Inspection on 06/07/05 for Maefin Lodge

This inspection was carried out on 6th July 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Maefin Lodge 06/02/07

Maefin Lodge 16/02/06

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 194 South Esk Road Forest Gate London E7 8HD Lead Inspector Lea Alexander Unannounced Inspection 6th July 2005 at 2.00 pm 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 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 Stationary 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 G57 G06 S22871 Maefin Lodge V237714 060705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Maefin Lodge Address 194 South Esk Road, Forest Gate, London, E7 8HD Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8586 7812 020 8586 7940 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 G57 G06 S22871 Maefin Lodge V237714 060705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 18th February 2005 Brief Description of the Service: Maefin Lodge is a three bedroomed 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 which 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 which 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, handbasin 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 closeby 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 G57 G06 S22871 Maefin Lodge V237714 060705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection by one inspector during the course of an afternoon and early evening. The main purpose of the inspection was to monitor progress in dealing with the 33 requirements made at the last inspection in February 2005. The Inspector met with the support worker on duty, with the registered manager and spoke with one service user. Personnel files and service user files were also examined as were records relating to medication and current medication supplies. The Inspector also viewed the homes policies and procedures. What the service does well: What has improved since the last inspection? What they could do better: The homes service user guide requires revision. To promote service users autonomy and independence individual support plans need to be developed to include details of the personal care provided and how the service user prefers to receive this. The homes practise in identifying and supporting service users with activities and areas of interest also needs to be developed. To promote service users role in the day to day running of the home they should be encouraged and supported to attend regular meetings and their views sought regarding staff recruitment. To promote service user health and well being a plan to deliver training in core areas needs to be developed. An up to date staffing rota must always be available. Maefin Lodge G57 G06 S22871 Maefin Lodge V237714 060705 Stage 4.doc Version 1.40 Page 6 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 G57 G06 S22871 Maefin Lodge V237714 060705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Maefin Lodge G57 G06 S22871 Maefin Lodge V237714 060705 Stage 4.doc Version 1.40 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 standard(s) 1 & 5. The home has made some progress in pursuing previous requirements regarding their contracts with service users. This needs further development to meet National Minimum Standards. EVIDENCE: The Inspector viewed the current service user guide. This contains a summary of the homes statement of purpose and most of the other information required by regulation. The service user guide requires minor revision to fully comply and details of the shortfalls are contained in the requirements section of this report. There have been no new admissions to the home since the last inspection and Standard 2 was not therefore inspected on this occasion. At the last inspection the home was required to develop its practise with regards to contracts with service users. Since then the home has sent a contract to one of its service users placing authority. This has not been returned. After discussion with the Registered Provider it was agreed that they should use the original placement contract generated by the local authority social services department and signed by them and the registered provider. This document, with appropriate advocacy and support services should be shared with the service user or their representative and then signed off by them to Maefin Lodge G57 G06 S22871 Maefin Lodge V237714 060705 Stage 4.doc Version 1.40 Page 9 indicate their agreement. Subsequent letters from the placing authority, usually received annually and detailing any changes to the contract should be dealt with in the same way. Maefin Lodge G57 G06 S22871 Maefin Lodge V237714 060705 Stage 4.doc Version 1.40 Page 10 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 standard(s) 6, 7, 8 & 9. In the home needs to develop its care planning processes to ensure that they are service user focused. Service users are not actively involved in the day to day running of the home and this is another area for development. EVIDENCE: The last inspection had resulted in a requirement for the home to review its current care plan document and to ensure that it contained sufficient information. The Inspector reviewed the care plans for both service users and noted that one receives support with personal care. The information recorded requires expansion to include what specific help with personal care is required, and how the service user prefers to receive this support. The Inspector noted that service users now sign their care plans to indicate their agreement. The Inspector noted that new members of staff had been taken up post since the last inspection. It was not evidenced that service users had participated in the recruitment process. The service user spoken to by the Inspector Maefin Lodge G57 G06 S22871 Maefin Lodge V237714 060705 Stage 4.doc Version 1.40 Page 11 expressed an interest in being more involved with staff selection and recruitment. The Inspector viewed minutes of recent service user meetings and noted that these were kept on individual service users files. For one service user there was one record of them having attended a service user meeting. After reading the minutes however, it became clear that this was in fact a recording of a particularly good day the service user had had and was not a service user meeting to discuss issues relating to the home. On the other service users file several copies of