Inspection on 16/02/06 for Maefin Lodge

This inspection was carried out on 16th February 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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Maefin Lodge 06/02/07

Maefin Lodge 06/07/05

Maefin Lodge 18/02/05

Maefin Lodge 01/07/04

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

CARE HOME ADULTS 18-65 Maefin Lodge Maefin Lodge 194 South Esk Road Forest Gate London E78HD Lead Inspector Lea Alexander Unannounced Inspection 16th February 2006 11:15 Maefin Lodge DS0000022871.V277095.R01.S.doc Version 5.1 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 Maefin Lodge DS0000022871.V277095.R01.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 Adults 18-65. 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. Maefin Lodge DS0000022871.V277095.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Maefin Lodge Address Maefin Lodge 194 South Esk Road Forest Gate London E78HD 020 8586 7812 020 8586 7940 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Theresa John Mrs Theresa John Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) Maefin Lodge DS0000022871.V277095.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th July 2005 Brief Description of the Service: Maefin Lodge is a three bed roomed terraced house situated on a residential road in Forest Gate. It is a registered care home for 3 adults with mental health needs. The accommodation comprises a communal lounge that is well maintained and includes a sofa, armchairs, television and stereo system. There is a kitchen/dining area to the rear of the ground floor with a toilet and shower room off. There is a patio area to the side of the kitchen that leads onto a small lawned area. There is a storage shed at the end of the garden. One service users bedroom is on the ground floor with a further two bedrooms, one of which has ensuite facilities, on the first floor. On this level there is a further bathroom comprising of toilet, hand basin and bath. The office is located to the rear of the first floor. There are currently two service users residing at the home. The home is situated close by to local bus links on the Romford Road with frequent services to both Stratford and Ilford. Local shops are available within walking distance on Green Street. The registered provider also owns the care home adjacent to Maefin Lodge, which provides residential care to 3 adults with learning difficulties. Maefin Lodge DS0000022871.V277095.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the Inspectors third visit to the home. The inspection was carried out over the course of two short visits on the 16th February and 3rd March. One of these was unannounced. The focus of the inspection was to review the progress made with the 11 requirements made at a previous inspection on 6th July 2006. The Inspector met with the Registered Manager and the support worker on duty. The Inspector sampled service users personal files, staff personnel files and other relevant documentation. What the service does well: What has improved since the last inspection? What they could do better: Five requirements were made as a result of this inspection. Maefin Lodge DS0000022871.V277095.R01.S.doc Version 5.1 Page 6 The home should further revise its statement of purpose to include information on the numbers and qualifications of staff. Service users individual plans must be regularly reviewed. Further improvement is required in the homes Medication Administration Recording (MAR) practises, and the homes recruitment policy should be updated to include the Registered Managers stated plans to include service users in future staff and service user selection. The home must obtain its own enhanced level Criminal Records Bureau checks for all staff. 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. Maefin Lodge DS0000022871.V277095.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Maefin Lodge DS0000022871.V277095.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 2. The homes statement of purpose helps prospective service users make decisions about where they will live. EVIDENCE: The Inspector reviewed the homes statement of purpose. This had been revised since the last inspection and includes a summary of the homes complaints procedure, including timescales and information on how to access inspection reports. The statement of purpose requires further minor revision to include the number, relevant qualifications and experience of staff working in the home. The home has had no new admissions since the last inspection, and standard 2 is not therefore applicable on this occasion. Maefin Lodge DS0000022871.V277095.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 & 8. Service users benefit from individual care plans and are consulted about the day-to-day running of the home. EVIDENCE: The Inspector sampled the personal files for both service users. Individual care plans have been developed for each. One of these was annotated to indicate that it had been reviewed in July 2005. The other service users care plan was dated March 2005. The Inspector noted that individual care plans include information relating to activities within the home and the community and information on how service users prefer to receive their care. The Registered Manager advised that no new staff have been recruited since the last inspection. They further stated that in future potential staff members and service users would be invited to visit the home and meet informally with service users, whose feedback would then be obtained. The Inspector advised that the homes policy and procedures be revised to reflect this. The Inspector viewed the minutes of service users meetings. This evidenced that both service users had been supported to attend meetings in August and October 2005. Issues discussed at these meetings included a request from Maefin Lodge DS0000022871.V277095.R01.S.doc Version 5.1 Page 10 one service user to have a covered outside smoking area. The Registered Manager stated that a further service user meeting had been held in December 2005, although no minutes were available for this. Key standards 7 and 9 were not inspected on this occasion. They were inspected and assessed as met on the 6th July 2005. Maefin Lodge DS0000022871.V277095.