Inspection on 01/11/05 for Maldon Lodge

This inspection was carried out on 1st November 2005.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Maldon Lodge 04/07/07

Maldon Lodge 21/08/06

Maldon Lodge 15/02/06

Maldon Lodge 09/03/05

Maldon Lodge 21/09/04

Maldon Lodge 18/03/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Maldon Lodge 123 Maldon Road Colchester Essex CO3 3AX Lead Inspector Steve Boyd Final Unannounced Inspection 09:30 1st November Maldon Lodge DS0000017877.V257394.R01.S.doc Version 5.0 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 Maldon Lodge DS0000017877.V257394.R01.S.doc Version 5.0 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. Maldon Lodge DS0000017877.V257394.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Maldon Lodge Address 123 Maldon Road Colchester Essex CO3 3AX 01206 506059 01206 510916 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) Mr Kalycoomar Samboo Persad Doobay Mrs Faridabibi Doobay Mrs A Wade Care Home 7 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (7) of places Maldon Lodge DS0000017877.V257394.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home accommodates seven people with learning disabilities who may also be over 65 years of age 9th March 2005 Date of last inspection Brief Description of the Service: Maldon Lodge is a detached property situated on the outskirts of Colchester. A bus route serving surrounding areas is within walking distance from the home. The home provides five single rooms, split between two floors, and one shared room. At the time of inspection there was no passenger lift. Communal areas consist of a large dining area, where in-house activities occur, a lounge to the front of the premises and a garden at the back. The hard-standing area to the front of the property is used for parking. Maldon Lodge DS0000017877.V257394.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in one day, in November 2005. Mrs Wade, Registered Manager, was available to assist the Inspector throughout the inspection process. The Inspector spoke with six of the seven service users at the home and also with the member of staff on duty. A tour of the premises was undertaken and various records and policies were looked at during the inspection. Seventeen out of the twenty-two standards assessed at the inspection were found to be met. What the service does well: What has improved since the last inspection? 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. Maldon Lodge DS0000017877.V257394.R01.S.doc Version 5.0 Page 6 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 Maldon Lodge DS0000017877.V257394.R01.S.doc Version 5.0 Page 7 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): 2 The aspirations and needs of prospective service users would be assessed. EVIDENCE: The home had not admitted any new service users since the previous inspection, at which time assessments were seen to be in place for existing service users. A policy on admission to the home was seen to be available. Maldon Lodge DS0000017877.V257394.R01.S.doc Version 5.0 Page 8 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, 7 & 9 Service users each have individual care plans, which outline goals for them to achieve. Service users are able to make decisions about their lives, with assistance as appropriate and needed. Risk assessment is seen as an integral part of promoting as independent lifestyles as possible. EVIDENCE: Care plans sampled during the inspection evidenced an individualised approach and detailed service users’ strengths, as well as their needs. Care plans showed the involvement of service users in their formulation and review. Reviews of plans were seen to take place on a regular basis. During the inspection the Inspector observed occasions when service users were helped to make choices and decisions for themselves and were seen to move freely around the home, engaging in activities they wished to. Service user files sampled were found to have risk assessments, which identified possible risks to their health and well-being, and had strategies as to how to minimise these. Maldon Lodge DS0000017877.V257394.R01.S.doc Version 5.0 Page 9 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, 15, 16 & 17 Service users were found to take part in appropriate activities of their choice and to have an involvement within the local community. Service users had appropriate contact with family, friends and advocates. The home demonstrated an awareness of service users’ rights and responsibilities in their day-to-day lives. The food provision for service users was found to be appropriate, with a good level of service user involvement. EVIDENCE: Service users were found to take part in a range of activities in the local community of Colchester. One service user attended the Lion Walk Activity Centre; another service user attended Grey Friars Education Centre. Another service enjoyed visiting a friend in the Colchester area and another service user enjoyed visiting the local shops. Three service users have relatively regular contact or keep in touch with family members. One older gentleman had friends who visited him. Two service users had their own advocates. Maldon Lodge DS0000017877.V257394.R01.S.doc Version 5.0 Page 10 Service users’ comments regarding the food were found to be positive. The home offers a five-week rotating menu, which changes periodically. Service users are able to give their views on what they would like to see on menus at monthly meetings in the home. One service user, spoken with in private, said of her lifestyle in the home “I love it here.” Maldon Lodge DS0000017877.V257394.R01.S.doc Version 5.0 Page 11 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 & 20 Service users received appropriate personal support. The home’s medicine administration system supported the well being of service users. EVIDENCE: Service users spoken with during the inspection indicated they were comfortable with the way personal support was delivered to them by staff. The interaction seen between staff and service users on the day of inspection was appropriate and clearly showed service users being treated as individuals. At the time of inspection, the home was operating a monitored dosage system of medicine administration. None of the service users were assessed as able to self-administer their medication. The home’s medicine system had been inspected by a pharmacist a few weeks prior to the inspection and was found to be working well, as evidenced by their written report. Maldon Lodge DS0000017877.V257394.R01.S.doc Version 5.0 Page 