minutes relating to service users meetings were found. These did not evidence that all service users had been invited to the meetings. The minutes did indicate that there had been discussions between this service user and the manager regarding a summer holiday. The home needs to develop its practises regarding service users meetings. Both service users should be invited and supported to attend. The meeting should be a forum that facilitates service user involvement in the running of the home. The Inspector reviewed risk assessments on both service users files and noted that these had been recently reviewed and were signed off by both the home and service user. Maefin Lodge G57 G06 S22871 Maefin Lodge V237714 060705 Stage 4.doc Version 1.40 Page 12 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 standard(s) 11, 12 & 17. The care home needs to develop its practises with regard to the activities service users are offered. All service users should have the opportunity to express and pursue their own interests. EVIDENCE: From viewing service users files it was evidenced that copies of reports prepared by other professionals had been obtained and are kept on the personal file. The Inspector reviewed the activities section on the care plan for one service user. This did not include contact with family members and that appears to be the main activity outside of the home for this person. Two activities were identified on the plan: going to the hairdressers and attending a tea dance. There was no record in the daily contact sheet for the last two months of these activities being offered. From the information recorded on the file there were only two entries since April 2005 that evidenced that this service user had left the house. The care plan did identify a request to the allocated social worker to refer this service user to a day centre. The Registered Provided advised the Inspector that the request had been made to the social worker and the home are waiting for feedback. Maefin Lodge G57 G06 S22871 Maefin Lodge V237714 060705 Stage 4.doc Version 1.40 Page 13 The home must ensure that it regularly reviews with service users the activities they would like to pursue inside and outside of the home and supports them in engaging with these. Records of activities offered and declined should inform this process. The Inspector did note that the other service currently residing at the home is engaged with a day service and luncheon club and chooses to visit staff and service users from the adjoining residential home. The Inspector viewed the contents of the fridge and freezer. It was noted that there had been improvements since the last inspection with regard to the labelling of opened foods and observing best before dates. There was however one item of packaged food in the fridge that had been opened and not labelled. Maefin Lodge G57 G06 S22871 Maefin Lodge V237714 060705 Stage 4.doc Version 1.40 Page 14 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 standard(s) 19 & 20. The home has ensured the health and safety of service users by improving its medication recording practises. EVIDENCE: The previous inspection had required the home to record all accidents in the accident book. The Inspector viewed this and noted that two accidents ha been recorded in it since the last inspection. At the last inspection had identified several shortfalls with regard to the administration of medication and associated medication records. The inspector viewed relevant documents and noted that the Medication Administration Record (MAR) system had been reviewed and a monthly MAR is now kept for each service user. The MAR was easy to follow and understand and had been correctly completed. There were no unexplained gaps. “As required (PRN)” medication was clearly marked, and the circumstances in which it should be administered clearly stated on the medication and the MAR sheet. The Inspector looked at the dossett boxes for each service user and was satisfied that these had been correctly loaded. The records of medication received into the home corresponded with the record of what had been administered and with what was currently available. Maefin Lodge G57 G06 S22871 Maefin Lodge V237714 060705 Stage 4.doc Version 1.40 Page 15 The Inspector did note that a pencil had been used to sign off a medication as finished. All records must be completed in ink. Maefin Lodge G57 G06 S22871 Maefin Lodge V237714 060705 Stage 4.doc Version 1.40 Page 16 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 standard(s) 23. The homes policy regarding adult protection ensures service users are protected and safe. The home needs to develop its adult protection-training programme to ensure that staff can implement the homes policy. EVIDENCE: The previous inspection had required the home to review its adult protection policy and procedure. The Inspector noted that this has been completed and that the policy now meets National Minimum Standards. The Inspector also noted that adult protection training had been identified as one of the homes core training programmes. Adult protection training is recorded as last occurring in February 2004. As several members of staff have joined since then the home should keep under review the need for further adult protection courses and refresher training. Maefin Lodge G57 G06 S22871 Maefin Lodge V237714 060705 Stage 4.doc Version 1.40 Page 17 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 standard(s) 24, 28 & 30. The home promotes service users well being by providing a homely, comfortable, clean, odour free and generally 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. The Inspector noted that potential hazards identified at the previous inspection including the safe storage of cleaning materials had been appropriately addressed. The Inspector did observe the continued practise of carpet off cuts being placed by fire doors. These pose a potential trip hazard. The Registered Provider advised that the fire doors are extremely loud when shutting and the off cuts provide a buffer. The Registered Provider further stated that a specialist contractor had visited to address the problem but this had not yet been resolved. Maefin Lodge G57 G06 S22871 Maefin Lodge V237714 060705 Stage 4.doc Version 1.40 Page 18 The Inspector noted that waking night cover is now provided in the home as a result of a review of service user need. Maefin Lodge G57 G06 S22871 