Inspection on 26/09/06 for Mablethorpe Hall

This inspection was carried out on 26th September 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 24/04/06

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 Announced Inspection 26th September 2006 09:15 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.V313219.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Mablethorpe Hall DS0000065213.V313219.R01.S.doc Version 5.2 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 472661 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.V313219.R01.S.doc Version 5.2 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. 2. 3. 4. Date of last inspection 24 April 2006 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. The current scale of charges at this home is from £348.00 to £415.00. Mablethorpe Hall DS0000065213.V313219.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took into account any previous information held by Commission for Social Care Inspection (commission) including the homes previous inspection reports, their service history, the providers action plan detailing what requirements have been addressed. Resident’s questionnaires sent to the home by the Commission prior to this inspection. The site inspection consisted of case tracking a sample of two resident’s records and assessing their care. The inspector spoke with two residents who were not being case tracked and joined two other residents for lunch. The inspector also spent time with the responsible individual, the cook and one member of staff. A partial tour of the home and a review of a sample of the records was also included. What the service does well: What has improved since the last inspection? What they could do better: Not all residents have the current providers contracts on file, which would give details of the conditions and fees for individual placements. Mablethorpe Hall DS0000065213.V313219.R01.S.doc Version 5.2 Page 6 Residents care plans were found not to have been reviewed by the providers, nor do they contain detailed information about the care needs of residents. This requirement was made in April 2006 with the timescale of 25/06/06 not met. The providers have not established a system for ensuring that there is a quality assurance process in which residents are informed of the outcomes. This requirement was made in 2005 and the timescale of 25/03/06 was not met. No action has been taken. The provider must visit the home at least once a month and supply the commission with a report of the findings of this visit. The commission has not received these reports for July and August 2006. The timescale of 25/03/06 has not been met. The provider has not carried out reviews as per the homes policies and procedures. The provider has not drawn up a care plan for a resident admitted on the 24/07/06. Care plans seen did not show how residents dignity and privacy are to be maintained when care workers undertake intimate care. Photographs have not been attached to residents medication files to help ensure that the right medication is given to he right resident. Day care support for residents has not been explored. The RI (responsible person) who is currently the acting manager is not included on the rota. An incident in the home between residents has not been forwarded to the adult protection team for their information. Risk assessments are not in place for rooms without window restrictors or for obstructions to elderly residents. The home does not have a manager. Emergency lighting has not been tested to ensure the safety of residents. 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.V313219.R01.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 Mablethorpe Hall DS0000065213.V313219.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 & 6 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a care needs admission assessment, which helps to ensure that a residents needs would be met. The current providers have not issued contracts and terms of conditions to all residents. EVIDENCE: A review of all information available prior to this inspection, including a previous inspection report dated 2/04/06 and evidence seen at this inspection in residents files and care plans, showed that the provider does not admit residents without a care needs assessment being undertaken. Prospective residents are also written to by the home confirming that they can meet the residents care needs or not. A resident who was admitted in July 06 was found to have in his file a care needs assessment completed by a social worker. Intermediate care is not provided in this home. Mablethorpe Hall DS0000065213.V313219.R01.S.doc Version 5.2 Page 9 The commission sent residents questionnaire forms entitled ‘Have Your Say About…’ to the home prior to this inspection and twelve were returned. Residents completed the questionnaires, with eleven residents stating that they did not receive a contract nor did they have information about this home prior to admission. One confirmed that he had information about the home prior to admission and that he had received a contract. Written comments made in questionnaires were;’ he was not with it when he got here, ‘had no choice but to move in’. Two residents files were seen with one not having a written contract from the current provider, giving the terms of conditions of occupancy. Mablethorpe Hall DS0000065213.V313219.R01.