Inspection on 21/08/06 for Maldon Lodge

This inspection was carried out on 21st August 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 8 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 15/02/06

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 Final Unannounced Inspection 21st August 2006 9:45 Maldon Lodge DS0000017877.V309249.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 Maldon Lodge DS0000017877.V309249.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 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.V309249.R01.S.doc Version 5.2 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.V309249.R01.S.doc Version 5.2 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 15th February 2006 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 on the ground floor. As there is no passenger lift, people on the first floor need to be able to use stairs safely. Communal areas consist of a large dining area, where in-house activities take place, a lounge to the front of the premises and a garden at the back. Part of the garden, beyond the patio, can only be accessed by a number of steps. The hard-standing area to the front of the property is used for parking. The current weekly charge for a room is between £550.00 and £650.00. Additional charges are made for chiropody, hairdressing, transport, holidays, outings and birthday parties. Maldon Lodge DS0000017877.V309249.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector went to the home without telling anyone she was going to visit on the morning of Monday 21 August 2006. During this visit the inspector • • • • • talked with residents talked with the manager and some staff watched how residents and staff got along together looked around some of the home looked at some records. In writing this report, the inspector also used records she already had about the home, including information sent in by the people in charge. Over all, 23 Standards were inspected. • 14 Standards were ‘met’. These are the things the home does well for residents. • 7 Standards were ‘nearly met’. These are the things that need a little improvement. • 2 Standards were ‘not met’. These are the things that need to be a lot better or where what is wrong means that residents could be made safer. Sometimes, if the people in charge carry on not putting things right, the Commission may have to take action to make sure they do what is required. What the service does well: These are a few of the good things that the inspector saw and the residents and the staff told her about. What residents said showed that they: • • • • liked their home enjoyed their meals enjoyed their activities liked the people in charge and the staff who supported them What staff said showed that they: • • felt well supported and knew what they should be doing each day liked working at Maldon Lodge Maldon Lodge DS0000017877.V309249.R01.S.doc Version 5.2 Page 6 What the inspector saw and heard showed that: • • • • • Maldon Lodge is a small, clean, comfortable and homely place, with a stable, family atmosphere. As far as possible, residents had a say in how they lived their lives and were supported. Staff helped residents to be as safe as possible. Staff did the right things to keep people healthy and supported them well when they became ill. Mrs Wade, the person in charge, got on well with staff and residents. Residents could rely on her being around. They felt comfortable asking her for advice or talking about the things that mattered to them. What has improved since the last inspection? What they could do better: Records of residents’ daily progress should be factual and not describe someone’s behaviour or mood as ‘good’ or ‘bad’. Such descriptions do not show that the person writing the record understands the behaviour. Records should also be signed and dated so that people know who made them and whether they are about ‘now’ or some time in the past. Staff knew what residents liked to eat and residents had a say in what was on the menus but the home should make it possible for them to choose what they fancied sometimes by making alternatives available. The home still has work to do to improve its Adult Protection procedures (important information telling staff what they needed to do to protect residents from being harmed). The arrangement of furniture in the shared bedroom did not help the occupants to feel they had their own space or could be private. The manager said they would think about changing things to benefit of both people in the room. The people in charge also had things to do to make residents safer, such as fixing another handrail in the garden and repairing the steps, fitting the Maldon Lodge DS0000017877.V309249.R01.S.doc Version 5.2 Page 7 radiator covers they had bought and asking the Fire Safety Officer to check that the new conservatory was as safe as it could be for everyone. There are some things that the people in charge need to know about staff to make sure they are the right person for the job they are doing. Not all of this important information was on staff files. For example, people who wish to work at the home must have references from people for whom they have worked before, in case there is anything that would mean they should not be supporting vulnerable people. For the same reason they must also complete an application form for the job, giving lots of details about themselves. The people in charge must also make sure that new staff have had enough training and have shown they know how to support residents before they are expected to do so. Although is some ways the home was well run, the people in charge had not completed all the things they are required to do by law as owners and managers of a care home. They also need to ensure that, at least every year, they review everything about the home to make sure it is as good as it can and needs to be for the people living and working there. 