Inspection on 18/08/05 for Maple Lodge

This inspection was carried out on 18th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 18 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Maple Lodge 09/08/07

Maple Lodge 23/05/06

Maple Lodge 03/01/06

Maple Lodge 12/10/04

Maple Lodge 22/04/04

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Edenvale

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Chatsworth Care - Dawson House

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Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 Maple Lodge 10 Southborough Road Surbiton Surrey KT6 6JN Lead Inspector Michael Stapley Unannounced 18 August 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Maple Lodge G53-G53 S13393 MapleLodge unann V221916 180805 Stage 0.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Maple Lodge Address 10 Southborough Road Surbiton Surrey KT6 6JN 020 8399 4356 020 8287 1950 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mental Aid Projects Mr Richard Weir Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Maple Lodge G53-G53 S13393 MapleLodge unann V221916 180805 Stage 0.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 121004 Brief Description of the Service: Maple Lodge is a large property situated in a pleasant residential area. The home is managed by Mental Aid Projects (MAP), a charitable organization, providing residential and day care services. The organization currently offers residential care in four smaller homes in Surbiton in addition to Maple Lodge. One of the aims of this is that varying degrees of support and independent living can be offered. Overall management of the smaller homes is retained by the registered manager of Maple Lodge. It is hoped that other projects will be developed locally by the charity and there may be opportunities for some of the current group at Maple Lodge to move on to more independent settings in the future, if this is appropriate and desired. Maple Lodge offers 24 hour support to the service users. Trained staff and volunteers offer support and a keyworking system is in place to meet individual needs. Service users are encouraged and supported to have a full programme of activities based on their strengths, needs and choices. Maple Lodge G53-G53 S13393 MapleLodge unann V221916 180805 Stage 0.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This home was inspected under the National Minimum Standards Care Homes for Younger Adults. The inspection took place over one day on 16th August 2005. The registered manager was on annual leave at the time of the inspection. Two team leaders, Cathy Corth and Sue Shields who have worked at the home for a number of years, therefore represented the home. They both had a wealth of knowledge and experience enabling the inspection process to be undertaken in a positive manner. The relatively new Chief Executive of Mental Aid Projects, Ms Kay Harris, offers the registered manager Mr Richard Wier professional support. Records examined included service user plans; care manager needs assessments and risk assessments, medication records, complaints, staffing records, health and safety and fire records. Previous requirements and recommendations were discussed with the two-team leaders. What the service does well: Service users are very much the centre of attention in the home; all of them have a programme of day care. The home seeks to promote the independence of service users and ensure equality of service. All of the service users have resided at the home for many years and as a consequence are very much involved in running the home. Individual care plans are very comprehensive and headings include a pen portrait of the service user, weekly activities, health needs and communication skills to mention a few. The arrangements for health care needs of the service users is good, all service users are registered with a local General Practitioner, the home has the support of the local pharmacist for advice on medication. Staff members have access to a range of training courses, including NVQ’s to build on their skills to ensure that they are able to meet the service users assessed needs. Maple Lodge G53-G53 S13393 MapleLodge unann V221916 180805 Stage 0.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: The London Fire and Emergency Planning Authority have recently served the registered providers with an enforcement notice. This notice sets out work that is required to be completed by Mental Aid Projects to ensure that Fire Safety regulations are met. It was noted that this work had been outstanding for over twelve months, which is of concern given the nature of the enforcement notice. The home is in the process of developing Personal Care Plans. Previous requirements regarding care plans had not been completed and these also need to be further developed in conjunction with service users and relatives/friends. Contracts for service users did not contain all the information required under standard five. There were a number of further outstanding requirements that had still not been complied with. Given some of these requirements have been outstanding for at least the last two inspections the managing company must address them within laid down timescales. While it was evident that key working was taking place with the service users there was no written records, save for a tick box. The home has not developed a quality assurance system or sought the views of service users and other stakeholders by means of surveys and has not carried out an annual audit. In addition a number of health and safety issues had not been addressed and comment is made in this report under the Maple Lodge G53-G53 S13393 MapleLodge unann V221916 180805 Stage 0.doc Version 1.40 Page 7 appropriate section. Requirements have therefore been made in respect of this standard. In addition the managing company must ensure the homes vulnerable adults’ procedure is available at the home and ensure that medication records are audited on a regular basis. 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. Maple Lodge G53-G53 S13393 MapleLodge unann V221916 180805 Stage 0.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Maple Lodge G53-G53 S13393 MapleLodge unann V221916 180805 Stage 0.