Inspection on 24/04/06 for Mablethorpe Hall

This inspection was carried out on 24th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Mablethorpe Hall 09/07/08

Mablethorpe Hall 24/04/07

Mablethorpe Hall 26/09/06

Mablethorpe Hall 25/01/06

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

CARE HOMES FOR OLDER PEOPLE Mablethorpe Hall Alford Road Mablethorpe Lincs LN12 1PX Lead Inspector Mr Doug Tunmore Key Unannounced Inspection 24th April 2006 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 Mablethorpe Hall DS0000065213.V290059.R02.S.doc Version 5.1 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. Mablethorpe Hall DS0000065213.V290059.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Mablethorpe Hall Address Alford Road Mablethorpe Lincs LN12 1PX 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) 01507 472240 Hamilton Community Homes Limited Care Home 24 Category(ies) of Dementia - over 65 years of age (13), Mental registration, with number disorder, excluding learning disability or of places dementia (11), Mental Disorder, excluding learning disability or dementia - over 65 years of age (13) Mablethorpe Hall DS0000065213.V290059.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide personal care for service users of both sexes whose primary needs fall within the following categories:Mental Disorder, excluding learning disability or dementia, under 65 years of age (11) MD. Mental Disorder, excluding learning disability or dementia, who are over 65 years (13) MD(E). Dementia over 65 years of age (13) DE(E). Maximum number of service users to be accommodated is 24. Pat Ingham, the manager will attend bespoke Mental Health training, which addresses clinical presentations (including alcohol & drug abuse), up to date interventions in the care of adults with mental health problems; multi disciplinary working, mental health law; managing and supervising staff within mental health settings. The training will be commenced within four months of registration dated 14/07/05, this training is to be in addition to NVQ Level IV and the registered managers award. Date of last inspection Brief Description of the Service: Mablethorpe Hall is a care home providing personal care and accommodation for 24 younger adults and older people with mental health problems. The care home is owned and operated by a company, Hamilton Community Homes Limited, whose headquarters are in Leicester. The home is located on the outskirts of the coastal town of Mablethorpe. Transport such as, taxis are required to access shops, hairdressers, pubs and the other amenities, which are in the town, over a mile away from the home. The home is set in its own grounds and is accessed over an un-adopted road, which also services other properties. Mablethorpe Hall has been adapted and extended to provide accommodation for service users on two floors. The home is staffed as one unit, but comprises of two separate areas, being the main house and an annex. 2. 3. 4. 5. Mablethorpe Hall DS0000065213.V290059.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took any previous information held by CSCI, about Mablethorpe Hall into account. The site inspection consisted of case tracking a sample of the resident’s records and assessing their care. The inspector spoke with two residents, joining two other for lunch and one member of staff. The acting manager and the homes responsible individual (RI) were on duty at the time of this inspection. A tour of the premises took place. What the service does well: What has improved since the last inspection? What they could do better: An immediate requirement was made relating to two new care staff being employed without the appropriate POVAFirst checks or Criminal Record Bureau checks being made in order to safeguard residents from potential harm. The home does not carry out pre admission care assessments on prospective residents neither do they have the policies or paper format to undertake this task. The home needs to include photographs in residents medication files to ensure that mistakes in giving medication are not made. The home has no links with the community and day care placements are not made available to Mablethorpe Hall DS0000065213.V290059.R02.S.doc Version 5.1 Page 6 residents. Residents monies and financial records were not accurate and residents would benefit from an advocate/representative. Recruitment procedures are not robust and do no protect residents. The home does not record the minutes of residents meetings neither do they seek their views and publish the outcomes on the notice board. Hoist, shaft lift or electrical testing has been undertaken. The Commission has not been informed of heating problems at the home. The home has not carried out fire safety checks. 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. Mablethorpe Hall DS0000065213.V290059.R02.S.doc Version 5.1 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 Mablethorpe Hall DS0000065213.V290059.R02.