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.V309249.R01.S.doc Version 5.2 Page 8 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.V309249.R01.S.doc Version 5.2 Page 9 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. The quality of service in this outcome area has not been assessed. EVIDENCE: These Standards were not inspected, as none of the existing residents were new to Maldon Lodge. A vacancy, which had arisen since the last inspection, had not been filled. Maldon Lodge DS0000017877.V309249.R01.S.doc Version 5.2 Page 10 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): 6, 7 and 9 The quality of service in this outcome area has been assessed as good, based on the following judgements: • • Residents’ health, personal and social care needs were set out in an individual plan of care. Residents were assisted to make choices and decisions about their lives. EVIDENCE: Maldon Lodge DS0000017877.V309249.R01.S.doc Version 5.2 Page 11 A sample of residents’ records showed that care plans covered a range of strengths, needs, risks and preferences, which had been reviewed and updated, where possible, in discussion with the resident concerned, although some records lacked signatures to show who had created them. The inspector saw examples of care plans being followed. Records of residents’ daily progress contained phrases, which implied a judgement on the person’s behaviour and showed some lack of understanding from the person making the record. In place of statements such as ‘got up in a mood’ and ‘bad tempered’ or ‘had bad behaviour’ should be descriptions of the actual behaviour and how it was handled. The inspector observed residents going to the manager for advice and being helped to make choices and decisions for themselves or to follow what had been agreed in their care plan. For example, in some cases, care plans included a budget plan to help residents cover their regular weekly outgoings or make their cigarettes last for the week. One person, without family or friends to represent their interests, received visits from an advocate. The home continued to act as an appointee for residents in respect of the Department of Work and Pensions and to support residents to manage their personal money. Maldon Lodge DS0000017877.V309249.R01.S.doc Version 5.2 Page 12 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): 12, 13, 15, 16 and 17 The quality of service in this outcome area has been assessed as good, based on the following judgements: • Residents found that the lifestyle experienced at Maldon Lodge suited them. DS0000017877.V309249.R01.S.doc Version 5.2 Page 13 Maldon Lodge • • • Residents maintained some contact with family, friends and the local community. Residents’ rights and privacy were respected. Residents were offered a balanced diet and enjoyed their meals and mealtimes. EVIDENCE: Arrangements for residents to take part in activities in the local community of Colchester had not changed since previous inspections. More mobile residents went out by themselves or with family and friends. Others depended on staff to take them out. Occasionally, additional staff were brought in for this purpose and this is to be encouraged. The registered persons should continually review staffing ratios to ensure that these are not affecting residents’ opportunities for outside recreation. One resident, who seldom went out, said they enjoyed what they did in the home and the things they had around them in their room. Several residents were supported with their own interests such as knitting, jigsaw puzzles and drawing. Residents showed that they liked to preserve the routines that were familiar to them. However, residents said they were able to get up and go to bed when they chose. They moved freely around the home, choosing whether to be on their own, in their rooms, or one of the communal areas. Staff spent time talking with residents as they supported them in other ways. Rules on smoking were clear and protected non-smokers. All the residents came together for their meals and a relaxed, family atmosphere prevailed. Observation and discussion showed that residents continued to enjoy nutritious and balanced meals. Residents were consulted about what should be on the menu and their individual preferences and dislikes were recorded and respected. However, it was evident that residents were used to being presented with what had been prepared for them and could benefit from having alternatives on the menu. Maldon Lodge DS0000017877.V309249.R01.S.doc Version 5.2 Page 14 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): 18, 19 and 20 The quality of service in this outcome area has been assessed as good, based on the following judgements: • • • Residents received personal support appropriate to their needs. Residents’ physical and emotional health needs were met. Residents were protected by the home’s procedures for dealing with medicines. EVIDENCE: Most residents continued to be receive personal support in the way they were used to. For most people, this was in the privacy of their own rooms. The arrangement of furniture in one shared bedroom did not promote the privacy of the occupants, who were new to being together, and the manager agreed to review this. Records, discussion and observation showed that residents were Maldon Lodge DS0000017877.V309249.R01.S.doc Version 5.2 Page 15 given appropriate support to maintain their personal hygiene, choose their clothes and express their individuality through their appearance. Arrangements for supporting residents to remain healthy had not altered since the last inspection. The manager reported that they had excellent support from the GP surgery, as shown during the recent decline of one of the residents. She also stated that the home had been commended by one of the GPs for the way in which they had cared for this resident. It was evident from discussion and records that the home was also proactive in obtaining the appropriate medical attention for residents and access to NHS facilities. None of the residents were assessed as able to self-medicate. Arrangements for storing, administering, recording and re-ordering their medication had continued to be satisfactory. The manager reported