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 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 poor. This judgement has been made using available evidence including a visit to this service. The home needs to undertake care needs reviews of residents and ensure that adequate information is available in care plans to deliver quality care. One resident did not have a care plan. The general health and welfare of residents is addressed. EVIDENCE: A previous inspection of this home evidenced that; daily entries had been made in care plans by care staff, which identified the care given. The homes accident book had been seen and it was found that accidents occurring to residents have been recorded appropriately in the residents file and body map. The homes service history held by the commission evidenced that the provider has informed the commission about those accidents or other incidents that has occurred to residents. Those residents who are able, are encouraged to sign their care plans and take a more active role in their care. However, the files of the two residents who Mablethorpe Hall DS0000065213.V313219.R01.S.doc Version 5.2 Page 11 were being case tracked were seen and it was found that care plans had not been reviewed. It is the responsibility of the provider to undertake monthly reviews of all those care needs of residents. One resident admitted in July 06 did not have a care plan setting out his care needs and how these were to be addressed. The provider has posted on the notice board the name and address of an advocacy service for those residents who are unable to take part in their care planning and do not have relatives to support them. The Social Services Department have 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 were 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. One care file seen did not outline how staff were to address the issue of maintaining residents dignity or privacy when undertaken intimate care needs. A resident stated that ‘staff are not to bad, they are most kind to me, and they treat me with respect’. Files seen in previous inspections confirmed that health care professionals visit the home when required by the residents. Residents confirmed at that inspection that they see the chiropodist, dentist and visit the diabetic clinic. The questionnaires returned by residents showed that six felt that they always receive the medical support that they need and two felt that they usually received the medical support that they need, two felt that they sometimes receive support and two felt that they never get medical support. The RI was informed of the outcome of the questionnaires throughout the inspection. Seven residents commented that they felt that staff are always available when they need them and five felt that staff are sometimes available when they need them. A written comment made by a resident was ‘you always have to wait for hours sometimes to see them’ (staff). One residents stated that staff are all right here, but I need one to one support’. The pharmacist inspected the home on the 28/03/06 and recorded that storage and administration records of medication is carried out appropriately. It was noted that individual medication sheets did not have photographs of residents to help carers to identify the right medication for the right resident. This was a recommendation made in the last inspection of April 06 and has not been addressed. Mablethorpe Hall DS0000065213.V313219.R01.S.doc Version 5.2 Page 12 Carers personnel files evidence that medication training had been undertaken in March 06 by an outside training agency. The Local Authority contracting monitoring visit undertaken on the 18/09/06 found that ‘ Marr’ (medication sheets) sheets were checked during this visit. Due to this no inspection was carried out of medication at this inspection. Mablethorpe Hall DS0000065213.V313219.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 &15 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. Residents do not access community services or day care provision. A range of activities are made available to residents. EVIDENCE: No visitors were seen at the time of this inspection. One resident commented that he ‘doesn’t get many visitors, my social worker comes now and again’. One carer confirmed that the residents do not receive many visitors. Residents files seen did not evidence that residents access community facilities or special day care provision for those residents who require this type of support. Care plans seen did not record resident’s likes and dislikes in relation to their daily living. The home has a policy relating to maintaining residents independence and no records were available to show that residents were encouraged to maintain daily living skills. One resident stated that she washes the pots and pans and keeps her room tidy although the cleaner does the hoovering. Mablethorpe Hall DS0000065213.V313219.R01.S.doc Version 5.2 Page 14 Residents questionnaires showed that four felt that activities are always available, four felt that they were usually available, one felt that they were sometimes available and three felt that activities were never available. One resident said that she does not do activities. Another resident said that he goes out on his own into town to buy things for himself. The homes activities book was seen and evidenced that efforts are being made to introduce activities into the home. A carer stated that she is now the homes activities organiser and has undertaken crafts with residents. She commented that she is going to organise an Indian night, with food and flags and colourful tablecloths with the help of residents. On the day of the inspection, four residents went out for a pub lunch supported by care workers. A previous inspection undertaken in April 06 found that there was a choice of meals on offer and the food prepared was hot and very tasty. The regulator received positive comments during this inspection from residents who commented that ‘I thought the lunch was nice’. One resident stated that ‘sometimes the meals are not big enough’. The Local Authority contracting monitoring visit found that ‘the cook has the responsibly for ordering of all food and provisions and that menu plans have been introduced’. Residents questionnaires showed that five always liked the meals and two usually liked the meals and three residents sometimes liked the meals. Mablethorpe Hall DS0000065213.V313219.