Inspection on 04/07/07 for Maldon Lodge

This inspection was carried out on 4th July 2007.

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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Maldon Lodge 21/08/06

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 ADULTS 18-65 Maldon Lodge 123 Maldon Road Colchester Essex CO3 3AX Lead Inspector Marion Angold Key Unannounced Inspection 4th July 2007 09:45 Maldon Lodge DS0000017877.V345176.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.V345176.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Maldon Lodge DS0000017877.V345176.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.V345176.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 21st August 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.V345176.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 4 July 2007. During this visit the inspector • • • • • spoke with residents spoke with the manager and some staff watched how residents and staff got along together looked around some of the home and garden 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. • 11 Standards were ‘met’. These are the things the home does well for residents. • 12 Standards were ‘nearly met’. These are the things that need some improvement. What the service does well: People thinking about coming to live at Maldon Lodge would have an assessment of their needs to determine whether the home could offer the care and support they required. People living at Maldon Lodge could expect • • • • • homely, comfortable surroundings; meals they enjoyed; support to look after their health and take any medication they needed; a say about their lives, such as when to get up, whether to be alone or how to spend their money; the people in charge to be available to listen and support them. Maldon Lodge DS0000017877.V345176.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: • Make sure staff have the training and supervision they need for their work of supporting people; that they have the necessary skills in communication and in dealing with anticipated behaviours; Arrange the roster so that staff have sufficient breaks to work effectively when they are on duty; Always have more than one member of staff on duty to provide adequate support to meet people’s needs and keep them safe. Give people a choice of what they have to eat; Make sure staff have all the right information about what action to take if they thought someone was being harmed in any way (safeguarding adults procedures); Make sure people can use all parts of the house and garden safely; Develop a system for reviewing and improving the quality of care so that people living at Maldon Lodge have the best possible experience. • • • • • • Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Maldon Lodge DS0000017877.V345176.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Maldon Lodge DS0000017877.V345176.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People thinking about coming to live at the home would have an assessment of their needs to determine whether Maldon Lodge could offer the appropriate care and support. EVIDENCE: None of the existing residents were new to Maldon Lodge. The home had for some time had two vacancies. The manager said she had considered people for these vacancies but felt that the home could not meet their needs at the present time without affecting the lifestyles of existing residents. This showed that the manager took seriously the need for a pre-admission assessment to determine whether the home would be suitable for someone interested in moving in. Maldon Lodge DS0000017877.V345176.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. In the main, people could expect most aspects of care to be delivered according to an individual plan and to be supported to take risks and make decisions within safe limits. EVIDENCE: Care plans, sampled for three people, documented a range of individual needs and circumstances and had been evaluated monthly. One person’s care plans had been updated in January and April 2007 to reflect their changing needs, with clear instructions to staff about how they should be supported. Another person, who went through their care plan with the inspector, showed that they were not used to seeing the document but were familiar, and agreed with, its contents; they had already shared with the inspector some of the arrangements the care plan described. This exercise demonstrated that the manager could involve people more in drawing up the plans so that they had greater ownership of them. Maldon Lodge DS0000017877.V345176.R01.S.doc Version 5.2 Page 10 Risks covered in the sample of plans included smoking, community activities, outings and hot radiators. Infringements of people’s rights were also documented, in respect of smoking and self-administration of medication. Daily records continued to make frequent references to the behaviour and mood of particular individuals, which were not linked to care plans. One entry showed that a member of staff facing a challenging situation had not known how to achieve the best outcome for the people concerned and had responded inappropriately. This is addressed under the section of this report, headed ‘Complaints and Protection’. Arrangements for supporting people with their personal money had remained consistent. The home kept it safe until they wanted it, recording all transactions and keeping receipts for any expenditures involving support from staff. Staff indicated that everyone currently living at the home understood how their money was spent, was involved in transactions and handled the money when they were out shopping. One person told the inspector that they decided how to spend their money. The sample of records receipts and balances was in order. Maldon Lodge DS0000017877.V345176.