipped and generally well maintained so that people lived in a clean, safe, pleasant environment that met their needs. EVIDENCE: People told us the home was always clean and fresh. A relative said, “The cleanliness of the home and clean smell when you enter is welcoming”. People told us they were pleased with their bedrooms – “it’s always clean”, and “I’ve got the best room in the house!” Several people commented on the fine views from the bedrooms and communal rooms. As found at the last key inspection in June 2008, there were ongoing problems with water coming in on the top floor, causing some minor damage to ceilings. Lilybank Hamlet DS0000002062.V375284.R01.S.doc Version 5.2 Page 19 The provider’s representative said work to repair the roof was planned, but there was no start date yet. We found that 2 bedroom doors were wedged open. One of these bedrooms was of a person who smoked and so the smell of smoke drifted out into the corridor. Work to make the garden more accessible had not been completed. People told us they were able to use the gardens and enjoyed sitting out in fine weather, though one person said they were wary of walking in the garden as the paths were uneven. Staff told us that more garden furniture was needed so that more people could sit out. New laundry equipment had been installed since the last inspection. A new cooker and ventilation system had been installed in the kitchen. The home appeared clean on the day of the inspection visit and was free from offensive odours. Most staff had received training in the control of infection. Lilybank Hamlet DS0000002062.V375284.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There were satisfactory recruitment procedures, good staff training, and sufficient staffing levels so that people were protected and their needs were met by a well motivated staff team. EVIDENCE: People told us that staff were usually available when needed. We observed that there appeared to be sufficient staff on duty to meet people’s needs on the day of the inspection visit. The staff rotas showed that staffing levels on the day of the inspection visit were typical. We looked at the records for 3 members of staff and found they all had the required documents and information in place. There was a gap in 1 person’s employment history with no written explanation. New staff completed an induction programme that met Skills For Care standards. There was a rolling programme of training for staff and most staff were up to date with all required training. 6 out of 24 care staff had already Lilybank Hamlet DS0000002062.V375284.R01.S.doc Version 5.2 Page 21 achieved National Vocational Qualification (NVQ) at level 2 or above, and another 12 were working towards the qualification. Staff told us they enjoyed working at the home - “it’s a happy place”, “very good at sending us all on all courses available”, and, “I believe the staff all have the service users needs as top priority on every shift”. The AQAA said the home had improved in the last 12 months by recruiting and training a team of staff to provide care for people with learning disabilities. They had implemented a rolling recruitment programme, rather than just as and when. Staff worked a rolling rota so they could plan for a better work / life balance. Lilybank Hamlet DS0000002062.V375284.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There were satisfactory systems in place to ensure the health, safety and welfare of people in the home, and to ensure the home was run in their best interests. EVIDENCE: The manager had achieved registration with CSCI / CQC since the last key inspection. The manager had not completed a management qualification, though was a qualified nurse and was suitably experienced. People told us they had confidence in the manager to address any concerns. Staff said the Lilybank Hamlet DS0000002062.V375284.R01.S.doc Version 5.2 Page 23 manager was approachable and that the home had improved and was better organised since she had taken over. The AQAA was completed by the manager. The AQAA included clear, relevant information supported by a range of evidence. The AQAA showed details of where the home needed to improve and how they planned to do this. The data section was accurately completed. Quality assurance surveys had been sent out in March 2009 and the manager said a report was being prepared on the results of the surveys and action taken to address issues raised. There were meetings for people in the home and their representatives approximately every 2 – 3 months, though the manager said these meetings were not well attended. The providers had appointed a person to be responsible for quality assurance in their homes. There were good records of the personal money held for people in the home. The money was held securely. We looked at records of the maintenance and testing of fire safety equipment and found these were up to date. We found that accident records were satisfactory and included a note of any action taken by the manager. As noted in the Environment section of this report, we found that 2 bedroom doors were wedged open, including a bedroom where smoking was allowed. This was a potential fire hazard. The AQAA showed that the maintenance of equipment and systems in the home was up to date. Also, that relevant policies and procedures were in place and had mostly been reviewed in the last 12 months. Some policies had not been reviewed for over 12 months. Lilybank Hamlet DS0000002062.V375284.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Lilybank Hamlet DS0000002062.V375284.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. 1 Standard OP38 Regulation 13(4)(c) Requirement Fire resisting doors must not be held open, unless by a device that allows the door to close automatically when the fire alarms sound. This will help to ensure the safety of people in the home. Timescale for action 30/06/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations There should be assessments of the nutritional needs of people in the home, and also of their risk of developing pressure sores. This will help to ensure people’s needs are fully met. Care plans should include more detail of how staff are to ensure the privacy and dignity of people in the home are promoted. The gardens should have safe, easy access and sufficient seating so that people can enjoy sitting outside and using the gardens. DS0000002062.V375284.R01.S.doc Version 5.2 Page 26 2. 3. OP10 OP19 Lilybank Hamlet 4. OP29 There should be a full employment history for each member of staff employed, with a written explanation of any gaps in employment. This will help to ensure a robust recruitment process that protects people in the home. Lilybank Hamlet DS0000002062.V375284.R01.S.doc Version 5.2 Page 27 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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