that the home was well supported by the local pharmacist. She was not only able to ring at any time for advice but was in monthly consultation with the pharmacist about the needs of each resident and hereby keeping their stock of medication to a minimum. The manager should ensure that any new entries to the list of residents’ medication are signed and dated. Maldon Lodge DS0000017877.V309249.R01.S.doc Version 5.2 Page 16 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): 22 and 23 The quality of service in this outcome area has been assessed as adequate, based on the following judgements: • • Residents’ views were listed to and acted on. Residents were well treated, although more could be done to ensure they would be protected in the event of an allegation or suspicion of abuse. EVIDENCE: The home had no recorded complaints. Residents showed they were confident in coming to the manager’s office or approaching staff and making their views and wishes known. The family atmosphere of the dining area, where everyone came together for meals and social activities lent itself to informal discussion about the things that mattered to the residents. They also had periodic meetings, when their comments were recorded. As at previous inspections, the home’s procedures for protecting vulnerable adults from abuse did not make clear the boundaries of their responsibilities with regard to investigation or that residents’ safety took precedence over the principle of confidentiality. As staff could be misled by these procedures, they need to be changed as a matter of priority. Also, as highlighted under the section on Staffing, management had not taken all the necessary steps to Maldon Lodge DS0000017877.V309249.R01.S.doc Version 5.2 Page 17 safeguard residents by making sure that the people recruited to support them were fit and trained to do so. Maldon Lodge DS0000017877.V309249.R01.S.doc Version 5.2 Page 18 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 and 30 The quality of service in this outcome area has been assessed as adequate, based on the following judgements: • Residents were living in homely and comfortable surroundings. Some attention to details of safety was needed and also to the arrangement of one of the shared rooms, to promote the individuality and privacy of the occupants. The home was clean and hygienic. • EVIDENCE: Maldon Lodge DS0000017877.V309249.R01.S.doc Version 5.2 Page 19 The home received a satisfactory report from the Fire Safety Officer a year ago. They had also complied with the recommendations of an independent fire risk assessor in May 2006. However, as the Fire Safety Officer’s visit had predated the new conservatory, designated as a smoking area, the manager was advised to consult with the Fire Service to ensure that the arrangement had their approval and was safe for everyone. The manger reported that radiator covers had been purchased ready to be fitted for the winter. This would ensure that residents could not burn themselves on the hot surfaces. The registered persons must also take action to remove any risk to residents presented by the radiator in the conservatory. The arrangement of furniture in the shared room did not provide a clearly defined area for each of the occupants. For example, one person had to go across the other’s space to get to their wardrobe and the position of commode and washbasin did not promote privacy. The manager agreed to review these arrangements for the benefit of both occupants. The main part of the garden, beyond the patio, is accessed by two sets of steps, set in a bank. Only one set of steps had a handrail. To keep residents safe, a handrail should be in place for both steps and they should also be in a good state of repair. The home was clean and fresh and had suitable arrangements for laundry. Maldon Lodge DS0000017877.V309249.R01.S.doc Version 5.2 Page 20 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, 35 and 36 The quality of service in this outcome area has been assessed as poor, based on the following judgements: • • Residents benefited from a flexible approach to staffing. Residents were not always protected by the home’s recruitment and training and supervision practices. EVIDENCE: The registered manager reported that the only person on the staff team with a vocational qualification (National Vocational Qualification in care, Level 2) had left. This meant that the home were still a long way from achieving the Maldon Lodge DS0000017877.V309249.R01.S.doc Version 5.2 Page 21 recommended minimum ratio of qualified staff (50 ) and none of the staff had done the Learning Disability Award Framework training, in preparation for the NVQ Award. Two of the staff files sampled also lacked induction training records, which suggested they had not been fully prepared for the work they had to do. However, the manager said that one person was due to attend a 2day external induction course covering all the health and safety topics and protection of vulnerable adults training. The home also continued to provide an ongoing programme of periodic training, which most staff were able to attend, and covered both health and safety and practice topics. Typically, two people covered each daytime shift, one of which could be the manager and their duties included cleaning, meal preparation and laundry. However, a flexible approach to staffing meant that an additional member of staff was brought in to support residents with appointments and outings, as happened on the day of inspection. On another occasion, a second person was temporarily rostered at night to support a person with deteriorating health. Particular staff put in time well over and above their contracted hours. One person confirmed that enjoyed working at Maldon Lodge and worked extra time by choice. Good interaction was observed between residents and staff throughout the day. Records were inspected for 4 relatively new members of staff. Three had been working without references; two had not completed application forms and one person’s Criminal Records Bureau disclosure