Maefin Lodge V237714 060705 Stage 4.doc Version 1.40 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33 & 35. The home promotes the quality of care service users receive by identifying core-training courses staff should attend. The home needs to follow through on this commitment by developing a plan for staff to attend these courses. EVIDENCE: The Inspector sampled two personnel files and noted that appropriate job descriptions were available on each. Based on discussion with the support worker on duty the Inspector was satisfied that this staff member had an appropriate understanding of their own and others roles and responsibilities. The Inspector noted that five support workers are currently employed within the home. Four of these are undertaking NVQ level II studies. The fifth employee is studying for a nursing qualification. The Registered Provider has identified core-training courses for staff and these include: * * * * * * Bereavement Challenging behaviour Epilepsy First aid Food hygiene Health and safety G57 G06 S22871 Maefin Lodge V237714 060705 Stage 4.doc Version 1.40 Page 20 Maefin Lodge * * * Manual handling Medication Incontinence management The training record seen by the Inspector indicates that in four of these areas no staff have received training. All staff have received training on medication in care homes in March of this year. The Registered Provider is required to develop a plan to ensure that identified core training areas are provided to staff. The Inspector was advised that one support worker had recently left the home and a part time worker had increased her hours during college holidays to cover this vacancy. The Inspector noted however that even with these arrangements a second support worker slot rota’d for Wednesday afternoon remains vacant. The Registered Provider advised the Inspector that she was covering the vacant slot at present. The Registered Provider must ensure that there are sufficient staff numbers to meet service users needs. Maefin Lodge G57 G06 S22871 Maefin Lodge V237714 060705 Stage 4.doc Version 1.40 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39, 40, 41, 42 & 43. Service users are benefiting from improvements in the management of the home. Identified policies and procedures have been reviewed and required records are being regularly kept. The home must ensure service user safety by having an up to date staffing rota. EVIDENCE: The Inspector noted that both service users had recently completed service user feedback questionnaires. In addition the views of several family members of one service user and their social worker had also been sought via a questionnaire. The feedback on these forms, particularly from service users families was positive. At the previous inspection several revisions to the homes policies and procedures remained outstanding. The Inspector noted that these have now been completed and meet National Minimum Standards. Maefin Lodge G57 G06 S22871 Maefin Lodge V237714 060705 Stage 4.doc Version 1.40 Page 22 The Inspector asked to see the current rota and noted that the one produced had expired five days earlier. The Registered Provider advised that she was at present working on a new rota. The Inspector checked current fridge and freezer temperatures and noted that these were within guidelines. A log of temperatures is being recorded daily and this also indicates that temperatures are within guidelines. The Inspector noted that the current registration certificate is now displayed in the upper landing hallway. Maefin Lodge G57 G06 S22871 Maefin Lodge V237714 060705 Stage 4.doc Version 1.40 Page 23 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x x x 2 Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 2 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x 3 x 3 Standard No 11 12 13 14 15 16 17 3 2 x x x x 2 Standard No 31 32 33 34 35 36 Score 3 2 2 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Maefin Lodge Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 3 2 3 3 G57 G06 S22871 Maefin Lodge V237714 060705 Stage 4.doc Version 1.40 Page 24 Yes Are there any outstanding requirements from the last inspection? 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 1 Regulation 5 Requirement The service user guide requires minor revision to include: (a) the number of staff employed within the home (b) the complaints procedure summary should state that complaints will be dealt with within a 28 day period (c) a reference on how to access the most recent inspection report kept in the home. Care plans must contain sufficent information. This is a restated requirement. Service users must be involved in staff and service user selection and the reviewing of policies and procedures. This is a restated requirement. Service users meetings that both service users are invited to, and supported to attend, should be held regularly. The home must identify with all service users activities they want to engage in and support them to do this. Records of activities offered and declined should inform this process. The home must ensure that opened food packages are Timescale for action 06/10/05 2. 3. 6 8 15(1) 12(3) 06/10/05 06/10/05 4. 8 12(2) 06/10/05 5. 12 12(2) & 12(3) 06/10/05 6. 17 16(2)(i) 06/08/05 Page 25 Maefin Lodge G57 G06 S22871 Maefin Lodge V237714 060705 Stage 4.doc Version 1.40 appropriately date labelled. 7. 8. 20 24 13(2) 13(4)(a) Medication Administration Records must be completed in ink. Off cuts of carpet used by the kitchen door pose a potential trip hazard and must be removed. This is a restated requirement. The Registered Provider is required to develop a training plan to ensure that staff receive training in all identified core areas. The Registered Provider must ensure sufficient staffing numbers. The Registered Provider must ensure that an up to date staff rota is available at all times. This is a restated requirement. 06/08/05 06/10/05 9. 32 18(1)(c)(I ) 06/10/05 10. 11. 33 41 18(1) 18(1)(a) 06/10/05 06/08/05 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 Good Practice Recommendations Maefin Lodge G57 G06 S22871 Maefin Lodge V237714 060705 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Gredley House 1-11 Broadway 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 G57 G06 S22871 Maefin Lodge V237714 060705 Stage 4.doc Version 1.40 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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