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 The quality outcome in this area is poor. This judgement has been made using available evidence including a visit to this service. The home does not undertake care needs assessments on prospective residents. The home does not write to prospective residents to state whether they can met their care needs or not. EVIDENCE: Two residents files seen did not contain a pre-admission assessment of residents care needs. No evidence was available to show that residents are written to by the home to confirm that the home can meet their assessed care needs. Those residents seen stated that they were not visited by the home prior to their admission and could not remember if they had received a letter from the home. The Responsible Individual nor the manager undertake pre-admission assessments of care although they stated that they have visited residents prior to admission. The home does not have forms available in the home to carry out an assessment of a prospective resident. Mablethorpe Hall DS0000065213.V290059.R02.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. The home needs to review the current care plans used. The general health and welfare of residents is addressed. Residents are encouraged to take part in the plan of care. On the day of the inspection medication was administered appropriately. Residents are treated with respect and their dignity is maintained. EVIDENCE: Daily entries had been made in care plans by care staff, which identified the care given. The homes accident book was seen and it was found that accidents occurring to residents have been recorded appropriately in the residents file and body map. A review of all information available prior to this inspection evidenced that the Commission is informed about those accidents or other incidents that has occurred to a resident. Those residents who are able are encouraged to sign their care plans, evidence was seen in residents files that this is being addressed. The Commission has received on the 30/03/06 the homes action plan, which confirms that care Mablethorpe Hall DS0000065213.V290059.R02.S.doc Version 5.1 Page 10 plans have been signed by residents and this task was completed by the 14/03/06. However, those residents who are unable to take part in their care planning and do not have relatives should be supported by a representative to act on their behalf. The homes care plans were seen to be limited in the information available and the space available for care issue entries. The acting manager said these are to be replaced by the companies care plans in the near future. The Social Services Department have recently carried out some eleven care reviews of residents at this home. The Commission was informed by the reviewing social worker that all but one residents care needs was being met. A carer demonstrated that she had knowledge of the personal care needs of residents and that she treated them with respect and was mindful of their dignity. The home has introduced a policy on giving personal care to residents. The homes rota showed that there was a gender mix of care staff to see to the personal needs of residents. A resident stated that she is treated with respect by staff and this has improved since the last inspection. Files seen confirmed that health care professionals visit the home when required by the residents. Residents confirmed that they see the chiropodist, dentist and visit the diabetic clinic. The pharmacist inspected the home on the 28/03/06 and recorded that storage and administration records of medication is carried out appropriately. Training is also being arranged for the home by the pharmacist. On the day of this inspection medication sheets were found to be in order. A system is now in operation that the key to the medication cupboard is signed out and medication is checked daily to ensure correct procedures are undertaken. Resident photographs should be included in the front of their medication sheets to ensure that the right medication is given to the right resident. Mablethorpe Hall DS0000065213.V290059.R02.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. The home offers a set menu, which has a range of choices for residents and accommodates individual dietary needs. Relatives and friends of residents are made welcome in this home. Residents do not access community services or day care provision. A range of activities are being made available to residents. There is no evidence that residents meetings are held. EVIDENCE: No visitors were seen on the day of this key inspection. The visitors book was seen and showed that a wide range of visitors attend this home. A carer confirmed that visitors are made welcome and tea or coffee is made available. The two residents stated that they do not have visitors although one said that he telephones his sister. A care plan seen showed that a resident liked drawing and painting. The homes activities book was seen and showed that activities are being introduced to this home, with bingo, aerobics to music, card making, and hairdressing and nail care being undertaken. Glass painting is to be introduced in the near future. The home does not have an activities coordinator at the present time. Mablethorpe Hall DS0000065213.V290059.R02.S.doc Version 5.1 Page 12 One resident commented that it is boring here there is nothing to do. Although she said that it is getting a little better with activities starting up. The resident also stated that she does not access the day centre as she cannot afford the taxi fares. A second resident said that he prefers to be on his own and has lots of CDs and tapes as well as a disco music centre. Residents files seen did not evidence