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The routines and lifestyles people experienced at Maldon Lodge suited them and they enjoyed a healthy diet. EVIDENCE: Three people living at the home were able to go out independently within the local area. Another person said that a day for them usually consisted of reading the newspaper, colouring and watching particular television programmes or films and that this was what they enjoyed doing. They understood that outings depended on the availability of staff to take them. Another person’s care plan had been revised in respect of activities because they were no longer attending college; the suggested alternatives were activities already going on in the home rather than a programme to reflect the individual’s interests. From observation it was evident that an important and Maldon Lodge DS0000017877.V345176.R01.S.doc Version 5.2 Page 12 significant part of everyone’s day was made up of social interaction and that the manager and staff made themselves available to talk with people. Most people completing the Commission’s survey said they always made decisions about what they did each day. One person specified that they decided when to get up and go to bed, and how they would spend their money and their time; but that they did not decide what to eat or what would be on the menu. Staff indicated that routines had to be flexible to take account of how people were feeling and that, for the same reason, plans might need to be altered at the last minute. They explained that, on the other hand, people living at the home guarded their routines, which meant, for example, that an outing would be cut short so they could get back for tea ‘on the dot’. This preference for regularity has been demonstrated over successive inspections. Arrangements for visitors had not changed since the last inspection but a newly created visitors’ policy showed a positive and welcoming approach to people who might come to the home. It was evident from discussion that people living at the home were encouraged to have contact with those who mattered to them. Meals were balanced and nutritious and included salad, fruit and vegetables. The manager said that she made a list of requirements, based on the week’s menus and the owners shopped accordingly. She indicated that this arrangement worked well. People indicated that they enjoyed their meals. One person said they liked the fact that breakfast was varied, with a cooked breakfast on Saturdays and Sundays, cereal twice and porridge on the other days. The manager said they had tried a variety of cereals but people always chose Cornflakes, so this is what they now served. A homemade cottage pie, potatoes and fresh vegetables were served for lunch during the inspector’s visit; one person was given swede instead of cabbage, showing that people’s particular dislikes were respected. The manager said that recent modifications to the menu were based on discussions with people living at the home (as evidenced by minutes of a residents’ meeting). However, one person did not think they had been involved in deciding the menu and said that they did not have opportunity to select from alternative menu options. Staff were on hand to support people with their meals and the atmosphere was mostly congenial, with plenty of conversation. Maldon Lodge DS0000017877.V345176.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People had the support they needed to maintain good personal hygiene and health but the manner in which they were supported, did not always promote their privacy and dignity. EVIDENCE: From observation and discussion it was evident that people were supported to maintain a clean and tidy appearance and wear clothes they had chosen. None of the people currently resident was sharing a room at the time of the inspection, so each could be supported in privacy. Although people who spoke with the inspector indicated that their privacy was respected, a member of staff was observed giving instructions to a person in the toilet with the door open and within hearing of people in the lounge and dining room. This situation compromised the privacy and dignity of people living at the home and showed that the member of staff concerned lacked necessary knowledge and skills. Maldon Lodge DS0000017877.V345176.R01.S.doc Version 5.2 Page 14 Individual care plans covered health and medication. They showed that the home monitored aspects of people’s health and provided staff with information about relevant medical conditions. Records showed that people had annual medical reviews with their GP. Arrangements for storing, re-ordering and returning medication had not changed since the last inspection with the manager having full responsibility in these areas. During the inspection the manager and a member of staff administered the lunchtime medication, working together. The member of staff had attended related training but was being supported while they gained confidence in practice, although the manager said that it was usual for staff to work in pairs. In this instance, it was acceptable that the manager signed the record even though the member of staff carried out the administration because both the manager and member of staff were fully involved and in agreement with each stage of the process. Usually the person who gives the medication must sign the record, as they are responsible for ensuring that no mistakes are made. Maldon Lodge DS0000017877.V345176.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People views were taken into consideration but they could not rely on all staff treating them with respect and dignity. EVIDENCE: The home’s annual quality assurance assessment, completed for the Commission, indicated that people living at the home had opportunities to express their views about things and that an open culture prevailed. The Commission’s surveys also showed that people living at the home knew whom to speak with if they were not happy about something and, during the site visit, people did not hesitate to approach the manager or come to her office to talk about the things on their mind. Most people indicated in the survey that carers listened and acted on what they said. However, one person didn’t think staff listened very well and said they were always in a rush. Records showed that the home had not received any complaints since the last inspection and none had been made via the Commission. One person, completing the Commission’s survey said they did not have any complaints. Minutes of residents’ monthly meetings showed that they were given opportunity to comment on aspects of the service, such as their meals. Most people who completed the CSCI survey indicated that staff treated them well although one person expressed the view that staff could be bossy