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the 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, 16 & 17. Service users are supported to engage in appropriate occupational, community and leisure activities. EVIDENCE: The Inspector sampled the personal records for both service users. These evidenced that one service user attends an elders day service and an African Caribbean luncheon club. They also go swimming one day per week. This service user has also recently been on holiday for three weeks to the destination of their choice. The other service user has been supported to spend time in the community by going on walks and visits to local parks. They have also had lunches at a local café and visited a local hairdresser. This service user is also supported to make phone calls to family members and have family visit them regularly in the home. This service user has also been referred for assessment by a local day service. Both service users have freedom passes and one is registered with a disability transport “door to door” service. Maefin Lodge DS0000022871.V277095.R01.S.doc Version 5.1 Page 12 The previous on the 6th July had required the home to date label opened processed foods. The Inspector sampled the homes fridge and freezer during this inspection and found all started food items to be appropriately labelled. Maefin Lodge DS0000022871.V277095.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18. Continued improvement is needed in the homes medication recording practises. EVIDENCE: The Inspector sampled the Medication Administration Records for both service users. These were completed in ink as required by the previous inspection. The Inspector noted that the MAR for one service user had been left blank for one date. No code had been entered to indicate missed medication or the reason for this. Key standards 19 and 20 were not inspected on this occasion. They were inspected on the 6th July 2005 and assessed as met. Maefin Lodge DS0000022871.V277095.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22. The homes complaints policy aims to listen to act on the views of service users and other interested parties. EVIDENCE: The Inspector sampled the homes complaints policy and complaints log. The log identified that the most recent complaint had been made in September 2005 and was made by a neighbour concerned about noise levels. The log indicated that the matter was dealt with by the manager speaking to the neighbour and taken action to reduce noise within the home. The home has a complaints policy that advises complainants that matters will be dealt with in a timescale of 28 days. The policy also contains information on the Commission for Social Care Inspection. Key standard 23 was not inspected on this occasion. It was inspected and assessed as met on the 6th July 2005. Maefin Lodge DS0000022871.V277095.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. Service users benefit from a comfortable, homely and well maintained environment. EVIDENCE: The Inspector toured the premises and found them to be clean, tidy, free of offensive odours and well maintained. Service users each have their own private bedrooms. One of these has en-suite facilities. There is a shared bathroom on the first floor and shared shower room on the ground floor. There is also a communal lounge and kitchen/dining area. Potentially hazardous cleaning materials are appropriately stored in a locked cabinet. The Inspector noted that potential hazards identified at the previous inspection including the safe storage of cleaning materials had been appropriately addressed. Maefin Lodge DS0000022871.V277095.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35. Service users benefit from competent, qualified staff. However the home must ensure that its recruitment practises protect service users. EVIDENCE: The Inspector sampled the homes current staffing rota and was satisfied that sufficient numbers of care staff are employed and rostered on duty to provide appropriate levels of care. At present the home employs five care staff, and since the last inspection a volunteer has also been recruited and has undertaken a short training course. The Inspector sampled the personnel records for two staff members. These each contained a job description and two satisfactory references. Proofs of identity were also available in the form of photocopied passports and National Insurance cards. The Inspector noted however that previous employers obtained the Criminal Records Bureau (CRB) checks on file, and that the home had not undertaken its own CRB check as part of the recruitment process. Three care staffs have successfully completed their NVQ level 2 studies and two other staff members are currently undertaking NVQ level 2 studies. Since the last inspection the home has developed a personnel development plan to be completed by all staff and an annual training plan. Drug administration training is scheduled to take place in March 2006. Maefin Lodge DS0000022871.V277095.R01.S.doc Version 5.1 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 41. Service users benefit from a well run home. EVIDENCE: The Registered Manager is also the proprietor for and adults with learning difficulties care home adjacent to Maefin Lodge. They are currently completing NVQ level 4 studies. The Inspector sampled the homes staffing rota and found this to be in order. A staff member was clearly identified as working each shift, and the rota ran for a five-week period. Key standards 39 and 42 were not inspected on this occasion. They were inspected and assessed as met on the 6th July 2005. Maefin Lodge DS0000022871.V277095.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 N/A 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 X ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X 2 X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 X X X 3 X X X 3 X X Maefin Lodge DS0000022871.V277095.R01.S.doc Version 5.1 Page 19 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 YA1 Regulation 5 Requirement The service user guide requires minor revision to include the number, relevant qualifications and experience of staff working in the home. Service users individual plans must be reviewed at least six monthly, or as their needs change. The home must revise its recruitment policy and procedure to include information on how service users will be involved. Medication Administration Records must be fully completed and appropriate codes entered for any missed medication. The home must apply for and obtain a Criminal Records Bureau check for all staff members. Timescale for action 01/07/06 2. YA6 15(2) 01/07/06 3. YA8 12(3) 01/07/06 4. YA20 13(2) 01/07/06 5. YA34 Sched 2 01/07/06 Maefin Lodge DS0000022871.V277095.R01.S.doc Version 5.1 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Maefin Lodge DS0000022871.V277095.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ 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 Maefin Lodge DS0000022871.V277095.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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