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The quality outcome in this area is poor. This judgement has been made using available evidence including a visit to this service. Residents are empowered by the homes complaints procedure. Carers have undertaken safeguarding vulnerable adult protection training to ensure the safety of residents. Safeguarding vulnerable adults procedures are not undertaken by the provider. EVIDENCE: This inspection found that the homes complaints process has a place for a complainant to sign to signify whether they agreed with the outcome of their complaint or not. A tour of the premises found that the homes complaints procedure was placed in resident’s bedrooms for their information. The home has also introduced a complaints box, which residents can ‘post’ their complaints if they so wish. The provider informed the commission in writing of an incident within the home on the 08/09/06 which resulted in an injury to a resident. A referral was not made to the social services adult protection committee for their information. The RI was reminded that incidents where residents come to harm must be reported so that action can be considered given the circumstances of the incident. Mablethorpe Hall DS0000065213.V313219.R01.S.doc Version 5.2 Page 16 Care workers personnel files were seen and found to contain certificates detailing that safeguarding vulnerable adults had been undertaken in May 06. One resident commented that ‘staff treat me with respect and I feel safe, I don’t lock my bedroom’. Residents questionnaires showed that seven knew how to make a complaint and five knew who to speak to if they were unhappy. Mablethorpe Hall DS0000065213.V313219.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected 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. The provider is making efforts to ensure that a homely and clean environment is available to all residents. There are no environmental risk assessments for residents who live in this home. EVIDENCE: Residents rooms seen were personalised with photographs and other personal possessions belonging to them. One resident showed the regulator his room and confirmed that his bedroom was to be decorated, with new carpets, curtains, bed and windows fitted. Risk assessments were not available in residents care plans, which should detail any risk to residents who had mobility problems in relation to the homes environment. Mablethorpe Hall DS0000065213.V313219.R01.S.doc Version 5.2 Page 18 During the last inspection of the home 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 Local Authority contracting monitoring visit found that ‘ the water problem within the home has been resolved’. 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. The providers action plan stated that the requirement made in the last inspection regarding introducing a plan of refurbishment would be implemented by June 06. The RI stated that she was undertaking an audit and a copy would be sent to the commission. The Local Authority contracting monitoring visit found that ‘an odour was coming from a residents bedroom’, advice was given that the responsible individual should contact the residents social worker ‘to see if he can provide any assistance’. The residents survey showed that six residents felt that the home always smells fresh and clean, with five residents stating that the home usually smells fresh and clean and one resident commenting that it never smells fresh and is never clean. Mablethorpe Hall DS0000065213.V313219.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected 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 good. This judgement has been made using available evidence including a visit to this service. Residents are protected by robust recruitment practices. Staff receive training specific to the needs of this client group. EVIDENCE: The Local Authority contracting monitoring visit found that ‘ it was evident that a POVA/CRB checks (Current Criminal Record Bureau & Protection Of Vulnerable Adults checks) had been carried out in respect of the most recent person employed’. A carer confirmed that she had provided two references, had undertaken an interview and a CRB had been undertaken prior to her appointment at this home. The home has obtained The General Social Care Council Codes of Practice, which sets out responsibilities as care workers looking after vulnerable adults. One care worker stated that she has not been given a copy of this document. 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; induction training is now available for all care staff in the form of ‘Skills For Care’. The RI stated that six carers have started Mablethorpe Hall DS0000065213.V313219.R01.S.doc Version 5.2 Page 20 NVQ training level 2, three carers are doing NVQ level 3, three carers have NVQ level 2 and one has NVQ level 3. Training specific to this client group was also seen to have been undertaken as well as fire training and first aid. 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 ‘staffing levels are normally good with three on in the morning and three in the afternoon’. The RI who works thirty hours a week at this home is not recorded on the rota. Mablethorpe Hall DS0000065213.V313219.