and that, although they knew this was intended for their good, they felt some staff Maldon Lodge DS0000017877.V345176.R01.S.doc Version 5.2 Page 16 could be kinder in their manner. Examples of poor practice were observed during the inspection, which indicated that people would be justified in complaining. The lack of complaints seems to be due to people accepting what they experienced without question. An entry in one set of daily records showed that a member of staff had ‘threatened’ the person in response to their behaviour. During the inspection the same member of staff showed impatience towards a person living at the home, telling them off and threatening not to speak with them. Both these situations highlighted the need for care plans to give specific guidance to staff to help them understand and deal with individual behaviour and for staff to be given related training and supervision. The details of these observations (and one referred to under the previous heading of Personal Healthcare and Support) were brought to the attention of the manager, who said she would address them with the person concerned. Although the home’s safeguarding adults policy had been amended following the last inspection, it still contained some guidance which was not in line with nationally and locally agreed safeguarding adults protocols and therefore could be misleading. Maldon Lodge DS0000017877.V345176.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment was comfortable and homely. People were benefiting from ongoing work to upgrade the property but particular aspects of provision posed some risk to their safety. EVIDENCE: The lounge, dining area, hall stairs and landing had been redecorated since the last inspection. A person had been employed to spend 2 days at the home, including the day of inspection, undertaking various repairs and checking and adjusting fire doors. No work had taken place in the garden to repair the steps and improve access. Maldon Lodge DS0000017877.V345176.R01.S.doc Version 5.2 Page 18 Two radiator covers had been fitted since the last inspection. The owner said he found them unsightly, especially as the radiator controls had to be accessible which meant that the covers did not meet the floor. He stated that he was planning to have a new boiler before the winter so that radiator surfaces did not overheat. He was that they had to provide low surface temperatures or risk assessments that showed that people were likely to burn themselves. Hot water sampled in two bedrooms and the washbasin in the first floor bathroom was a safe and comfortable temperature. Bedrooms inspected were in need of redecoration and refurbishment; some furniture and carpets were shabby and worn. The manager said that she would ask the handyman to make necessary repairs to furniture and that arrangements were in hand for carpet to be replaced as necessary. Manager acknowledged that the Food Safety Management System had not been implemented in line with a requirement issued by the Environmental Health Officer. Everyone who completed the Commission’s survey said their home was always clean. The cleanliness of the home was found to be satisfactory, particularly in communal areas. The home’s infection control policy covered the use of personal protective clothing and washing hands. In line with this policy, the manager and a member of staff indicated that protective gloves and aprons were used by anyone providing intimate support to people living at the home. Instructions for washing hands were also displayed in the laundry and staff toilet but the means for doing this hygienically were not available. The paper towel dispenser in the laundry was empty. Communal towels were in use in the first floor bathroom and the staff toilet. Soap dispensers were available in the laundry and staff toilet but there was none in the bathroom upstairs, used by the residents. Maldon Lodge DS0000017877.V345176.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People were protected by a more thorough approach to staff recruitment but gaps in training and supervision, and arrangements for covering the duty roster, did not fully promote their safety and wellbeing. EVIDENCE: Rosters had been completed in pencil. The manager said this was because people were always changing their shifts. She was advised that they must be written in ink in order to provide a permanent record and make any subsequent alterations visible. It was encouraging to note that extra staff had been rostered to cover for training on the day of inspection. The roster for Saturday 7/7/07 showed that there were 2 people scheduled to be on duty between 7:00 and 9:00 a m and between 15.00 and 22:00 p m, but only one person between 9:00 a m and 15:00 p m. The pattern was similar for Sunday 8/7/07. Although the home had 2 vacancies it would not be possible for one person to meet the individual needs of 5 people, provide lunch Maldon Lodge DS0000017877.V345176.R01.S.doc Version 5.2 Page 20 and cover for any contingencies that might occur if people went out on their own. The roster for the week beginning 2/7/07 showed one person twice working more than 2 shifts in succession; they had covered the sleeping night shift leading into the day of inspection, a further 2 hours supporting people getting up and were back on duty for the 3:00 to 22:00 p m and again the following morning at 7:00 a m. It was on one of these shifts that the person was impatient with people living at the home. Staff need proper breaks to work effectively and professionally in the best interests of the people they are supporting. Records, inspected for a very new member of staff showed that satisfactory references and police checks had been obtained prior to their start date. There was no application form on the file although the person concerned was sure they had completed one. A checklist had been completed, showing the areas of training covered on their first day of employment. On the day of inspection, they spent time reading through the folder containing the home’s policies and procedures as part of their induction. They confirmed that had been arranged for them to complete 2 days of health and safety training and also to work through the Skills for Care induction programme. Satisfactory recruitment records were now in place for