that residents access community facilities or special day care provision for those resident who require this type of support. Care plans seen did not record residents likes and dislikes in relation to their daily living. The home does not have a policy relating to maintaining residents independence and no records were available to show that residents were encouraged to maintain daily living skills. The inspector joined two residents for lunch and found that there was a choice of meals on offer and the food prepared was hot and very tasty. A resident commented that ‘the food is lovely and being a diabetic the cook makes cakes which I can eat’. Two residents also stated that they enjoyed the food and a range of choices are available. The cook was seen and confirmed that he has a wide range of experience and training relating to his duties. Mablethorpe Hall DS0000065213.V290059.R02.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 17 The quality outcome in this area is poor. This judgement has been made using available evidence including a visit to this service. Residents are not empowered by the homes complaints procedure. The home has not undertaken safeguarding vulnerable adult protection training to ensure the safety of residents. EVIDENCE: The homes complaints process does not have a place for a complainant to sign to signify whether they agreed with the outcome or not. A tour of the premises found that the homes complaints procedure was placed in residents bedrooms for their information. The home has also introduced since the last inspection a complaints box, which residents can ‘post’ their complaints if they so wish. Two safeguarding adult protection allegations have been made regarding the home. The Police and Social Service investigated these allegations and it was found that there was no case to answer. A review of all information available prior to this inspection including the homes action plan received by the Commission on the 30/05/06 and evidence seen at this inspection is that the home has obtained those documents required for the safeguarding of residents. The home has not arranged adult protection training, which must be compulsory for all staff. Mablethorpe Hall DS0000065213.V290059.R02.S.doc Version 5.1 Page 14 Two residents commented that staff are kind to us now and I am happy with them, the second resident stated that she is also happy with the current attitude or care staff. A carer confirmed that she would report any concerns she had about the treatment of residents to the acting manager or further, be the abuse mental, physical or financial. Mablethorpe Hall DS0000065213.V290059.R02.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,25 & 26 The quality outcome in this area is poor. This judgement has been made using available evidence including a visit to this service. Residents do not live in a well-maintained environment. The homes cleaning programme is not effective in addressing unpleasant odours in the home. EVIDENCE: The home maintenance book was seen and showed that the handyman carries out general maintenance. The home was seen to be in a poor state of repair with a number of rooms seen needing to be decorated. Carpets seen in residents bedrooms, corridors and communal areas need replacing as they are stained and warn. The home does not have an annual development plan which would record what improvements to the fabric of the home has been planned for the coming year. Residents rooms seen were personalised with photographs and other personal possessions belonging to them. Mablethorpe Hall DS0000065213.V290059.R02.S.doc Version 5.1 Page 16 A resident stated that the boiler had gone and she couldn’t get a bath and a man came out to fix it and it went again. The acting manager confirmed that the boiler had broken down and the plumber attended the home on the 20/04/06 and again on the 21/04/06. The boiler stopped again on the morning of the 24/04/06. On the day of the inspection the home was cold and there was no hot running water. The acting manager confirmed that she had not reported the heating problem to the Commission. Contact made by the regulator to the acting manager on the 26/04/06 determined that the heating was working in the home but not the hot water system. The acting manager stated that the plumber is currently at the home attending to the fault. A tour of the environment found that there was an unpleasant odour from one upstairs toilet, which had a dirty carpet on the floor. Others areas seen looked dirty with dust and cobwebs collected in corners of rooms. The inspector was accompanied by the acting manager during the tour of the building and is aware of the issues raised. The home has one cleaner who works from 9.00 am to 3.00 pm five days a week. A social worker who was contacted said that she had visited the home and felt that it was dirty and needed cleaning. Mablethorpe Hall DS0000065213.V290059.R02.