Inspection on 15/02/06 for Maldon Lodge

This inspection was carried out on 15th 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 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 5 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 01/11/05

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 MIXED CATEGORY MAJORITY ADULTS 18-65 Maldon Lodge 123 Maldon Road Colchester Essex CO3 3AX Lead Inspector Marion Angold Unannounced Inspection 15th February 2006 11:00 Maldon Lodge DS0000017877.V283884.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 Maldon Lodge DS0000017877.V283884.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 Older People and 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.V283884.R01.S.doc Version 5.1 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.V283884.R01.S.doc Version 5.1 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 1st November 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.V283884.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 12.30 and 17.15 pm, assisted by the Manager, staff and residents, and a community nurse, who regularly came to the home. The inspection also involved observation and looking at records. This inspection covered only the few core National Minimum Standards not inspected on 1 November 2005 and the shortfalls, identified in the last report. Therefore, for a fuller picture of the home, it would be necessary to read the last report as well. Of the 10 Standards inspected on this occasion, 5 were met, and 5 presented minor shortfalls. It should be noted that 17 out of the 22 Standards assessed at the last inspection, were met. What the service does well: Maldon Lodge continued to run on family lines and provide a comfortable environment. Residents showed that they regarded it very much as their home and liked knowing what they could expect from day to day. A visiting community nurse spoke positively about their experience of the home, including the number of staff on duty and how staff supported and interacted with residents. The Inspector also observed how staff used an activity to distract a resident from something that was troubling them, but could not be changed. Mealtimes provided a focus for interaction between residents and staff, with plenty of conversation taking place. The community nurse had observed that residents had plenty of food, including cooked breakfasts sometimes. Residents received appropriate help to look after their health, as confirmed by the community nurse, who spoke about the competence of the home in helping one resident manage their diabetes. Residents were protected by the way staff were being recruited and introduced to the home. Mrs Wade demonstrated a good rapport with staff and residents; residents showed that they could rely on her being there and readily approached her for advice or to share information about the things that mattered to them. One member of staff had also found Mr Doobay very supportive. Maldon Lodge DS0000017877.V283884.R01.S.doc Version 5.1 Page 6 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.V283884.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Maldon Lodge DS0000017877.V283884.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these Standards were inspected. EVIDENCE: Maldon Lodge DS0000017877.V283884.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these Standards were inspected. EVIDENCE: Maldon Lodge DS0000017877.V283884.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. Service Users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these Standards were inspected. EVIDENCE: Maldon Lodge DS0000017877.V283884.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 Residents received appropriate support to look after their health. EVIDENCE: A sample of residents’ files showed that appropriate action had been taken by the home to monitor their health. This included medical reviews, weight monitoring, consultation with a continence advisor and arranging routine appointments for chiropody, dental and eye checks. The Manager reported that the home received good support from the GP practice. All appointments were documented in residents’ individual files and a separate record maintained of relevant information and outcomes. One resident said they thought the home looked after everyone’s’ health. A visiting community nurse described how the home had worked well with a dietician to ensure that one resident was eating the right foods. This person’s care plan had been updated to take account of their diabetes. A member of staff described appropriate Maldon Lodge DS0000017877.V283884.R01.S.doc Version 5.1 Page 12 action to promote food and fluid intake when residents were not well. Although residents were permitted to smoke in a designated area, the Manager had worked with at least one person to significantly reduce their smoking. Arrangements had been made on the day of inspection for staff to be in attendance with a resident having day surgery and staff were attentive to this person’s needs on their return to the home. Maldon Lodge DS0000017877.V283884.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Although the home had taken steps to prevent abuse by providing appropriate staff training, its protection of vulnerable adult procedures would be misleading in the event of an allegation or suspicion of abuse. EVIDENCE: All staff had attended a training session on the protection of vulnerable adults, led by their usual training provider. The Inspector had already received information to show that this course provided appropriate guidance, in line with agreed protocols. However, as before, the Manager needed to amend the home’s procedures to make clear the boundaries of their responsibilities with regard to investigation and that the safety of the residents took precedence over the principle of confidentiality. With one exception, good interaction was observed between residents and staff throughout the inspection. A community nurse also spoke positively about their experience of the way staff treated and interacted with residents and finding their patient consistently in a good frame of mind. However, at one point, a member of staff spoke sharply to a resident and raised a finger in an attempt to halt their repeated questioning of the Inspector. The Manager said she had taken the person aside to address their handling of the situation and Maldon Lodge DS0000017877.V283884.R01.S.doc Version 5.1 Page 14 would continue to monitor their approach through observation and supervision. The Manager said that the person’s reaction had been out of character and possibly triggered by anxiety over the Inspector’s arrival minutes earlier. It should be noted that the same member of staff later handled another situation very appropriately, successfully introducing an activity to distract a resident from something that was bothering them. However, as this member of staff was scheduled to be on shift from 5 pm to 9 am (including night sleeping duty) several days in succession, the manager was advised to ensure that the person was getting sufficient breaks. Maldon Lodge DS0000017877.V283884.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) 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 (OP NMS 25), 27 Residents were benefiting from an ongoing programme of improvements to their home, but this should include any necessary action to protect them from exposed radiators. EVIDENCE: A partial tour of premises was made to inspect recent additions and refurbishments. These included replacement windows, new curtains, a conservatory (to serve as a smoking room), a second stair rail, a shower in Maldon Lodge DS0000017877.V283884.R01.S.doc Version 5.1 Page 16 place of the bath downstairs and improvements to the upstairs bathroom. The Manager stated that the decorator had been booked to work through the house, starting with the dining room and lounge, and that carpets would be replaced where they were worn. Although the manager stated that all radiators were thermostatically controlled and cut out before the surface temperatures got too hot, related risk assessments must be reviewed periodically and appropriate action taken to protect residents from any risk of getting burnt. Maldon Lodge DS0000017877.V283884.