Inspection on 06/02/07 for Maefin Lodge

This inspection was carried out on 6th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Maefin Lodge 16/02/06

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 E7 8HD Lead Inspector Lea Alexander Unannounced Inspection 6 February 2007 11:00 th Maefin Lodge DS0000022871.V322735.R01.S.doc Version 5.2 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.V322735.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 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.V322735.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Maefin Lodge Address Maefin Lodge 194 South Esk Road Forest Gate London E7 8HD 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.V322735.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th February 2006 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.V322735.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the Inspectors fourth visit to the home. The inspection was carried out over the course of a day on the 6th February 2007. The inspection focused on key National Minimum Standards and the progress made with requirements made at an earlier inspection on the 16th February 2006. The Inspector met with the Registered Manager and the support worker on duty and spoke privately with one service user. 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? The home has revised and updated its recruitment policy and procedure to include guidance on how service users will be involved in staff recruitment. Medication Administration Records are properly completed. Maefin Lodge DS0000022871.V322735.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Maefin Lodge DS0000022871.V322735.R01.S.doc Version 5.2 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.V322735.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home carries out its own assessments for potential service users, but should update its service users guide to give accurate information. EVIDENCE: A previous inspection had identified the need for the home to update its service user guide to include information on the numbers, experience and qualifications of staff working at the home. The Inspector sampled the guide and found this to be outstanding. There have been no new admissions to the home since the last inspection. The Inspector case tracked the two service users currently living at the home, and evidenced that relevant information from other professionals had been obtained in addition to the home carrying out its own assessment. Maefin Lodge DS0000022871.V322735.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has developed individual plans for service users and assesses potential risks. The home should ensure that plans are reviewed at least every six months and that service users are supported to take part in the day-to-day running of the home. EVIDENCE: By sampling the personal records of the homes service users, the Inspector evidenced that each has an individual plan that addresses their personal, health and social care needs. These plans are signed by the service user to evidence their participation in the process. One service users plans were signed and dated to evidence that they had been reviewed every six months. However, the other service users plan was dated February 2006 with no evidence of a review since. One service user was identified as requiring assistance in managing their personal finances, but the nature of this support Maefin Lodge DS0000022871.V322735.R01.S.doc Version 5.2 Page 10 was not detailed in their individual plan. Completed risk assessments relating to the individual plan were found on the personal file and it was evidenced that these had last been reviewed in August 2006. The Inspector viewed the minutes of service users meetings and noted that these are held regularly. However, the minutes are kept in individual service users personal files and to maintain confidentiality the home should review this arrangement. The Inspector reviewed the homes recruitment policy. This includes information on how the home plans to include service users in the recruitment of new staff members. Consultation with the Registered Manager and one service user evidenced that service users had not been included in recent recruitments. During the course of the inspection the Inspector observed that the home accepts students on placement. Discussion with the Registered Manager and one of the service users evidenced that student placements had not been discussed and agreed with service users. Maefin Lodge DS0000022871.V322735.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home supports service users to engage in a range of community and leisure activities. EVIDENCE: Sampling of service users individual plans, daily record logs, discussions with service users and the Registered Manager all evidenced that service users are supported to engage in a range of activities according to their needs and abilities. Both service users have been registered with the “door to door” transport service. One service user has a full weekday activity programme during which they attend several different community and social groups and the local swimming baths. The other service user does not engage with structured activities, but is supported to visit local shops, to have their lunch at Maefin Lodge DS0000022871.V322735.R01.S.doc Version 5.2 Page 12 a local café and to visit the local cemetery and hairdressers. Family members also regularly visit them. During the course of the inspection the Inspector observed that staffs interact with service users and service users choose when to be alone and when to join in an activity. Discussion with service users evidenced that they are offered a choice of suitable menus that meet their dietary and cultural needs. Maefin Lodge DS0000022871.V322735.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes medication policy should be updated and all as required medication properly listed on the Medication Administration Record. Service users receive personal care in the way that they prefer and are supported to attend regular healthcare appointments. EVIDENCE: Sampling of service users personal files and discussion with one service user evidenced that the home recognises service users preferences in the way assistance with personal care is provided and implements these in practise. A record was found on each service users personal file of the healthcare appointments they had attended. These included check ups with the GP, practise nurse, dentist, optician and chiropodist. A record of the appointment along with its outcome and any follow up was recorded. The Inspector sampled the homes medication policy. The copy provided appeared incomplete as it finished halfway through a sentence. The policy did Maefin Lodge DS0000022871.V322735.R01.S.doc Version 5.2 Page 14 not address the need for self-medication to occur within a risk assessment framework or address the disposal of controlled drugs. The Inspector sampled the medication kept in the home. The Registered Manager advised that a pharmacist loads dossett boxes for each service user for a four-week period. Comparison of the Medication Administration Record (MAR) with the medication available highlighted that an “as required (PRN)” medication had not been listed on the MAR. MAR sheets were evidenced as being properly completed with no omissions. Maefin Lodge DS0000022871.V322735.