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 ,29 & 30 The quality outcome in this area is poor. This judgement has been made using available evidence including a visit to this service. There are sufficient staff to care for the residents. Staff training is now in place and all carers undertake induction training when starting at the home. The home does not have a robust and thorough staff recruitment process for the protection of residents. EVIDENCE: Two care workers personnel files were seen and it was found that appropriate checks had not been sought with regard to POVAFIRST or Current Criminal Record Bureau checks to ensure the safeguarding of vulnerable residents. An immediate requirement letter was sent to the owner regarding the above matter. The home has not obtained The General Social Care Council Codes of Practice, which sets out responsibilities as care workers looking after vulnerable adults. A review of all information available prior to this inspection including the homes action plan received by the Commission and evidence found on the day of the inspection showed that; the home has a staff training profile which address mandatory training needs and induction training for all care staff. The acting manager commented that three care workers have NVQ (National Vocational Qualifications level 2, with one carer having NVQ level 3. A funding Mablethorpe Hall DS0000065213.V290059.R02.S.doc Version 5.1 Page 18 application was seen for two workers to undertake NVQ level 3. The home evidenced that they are also introducing Skills for Care induction training for all carers. A carer stated that she has NVQ level 2 and is currently completing level 3 which she started with a previous employer. The homes rota was seen and it was found that adequate staffing levels are maintained with a gender balance to meet the needs of residents. One carer stated that there are always enough staff on duty to cover shifts and that a number of residents are very independent. A resident commented that there are enough male and female staff on duty. Mablethorpe Hall DS0000065213.V290059.R02.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 35 & 38 The quality outcome in this area is poor. This judgement has been made using available evidence including a visit to this service. Records seen show that residents’ health and general welfare and safety are not always promoted. There was no evidence that the home holds residents meetings. Quality assurance audits of residents and visitors views are not carried out. Accurate records are not kept of residents’ monies. EVIDENCE: The providers are to apply for a ‘fit person’ application for the current acting manager of this home. Due to this no requirement will be made relating to the home not having a registered manager. There was no evidence available to show that the home conducts an in-house quality assurance check or report. The acting manager confirmed that a Mablethorpe Hall DS0000065213.V290059.R02.S.doc Version 5.1 Page 20 residents meeting was held on the 06/04/06 but no minutes were available in the home of this meeting. The home deals with a number of residents personal allowances, with four residents managing their own monies. Some residents are subject to power of attorney or guardianship orders with their finances managed by the social services department or their families. Receipts are kept of monies spent by the home on residents behalf. Two residents monies were checked against the record of monies held on their behalf and it was found that in one instance an inaccurate record was not kept. It was also found that a carer had crossed out a record of monies given and not obtained a second signature of a senior care worker. The home is undertaking to obtain a bank account for all residents. There are a range of policies and procedures available in the home relating to fire safety and fire risk assessments. There was no evidence that that fire alarms, fire drills and emergency lighting checks have been undertaken. Care staff receive fire training as part of the homes initial training and as a regular training event. On the day of the inspection a fire training consultant visited the home to undertake training and advise the home regarding its fire risk assessments and the keeping of fire records. Certificates were not available showing that hoists and the shaft lift had been serviced on a six monthly basis as required. Evidence was not available to show that portable electrical equipment checks had been carried out by a competent person. Risk assessments are not available for windows on the first floor, which do not have window restrictors. The Commission has not received Regulation 26 reports from the providers regarding the running of the home. This was a requirement from the last inspection of this home. Mablethorpe Hall DS0000065213.V290059.R02.S.doc Version 5.1 Page 21 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 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 2 X X X X X 2 2 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X X 2 Mablethorpe Hall DS0000065213.V290059.R02.