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) 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 and 35 The home’s staffing arrangements were flexible to meet the needs of residents, but some of the shift patterns worked by particular staff were not clearly in residents’ or their own best interests. Residents were protected by the home’s recruitment practice and provision of mandatory training. With recent recruitment, the Manager was endeavouring to ensure that the home met the requirements for induction and National Vocational training. EVIDENCE: The rota for the week beginning 13/02/06 was inspected and discussed. It evidenced that two people, including the Manager were available to support Maldon Lodge DS0000017877.V283884.R01.S.doc Version 5.1 Page 18 residents from 7 am until 9 pm and one person from 9 pm until 7 am, usually on sleeping duty. The Manager stated that they were able to call on staff from their sister home and that their own staff were keen to do extra shifts, as needed. For example, it was reported that a second person covered the night shift, if any of the residents were unwell and, as on the day of inspection, additional staff were rostered to accompany one of the residents to hospital. Supporting residents with activities outside the home also necessitated an additional person being on duty. One person had a sound monitor, connected to the staff room for the night. A relatively new member of staff and the community nurse expressed the view that the home was adequately staffed. However, the Manager was advised to carefully monitor the present arrangement whereby particular staff were covering the 5 pm – 10 pm shift, followed by sleeping duty (10 pm – 7 am) and further awake duties from 7 am – 9 am, 3 or 4 nights in succession. Staff had attended periodic training in a range of relevant topics and, although none of the current team had undertaken any National Vocational Qualifications, the 3 new members of staff had registered for training at Level 2, with an imminent start date. The recruitment records for one new member of staff showed that the legal requirements had been met. The criminal Record Bureau disclosure, sampled for another new person, was also found to be satisfactory. The newest recruit to the staff team had completed a basic induction programme, which had included in-house fire training and attendance on the Protection of Vulnerable Adults (POVA) course (see NMS 23). They also had food hygiene and moving and handling certificates, obtained in their last place of work. During the course of their induction, other new members of staff had completed care of medicines and POVA training and one person had also obtained a certificate in relation to food hygiene. Although none of the new recruits had completed the TOPSS (Skills for Care) induction programme, this had been obtained for use by the home and the Manager had attended the Skills for Care’s Common Induction Standards training, with a view to providing a more robust induction programme at Maldon Lodge. The new member of staff on duty said that they had spent time with the residents before joining the staff team and then worked alongside more experienced staff for 3 weeks, to observe and learn. They had also shadowed a member of the night staff as part of their learning programme. They felt this had provided a good introduction for their work with residents. Maldon Lodge DS0000017877.V283884.R01.S.doc Version 5.1 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. Service users live in a home which is run and managed by a person who is fit to be in charge of good character and able to discharge his or her responsibilities fully. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) 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 and 39 Residents continued to benefit from a well run home, although the quality assurance system had still not been fully implemented. EVIDENCE: Maldon Lodge DS0000017877.V283884.R01.S.doc Version 5.1 Page 20 Mrs A Wade, Manager, reported that arrangements had been made for her to commence training for the National Vocational Qualification, Level 4, in management and care, in two weeks. She anticipated that her previous training would count towards the qualification and enable her to work quickly through some of the modules. Mrs Wade had continued to undertake periodic training, including, on 13/12/06, attendance at a workshop on the Common Induction Standards. Mrs Wade demonstrated a good rapport with staff and residents; residents showed that they could rely on her being there and readily approached her for advice or to share information about the things that mattered to them. Since the last inspection the Manager had gathered information about various models of quality monitoring, but not applied them to the home. Questionnaires had been completed by residents, with the support of staff, but not dated. Discussion took place with the Manager about the various tools and measures, which could be used for quality monitoring. During the inspection it was evident that residents readily consulted or made their views known to the Manager and staff. However, it was recommended that, for the purpose of quality monitoring, residents completed surveys through relatives and representatives, rather than people working in the home. It is also essential that all records are dated. Maldon Lodge DS0000017877.V283884.R01.S.doc Version 5.1 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. Where there is no score against a standard it has not been looked at during this inspection. 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 X 2 X 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 X 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 3 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT Standard No Score 37 3 38 X 39 2 40 X 41 X 42 X 43 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Maldon Lodge Score X 3 X X DS0000017877.V283884.R01.S.doc Version 5.1 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 YA23 Regulation 13 Timescale for action The Registered Person must 15/03/06 ensure that there is one adult protection policy and that this complies with locally agreed procedures. This requirement has exceeded agreed timescales for action. The Registered Person must take 15/03/06 any necessary action to protect residents from exposed radiators. 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 but has not exceeded the last agreed timescale for action. Arrangements had been put in place with a view to meeting this requirement. DS0000017877.V283884.R01.S.doc Version 5.1 Page 23 Requirement 2. YA24OP25 13 3. YA32 18 Maldon Lodge 4. YA39 24 The Registered Person must 30/04/06 ensure the home’s quality assurance system is fully put into practice. This requirement has exceeded agreed timescales for action. 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 YA37 Good Practice Recommendations It is recommended that the Manager undertake National Vocational Qualifications at Level 4 in Care and Management. Arrangements to meet this recommendation have been put in place. It is recommended that staff do not undertake double shifts over several successive days. The registered person should continue to develop the induction programme. It is also recommended that new members of staff undertake Learning Disability Award Framework training to provide underpinning knowledge for undertaking NVQ training. 2. 3. YA23YA33 YA35 Maldon Lodge DS0000017877.V283884.R01.S.doc Version 5.1 Page 24 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.V283884.R01.S.doc Version 5.1 Page 25 - 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. 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