a person employed in July 2006, including proof of identity, a contract and job description. Records showed that they had since completed training covering a range of health and safety topics, including basic first aid, the administration of medication and protecting vulnerable adults. The manager stated that all but one member of staff were involved in training for the National Vocational Qualification in care, Level 2 (NVQ 2). The NVQ tutor, who was present on the day of the inspection, was also providing health and safety training for the staff team (covering food hygiene, infection control, basic life support, safer moving and handling, general health and safety, including the care of substances hazardous to health (COSHH) and fire safety, and the protection of vulnerable adults). It had been arranged for everyone to complete the two days of training over the course of several weeks. The manager said they had all found the tutor’s teaching style conducive to learning. Staff confirmed that they had dates for training. Records showed that one to one supervision for staff was not taking place routinely. One person, who started their employment in July 2006, had attended only one supervision meeting in almost a year. Situations described earlier in the report (impatience with a person’s behaviour and poor practice in respect of a person being assisted in the toilet) demonstrated a need for further staff training and supervision. Maldon Lodge DS0000017877.V345176.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management ethos and style fostered positive working relationships but a more robust approach to quality monitoring would improve outcomes for people living at the home. EVIDENCE: The manager had completed her part of the National Vocational Qualification in Management and Care, Level 4, but was still waiting for a visit from the external verifier to confirm the award. A letter evidenced that this visit had been postponed from June to August 2007. The manager continued to demonstrate a good rapport with people living and working at the home. She was very much involved in giving practical and emotional support to residents, making herself available throughout the day. Maldon Lodge DS0000017877.V345176.R01.S.doc Version 5.2 Page 22 People also came readily to her office to talk with her about the things on their minds. Despite the home having two vacancies, and the implications for its financial viability, the manager had not admitted people whose needs she felt might conflict with those of existing residents. She said that the providers had supported her decisions on this and were committed to providing continuity for the people who had experienced Maldon Lodge as home for many years. Discussions are taking place with the Commission about the possibility of admitting someone outside of the home’s registration category, who they feel would fit in well and benefit from what the home could offer. The Annual Quality Assurance Assessment (AQAA) completed by the manager showed that they had reviewed various aspects of provision but not identified the shortfalls highlighted by this inspection. The manager and staff continued to spend time listening to the views of people living at the home both informally and at their regular meetings. Information contained in the AQAA, and safety certificates sampled during the inspection, showed that installations and appliances had been serviced for the safety of people living and working at the home. Records evidenced that the home was carrying out routine fire safety checks. Arrangements were in hand for all staff to attend health and safety training as part of their induction or to refresh their knowledge and skills. The manager had not implemented food safety procedures in accordance with a requirement made by the Environmental Health Officer. Arrangements for people to wash their hands did not promote good hygiene. There were safety issues in the garden, outlined under the section on environment. The provider indicated that people would be protected from hot radiator surfaces before the winter but he was seeking an alternative to the covers, already fitted over some radiators, which he found unsightly and not in keeping with a homely environment. Maldon Lodge DS0000017877.V345176.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 X 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 3 X 2 X X 2 X Maldon Lodge DS0000017877.V345176.R01.S.doc Version 5.2 Page 24 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 home’s safeguarding adults procedures must comply with locally agreed procedures. Amendments had been made to existing procedures but they were still not fully in line with requirements. This requirement has been ongoing since 2004. Action must be taken to address all risks to the health and safety of people living at the home, that are presented by their environment. Staff must have the training they need to promote good practice. The number of staff on duty must be sufficient to support and protect everyone living in the home. Staff must have the supervision they need to carry out their jobs effectively. This requirement has not met the agreed timescale of 30/09/06. Timescale for action 01/09/07 2. YA19 YA30 YA38 13 01/09/07 3. 4. YA23 YA35 YA33 18 18 01/09/07 09/08/07 5. YA36 YA23 18 01/09/07 Maldon Lodge DS0000017877.V345176.R01.S.doc Version 5.2 Page 25 6. YA39 24 The manager and providers must 30/09/07 develop an effective quality monitoring system to address shortfalls in care and provision. 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 YA6 YA23 YA17 YA33 YA23 YA33 YA37 Good Practice Recommendations Care plans should give staff clear guidelines for meeting individual needs to ensure consistent good practice and the best possible outcomes for the person they are supporting. People should be given some choice of menu. Staff should have sufficient breaks to work effectively and professionally in the best interests of the people they are supporting. Rosters and other records required by regulation need to be written in ink so that they provide a permanent record that cannot be altered by anyone retrospectively. 2. 3. 4. Maldon Lodge DS0000017877.V345176.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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