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? yes 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 OP3 Regulation 14 Requirement The registered provider must ensure that that the home undertakes a full needs assessment of prospective residents before any decision is made for admission. Confirmation in writing must be given to residents after assessment, as to whether the home is suitable to meet residents needs in respect of their health and welfare or not. The home must provide a pre admission assessment tool for the home to carry out appropriate assessments of residents. The home must not provide accommodation to a resident unless a suitably qualified trained person has assessed the needs of the resident. (This is ongoing as no resident has been admitted prior to this inspection.) Care plans must be reviewed so as to contain more detailed information about the needs of DS0000065213.V290059.R02.S.doc Timescale for action 19/05/06 2. OP3 14(d) 19/05/06 3 OP3 14 19/05/06 4. OP7 14(a) 19/05/06 5. OP7 17 (1) Schedule 3 25/06/06 Mablethorpe Hall Version 5.1 Page 23 6. OP13 16(m) 7. OP14 16(f)(h) 8. OP14 12(2) 9. OP18 13(6) residents. The home must consult residents about their social interests and make arrangements for them to engage in local, social and community activities. The home must introduce a policy relating to maintaining the independence of residents and record in their care plans those daily living skills that residents need to enhance. The home must ensure that a record is made relating to the likes and dislikes of residents relating to all aspects of the daily living needs. The home must ensure that all workers employed at this home undertake adult protection training. (The timescale of the 25/04/06 has not been met). The registered person must have a maintenance programme for the renewal of the fabric and decoration of the premises. A plan of refurbishment must also be sent to the Commission for their information. All parts of the home must be kept clean and reasonably decorated. The home must provide heating and hot water suitable for residents in all parts of the home and inform the Commission of any reason that this service is not working. The home must keep the care home free from offensive odours. The registered person must ensure that there are robust staff recruitment procedures. This inspection found that POVAFIRST checks and Criminal Record Bureau checks had not been undertaken to ensure the DS0000065213.V290059.R02.S.doc 25/06/06 25/06/06 25/06/06 25/06/06 10. OP19 23(b) 25/06/06 11. 12. OP19 OP25 23(d) 23(2) (p) 25/06/06 25/06/06 13. 14. OP26 OP29 16(2)(k) 19 25/06/06 24/04/06 Mablethorpe Hall Version 5.1 Page 24 safety of vulnerable adults. An immediate requirement was made regarding the above. 15. OP33 24 The home must hold residents and relatives meetings and keep minutes of the meeting in order to seek their views about the running of the home. The home must undertake an effective quality monitoring system based on seeking the views of residents/relatives and visitors with the results of any surveys published for their information. The registered person shall not pay money belong to any resident into a bank account unless- the account is in the name of that individual resident. This requirement is ongoing and it is acknowledged that efforts are being made by the provider to met this requirement. 25/06/06 16. OP33 24 (3) 25/06/06 17. OP35 20(a) 25/06/06 18. OP35 16(i) 19. OP38 23(4) The home must keep an 25/06/06 accurate record of residents monies and obtain the required two signatures of staff and the residents when withdrawals and deposits are made. The home must consult with the 25/05/06 fire authority for keeping records relating to the safety of residents and the prevention of a fire. (The timescale of the 25/03/06 has not been met). The registered person must visit the home at least once a month and interview residents and persons working at the home as appears necessary in order to form an opinion of the standard of care provided in the home. The provider must supply a written report to the Commission DS0000065213.V290059.R02.S.doc 20. OP38 26 25/05/06 Mablethorpe Hall Version 5.1 Page 25 21. OP38 23(4)(v) 22. OP38 23(c) 23. OP38 13(4)(a) of the findings of the unannounced visit. (The timescale of the 25/03/06 has not been met). The registered person must take 25/05/06 adequate precautions against the risk of fire; and make arrangements for reviewing fire precautions and testing fire equipment at suitable intervals. The home must ensure that all 25/06/06 hoists and shaft lift are serviced as required. Lifting Operations & lifting Equipment Regulations 1998. All rooms without window 25/06/06 restrictors must have a risk assessment to minimise the risk to service users. 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. 3 Refer to Standard OP7 OP9 OP13 Good Practice Recommendations The home should ensure that residents have access to representatives if they have no family or friends to act on their behalf. Residents photographs should be included in the front of their medication sheets to ensure that the right medication is given to the right person. The registered person must consult with residents about their interests and make arrangements to enable them to engage in local, social and community activities. The home should empower residents/representatives in enabling them to sign the complaints form agreeing or otherwise to the outcome of any complaint they have made. The home must have a minimum ratio of 50 trained staff members to NVQ level two excluding the registered manager. DS0000065213.V290059.R02.S.doc Version 5.1 Page 26 4. OP16 5. OP28 Mablethorpe Hall 5. OP30 The home should furnish all staff with the General Social Care Councils Conduct of Practice for their information. Mablethorpe Hall DS0000065213.V290059.R02.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mablethorpe Hall DS0000065213.V290059.R02.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!