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected 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. The home holds residents meetings. Quality assurance audits of residents and visitor’s views are not carried out. Accurate records are kept of residents’ monies. Risk assessments are not available regarding first floor windows. EVIDENCE: This home is currently without a registered manager, with the RI taking on this task. The provider now needs to employ a qualified, competent and experienced person with at least two years experience in a senior management position to run this home. The commission must be kept informed about the progress of the providers efforts in employing a manager. Mablethorpe Hall DS0000065213.V313219.R01.S.doc Version 5.2 Page 22 There was no evidence available to show that the home conducts an in-house quality assurance check or report. Evidence was seen in the minutes of residents meetings that these were held on the 25/06/06 and 15/08/06. A previous inspection found that the provider deals with a number of residents personal allowances, with four residents managing their own monies. Some residents are subject to power of attorney, guardianship orders with their finances managed by the social services department/the courts or their families. Receipts are kept of monies spent by residents. Two residents monies were checked against the record of monies held on their behalf and it was found that accurate record was kept. There are a range of policies and procedures available in the home relating to fire safety and fire risk assessments. There was evidence that that fire alarms, fire drills had been undertaken but emergency lighting had not been tested. Care staff receive fire training as part of the homes initial training and as a regular training event. Certificates were available showing that hoists and the shaft lift had been serviced on a six monthly basis as required. Risk assessments are not available for windows on the first floor, which do not have window restrictors. This was a requirement from the last inspection. The homes service history shows that the Commission has not received Regulation 26 reports from the providers for the months of July and August 06 regarding the running of the home. This was a requirement from the last inspection of this home. Mablethorpe Hall DS0000065213.V313219.R01.S.doc Version 5.2 Page 23 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 2 3 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 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 x x x x x 3 2 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 2 x 2 x 3 x x 2 Mablethorpe Hall DS0000065213.V313219.R01.S.doc Version 5.2 Page 24 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 OP2 Regulation 5(c) Requirement The provider must ensure that residents have a contract setting out the terms and conditions of their placement. The provider must ensure that all residents have care plans detailing the care that is to be provided. Care plans must be reviewed so as to contain more detailed information about the needs of residents. (The timescale of the 25/06/06 has not been met) Timescale for action 25/11/06 2 OP7 17(1) 25/11/06 3 OP7 17 (1) Schedule 3 25/11/06 11. OP13 16(m) The home must consult residents 25/11/06 about their social interests and make arrangements for them to engage in local, social and community activities. Some action has been taken but community involvement needs to be explored. (The timescale of the 25/06/06 has been partially met) The home must ensure that a 25/11/06 record is made relating to the likes and dislikes of residents relating to all aspects of the daily DS0000065213.V313219.R01.S.doc Version 5.2 Page 25 4. OP14 12(2) Mablethorpe Hall living needs. (The timescale of the 25/06/06 has been partially met) 5 OP18 13(6) The provider must notify the appropriate authorities regarding any adult protection issues that arises. The provider must ensure that all parts of the home to which residents have access as so far as reasonably practicable free from hazards to their safety. 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. (The timescale of the 25/06/06 has not been met) 25/11/06 6 OP19 13(4) 25/11/06 7. OP19 23(b) 25/11/06 8. OP26 16(2)(k) The home must keep the care 25/11/06 home free from offensive odours. (The timescale of the 25/06/06 has been partially met) 25/11/06 9 OP31 10. OP33 Op9 The provider must appoint a (2)(a)(b)(i suitably qualified and )(c) experienced manager to the home. The commission must be kept informed of progress relating to an appointment. 24 (3) 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. 26 The registered person must visit the home at least once a month and interview residents and persons working at the home as DS0000065213.V313219.R01.S.doc 25/11/06 11 OP38 25/11/06 Mablethorpe Hall Version 5.2 Page 26 12. OP38 23(4)(v) 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 of the findings of the unannounced visit. (The timescale of the 25/03/06 and 25/05/06 has not been met with July and August 06 not being received by the commission a new compliance date has been set). The registered person must take 25/11/06 adequate precautions against the risk of fire; and make arrangements for reviewing fire precautions and testing fire equipment at suitable intervals. This is partially met but emergency lighting was found not to have been tested and a new time scale has been set. All rooms without window restrictors must have a risk assessment to minimise the risk to service users. (The timescale of the 25/06/06 has not been met) 25/11/06 13. OP38 13(4)(a) 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 OP30 Good Practice Recommendations The home should furnish all staff with the General Social Care Councils Conduct of Practice for their information. DS0000065213.V313219.R01.S.doc Version 5.2 Page 27 Mablethorpe Hall One staff member confirmed that she had not received this document. This recommendation is not met. 2. OP9 Resident’s photographs should be included in the front of their medication sheets to ensure that the right medication is given to the right person. This recommendation has not been met. The provider should consult with residents, health care and social workers concerning community day care provision for residents. The home must have a minimum ratio of 50 trained staff members to NVQ level two excluding the registered manager. This recommendation is partially met. 3 4. OP13 OP28 Mablethorpe Hall DS0000065213.V313219.R01.S.doc Version 5.2 Page 28 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.V313219.R01.S.doc Version 5.2 Page 29 - 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. 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