12 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 & 23 Service users felt their views were listened to and acted upon, where necessary. The home needs to ensure it has one adult protection policy, which dovetails with Essex Vulnerable Adults Protection Committee procedures and guidelines. EVIDENCE: The home was found to have a complaints policy available to service users and other interested parties. No complaints had been received since the previous inspection. In discussion with service users, none of them had any issues or concerns they wished to raise. As found at the previous inspection, the home had three policies in the policy folder regarding Adult Protection. The Manager was advised that the home must adopt just one policy and ensure that this makes reference to the Essex Vulnerable Adults Protection Committee procedures and guidelines, as no reference was made to these in any of the existing policies. Maldon Lodge DS0000017877.V257394.R01.S.doc Version 5.0 Page 13 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, 27 & 30 Service users were found to live in a homely, comfortable and safe environment. The toilets and bathrooms utilised by service users offered privacy and met their individual needs. The home was found to be both clean and hygienic during this inspection. EVIDENCE: All rooms seen during the inspection were found to be well decorated and personalised for service users individual tastes e.g. music systems, televisions, ornaments, pictures and photographs etc. All rooms were found to be warm and no obvious safety hazards were apparent. The home provides a downstairs shower room and an upstairs bathroom for service users. These were found to have suitable equipment to meet service users’ current needs and both offered privacy through looks. All rooms seen during the inspection were found to be clean and no odour was apparent in any of the rooms in the home. Maldon Lodge DS0000017877.V257394.R01.S.doc Version 5.0 Page 14 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, 34 & 35 Although the staff presented as competent, none of the current staff team had National Vocational Qualifications. In general the home’s recruitment policy and practices supported the protection of service users. Although staff did not have NVQ qualifications, training in various relevant areas had been undertaken. EVIDENCE: The home had experienced some recent staff turnover, which meant that the home no longer had any staff with National Vocational Qualifications at Level 2 or above. Only one staff member was currently working towards achieving this qualification and Mrs Wade, Manager, was advised that home needed to improve upon this to meet the 50 of qualified staff requirement. The staff member spoken with during the inspection, although new, presented as competent. The home’s recruitment policies and practices included application forms being filled in, interviews undertaken, references taken up, CRB checks being made and photographic identity of staff being available. However, completed induction forms for two new staff to the home were not available. Maldon Lodge DS0000017877.V257394.R01.S.doc Version 5.0 Page 15 Since the previous inspection staff had received training in various areas relevant to the care of the service user group. This included infection control training, medicine administration, care planning, diabetes care, fire procedures and manual handling. Maldon Lodge DS0000017877.V257394.R01.S.doc Version 5.0 Page 16 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, 39 & 42 Service users benefit from a well run home. The home had a quality assurance system, but this had not been fully implemented. Service users’ health and safety was promoted and protected. EVIDENCE: Mrs Wade, Manager, has been the home’s registered manager for approximately nine years. Although a qualified nurse, she has yet to undertake and achieve National Vocational Qualifications at Level 4. At the previous inspection, it was noted that service user questionnaires had been completed as part of a quality assurance system. However, an evaluation of these questionnaires and an action plan arising from comments made had not been completed. This situation had not progressed at the time of this inspection. Maldon Lodge DS0000017877.V257394.R01.S.doc Version 5.0 Page 17 Policies, procedures and certificates relating to health and safety within the home were seen during the inspection. These included gas safety certificates, first aid certificates for staff, fire safety certificates, COSHH assessments etc. No obvious safety hazards or issues were seen during the course of the inspection. Maldon Lodge DS0000017877.V257394.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X 3 X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 X 2 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Maldon Lodge Score 3 X 3 X Standard No 37 38 39 40 41 42 43 Score 2 X 2 X X 3 X DS0000017877.V257394.R01.S.doc Version 5.0 Page 19 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 YA23 Regulation 13 Timescale for action The Registered Person must 15/12/05 ensure that there is one adult protection policy and that this complies with locally agreed procedures. This is a repeat requirement. The Registered Person must 31/05/06 ensure that the home has an effective staff team, with skills and qualifications to support service users’ assessed needs at all times. Specifically the home must work towards achieving at least 50 of care staff with National Vocation Qualifications at Level 2 or above. This is a repeat requirement. The Registered Person must 01/11/05 ensure that all new members of staff receive documented induction training. The Registered Person must 31/12/05 ensure the homes quality assurance system is fully put into practice. This is a repeat requirement. Requirement 2. YA32 18 3. YA34 18 4. YA39 24 Maldon Lodge DS0000017877.V257394.R01.S.doc Version 5.0 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. 1. 2. Refer to Standard YA37 YA35 Good Practice Recommendations It is recommended that the Manager undertake National Vocational Qualifications at Level 4 in Care and Management. It is recommended that new members of staff undertake Learning Disability Award Framework training to provide staff with underpinning knowledge for undertaking NVQ training. Maldon Lodge DS0000017877.V257394.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Maldon Lodge DS0000017877.V257394.R01.S.doc Version 5.0 Page 22 - 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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