was not valid for their employment at Maldon Lodge. These omissions constituted a serious breach of the Care Homes Regulations 2001, which specify the information and documents, which must be obtained in respect of all persons working at a care home to ensure that residents are in safe hands. One person, employed since the end of May 2006 had no record of supervision. The registered manager took appropriate action to address the recruitment, induction and supervision omissions, following the issue of an Immediate Requirement Notice. Maldon Lodge DS0000017877.V309249.R01.S.doc Version 5.2 Page 22 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, 39 and 42 The quality of service in this outcome area has been assessed as adequate, based on the following judgements: • In the main, residents were benefiting from a well run home but, in some respects, management were not meeting regulatory requirements and compromising the safety and welfare of residents. DS0000017877.V309249.R01.S.doc Version 5.2 Page 23 Maldon Lodge • • Residents’ views were considered but the monitoring, review and development of the home needed to be more robust. The health and safety of residents were put at risk by inconsistencies in provision of induction training for staff. EVIDENCE: Mrs A Wade, registered manager, reported that she had completed the Registered Managers Award and awaited her certificate of qualification. Mrs Wade had years of experience as manager of Maldon Lodge and 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. Staff said that the home was well run and so they knew what they should be doing each day. However, a number of the shortfalls identified in this report involved key management tasks, such as recruitment and training. The manager gave examples of how residents were consulted about the things that affected them, such as admitting a new resident or taking on a new member of staff. Residents’ views had been sought with questionnaires and periodic meetings to talk about matters of importance to them. The manager had just completed a quality assurance report. Although the report considered some outcomes for the residents, it focussed mainly on the environment and did not cover a number of aspects of importance, such as staffing levels, recruitment and training. Discussion took place with the manager about developing a broader approach to quality assurance. In the main, arrangements for promoting and protecting the health and safety of residents and staff had not changed since November 2005 and remained satisfactory. The last inspection report by the Colchester Borough Council in respect of food hygiene and health and safety contained no requirements or advice to indicate shortfalls. As referred to under the section headed, ‘Environment’, the manager was advised to seek approval of the fire safety arrangements in respect of the new conservatory and ensure radiator covers were fitted as necessary. She must also ensure that people who work at the home have induction training, which covers all the safe working practice topics. Maldon Lodge DS0000017877.V309249.R01.S.doc Version 5.2 Page 24 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 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 1 35 1 36 2 CONDUCT AND MANAGEMENT Standard No Score 37 2 38 X 39 2 40 X 41 X 42 3 43 X 3 3 X 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 Maldon Lodge Score 3 3 3 X DS0000017877.V309249.R01.S.doc Version 5.2 Page 25 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 Requirement The registered persons must ensure that there is one adult protection policy and that this complies with locally agreed procedures. THIS REQUIREMENT HAS EXCEEDED AGREED TIMESCALES FOR ACTION SINCE BEFORE THE INSPECTION ON 11/02/04. Timescale for action 30/09/06 2. YA24 23 (2) f 13 3. YA32 18 The registered persons must 31/10/06 ensure that the layout of rooms occupied by residents is suitable for their needs. The registered persons must also take any necessary action to protect residents from exposed radiators. THIS REQUIREMENT WAS BEING PROGRESSED. They must also obtain approval from the Fire Safety Officer in respect of the new conservatory. The Registered Person must 31/10/06 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 DS0000017877.V309249.R01.S.doc Version 5.2 Page 26 Maldon Lodge must work towards achieving at least 50 of care staff with National Vocation Qualifications at Level 2 or above. THIS REQUIREMENT HAS EXCEEDED AGREED TIMESCALES FOR ACTION SINCE THE BEFORE THE INSPECTION ON 11/02/04. 4. YA34 17 Sch 4 19 Sch 2 The registered persons must ensure that the home’s recruitment procedures protect residents and that satisfactory information and documentation, as required by these regulations, are obtained before staff begin working at the home. The registered persons must ensure that staff have the induction training necessary for the work they are to do. The registered persons must ensure that all staff have the supervision they need to carry out their jobs. The registered persons must ensure the home’s quality assurance system is fully put into practice. THIS REQUIREMENT HAS EXCEEDED AGREED TIMESCALES FOR ACTION SINCE BEFORE THE INSPECTION ON 11/02/04. 20/09/06 5. YA35 YA42 18, 13 30/09/06 6. YA36 18 30/09/06 7. YA39 24 31/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000017877.V309249.R01.S.doc Version 5.2 Page 27 Maldon Lodge 1. 2. 3. 4. YA6 YA32 YA6 YA20 YA17 YA35 The registered persons should ensure that comments about residents’ behaviour in their daily records are not judgemental. The registered persons should ensure that all records are signed and dated. It is recommended that the registered persons introduce some choice of menu. The registered persons 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 NVQ training. Maldon Lodge DS0000017877.V309249.R01.S.doc Version 5.2 Page 28 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.V309249.R01.S.doc Version 5.2 Page 29 - 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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