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home listens to service users and protects them from abuse. EVIDENCE: The Inspector viewed the homes complaints policy and procedure. This clearly outlines the ways in which service users and other parties can make a complaint, the timescales in which the home aims to deal with complaints, and gives contact details for the Commission for Social Care Inspection. The home maintains a record of complaints made that includes the date and nature of the complaint and the action taken. The home has an adult protection policy that includes definitions of abuse and possible indicators that a service user is being abused. The policy also outlines individual staff responsibilities and makes appropriate reference to local multi agency adult protection procedures. Discussion with the member of care staff on duty evidenced a good understanding of adult protection issues and their responsibilities. There have been no adult protection matters notified since the last inspection. Maefin Lodge DS0000022871.V322735.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a comfortable, homely environment that is well maintained and free from odours. 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. Maefin Lodge DS0000022871.V322735.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Suitably qualified staff appropriately staffs the home. However, the home must ensure that its recruitment practises protect service users and that staffs receive minimum levels of supervision. EVIDENCE: The Registered Manager advised the Inspector that they are introducing a new computer system to record the training undertaken by staff and to automatically identify when refresher training is required. The Registered Manager advised the Inspector that the home plans to offer continence, medication and adult protection refresher training to staff in the coming year. The Inspector sampled the personnel files for three staff members and evidenced that a completed induction record was available for each. However, one staff member had only one reference available and two staff members did not have Criminal Records Bureau checks that had been obtained by the current employer. Maefin Lodge DS0000022871.V322735.R01.S.doc Version 5.2 Page 18 The Inspector also sampled supervision records for three members of care staff. Two staff members were recent recruits, and both had received supervision since taking up their post. A third, longer serving member of staff was evidenced as receiving four supervision sessions in the last year, and five in the previous year. The home currently employs four full time and one part time care staff. The Registered Manager advised that three of these had successfully completed NVQ level 2. The Inspector viewed the homes current staffing rota and found that this accurately reflected the staffing situation found in the home on the day of the inspection. Maefin Lodge DS0000022871.V322735.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well managed home. EVIDENCE: The homes Registered Manager has successfully completed NVQ level 4 and the Registered Managers Award. The home has a quality assurance process in place that includes obtaining the views of service users and their relatives through questionnaires. The Inspector viewed completed questionnaires and noted that service users are satisfied with the service they receive. The Inspector also noted that these questionnaires were dated 2005, and the Registered Manager advised that the Maefin Lodge DS0000022871.V322735.R01.S.doc Version 5.2 Page 20 home was reviewing and updating its quality assurance process and would issue revised questionnaires in the coming year. The Inspector viewed a sampled of the homes health and safety records. These evidenced that weekly fire alarm tests are carried out and regular evacuation drills are practised. A weekly record of water temperatures is also maintained. However, sampling of the homes record of fridge and freezer temperatures evidenced that these are not carried out on a daily basis. The Inspector viewed the homes accident and incident records and found these to be in order. Maefin Lodge DS0000022871.V322735.R01.S.doc Version 5.2 Page 21 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 3 2 3 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 3 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 X 34 1 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 2 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Maefin Lodge DS0000022871.V322735.R01.S.doc Version 5.2 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 YA6 Regulation 15(2) Requirement Service users individual plans must be reviewed at least six monthly, or as their needs change. This is a restated requirement. The previous target of the 01/07/06 was not met. Service users who require support in managing their finances should have the details of this support outlined in their individual plan. The home should implement its policy relating to the involvement of service users in staff recruitment. Timescale for action 30/05/07 2. YA7 16 & 20 30/05/07 3. YA8 12(3) 30/05/07 4. 5. YA20 YA34 13(2) Sch 2 Future student placements should be discussed and agreed with service users in advance. As required (PRN) medication 30/05/07 should be properly entered onto the MAR sheet. The home must apply for and 30/05/07 obtain a Criminal Records Bureau check for all staff members. This is a restated requirement. The previous target of the Maefin Lodge DS0000022871.V322735.R01.S.doc Version 5.2 Page 23 01/07/06 was not met. The home must evidence that it obtains two satisfactory written references for potential employees. Staff must receive a minimum of six supervisions a year. The home must record fridge and freezer temperatures on a daily basis. 6. 7. YA36 YA42 12 & 18 16 30/09/07 30/05/07 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 YA2 Good Practice Recommendations To support service users to make informed decisions about the home the service user guide should include information on the number, relevant qualifications and experience of staff working in the home. To ensure service users confidentiality the home should review the current storage arrangements for the minutes of service users meetings. 2. YA10 Maefin Lodge DS0000022871.V322735.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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