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3 and 5 The home provides good information and introduction opportunities for prospective service users to make an informed choice about moving to the home. Contracts between the home and the service users do not contain all the information required under standard potentially reducing the rights of the residents of Acorn Lodge. Staff at the home have access to a wide range of training programmes thus enabling them to offer an effective care programme for service users. EVIDENCE: The home has a preadmission procedure; prospective service users are able to visit the home on an individual basis. Service users are only admitted to the home once a full assessment of their needs; compiled by their care manager or other relevant person has been received. All of the service users at Maple Lodge have lived at the home since 1997 and in discussion with the staff it was evident that assessment is on going and is seen as very much part of the care plan. Personal Care plans are shortly to be introduced for all service user’s this will include an in depth assessment of all aspects of service users personal care, social, recreational and emotional needs. The home carries out internal six monthly reviews where information is up dated and care plans changed as appropriate. There are also yearly reviews carried out with the service users, their families and other professionals as appropriate. The registered manager Maple Lodge G53-G53 S13393 MapleLodge unann V221916 180805 Stage 0.doc Version 1.40 Page 10 must ensure all care plans are reviewed on a regular basis. It is suggested a summary of the care plans and support needs, including management guidelines and daily routines are written for each service user. These could then be used by any new or bank staff for quick reference. The home has an excellent training programme including NVQ training. The home has a training coordinator. The training programme includes mental health, epilepsy, medication, working with symbols. There has been some progress in improving contracts between the home and the service users. However contracts did not state that all residents would have a three month ‘settling in’ period of residence at the home. In addition contracts inspected did not contain all the information as required under standard 5.2. The home must accordingly amended service users contracts as at present there is the potential for their rights to be reduced. Maple Lodge G53-G53 S13393 MapleLodge unann V221916 180805 Stage 0.doc Version 1.40 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 9. Service user care plans do not contain all the information required as per standard six. Staff at the home do not have all the information they require to satisfactorily meet the needs of the service users. Service users have individual risk assessments and risk management strategies carried out to enable them to participate in activities in the home and in the community with appropriate support. EVIDENCE: Although Service users individual care plans are fairly comprehensive they do not contain all the elements of standard six. Care plans should contain a pen portrait of the service user, weekly activities, health needs and communication skills. Service users and their respective families must be involved in drawing up such plans as outlined in standard 6.6. In addition although service users have a home based day each week there was little evidence of the daily programme. The home must ensure care notes contain evidence of not only key working but also current and changing needs of service users in sufficient detail for a new member of staff and other stakeholders to understand as opposed to a ‘tick box’ at present. Service users are encouraged to become Maple Lodge G53-G53 S13393 MapleLodge unann V221916 180805 Stage 0.doc Version 1.40 Page 12 far more involved in the home; staff advised the inspector that they had become involved in the interview process for prospective staff. While this is acknowledged as good practise evidence must be available to support their involvement. House meetings continue to take place on a monthly basis and are used as a communication tool. The team leaders explained that the home is moving towards Person Centred Plans where ownership of the plan is given to the individual service user. Staff at the home have undertaken appropriate induction training in order to facilitate the care plans. Service users files sampled at random all had individual risk assessments and risk management strategies. However these were all out of date and needed reviewing and amending. Service users are encouraged to make their own decisions within the context of risk assessment wherever possible. All service users have individual choice and the home provides an independent advocate where desired. The home seeks to empower service users through group meetings and key working. While this is to be commended the overall picture of care plans and risk assessments was poor and this is an area that must be improved. Maple Lodge G53-G53 S13393 MapleLodge unann V221916 180805 Stage 0.doc Version 1.40 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 and 17. The daily routines and house rules promote residents’ rights and encourage independence. Service users are given opportunities to engage in age appropriate activities with an emphasis on using community-based facilities. Dietary needs are catered for and a balanced diet is provided, to ensure a nutritious diet based on personal preferences. EVIDENCE: The home is supporting service users to access appropriate activities through the activity programme. The service users access local parks, cafes, theatres, local leisure facilities and shops. In addition to swimming, gym and library. The staff team are available to support service users while accessing community resources. Service users spoken to stated that they enjoyed the activities on offer at the home. The home encourages family, friends and parents to visit wherever possible and suggestions/comments about the running/management of the home are always welcome. Service users do not, at present have access to computers although the inspector was advised by the staff of the home that Maple Lodge G53-G53 S13393 MapleLodge unann V221916 180805 Stage 0.doc Version 1.40 Page 14 they were currently fundraising in order to purchase suitable IT equipment and appropriate and accessible software. Maple Lodge G53-G53 S13393 MapleLodge unann V221916 180805 Stage 0.doc Version 1.40 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20 and 21 The home has failed to improve their procedures for administering medication placing service users at risk and harm. The home has failed to establish and record the service user’s wishes at death. Thus the potential for making the wrong funeral arrangements exists. EVIDENCE: Medication records examined at this inspection were for the most part found to be in order. However it was that one prescribed tablet had not been given to a service user but a member of staff had signed to state this had been given. Further there was no report of this incident available in the home. Some medication tubs had not been disposed of within laid down time scales and tubes did not have the date they had been opened on written on them. A list of staff signatures was also not available. These errors are of serious concern particularly given the recent inspection by the homes pharmacist. Health records are maintained for each service user. Service users record examined during the inspection demonstrate that the service user had access to routine health checks and specialist health care. Significant events and accidents are recorded and monitored, save for above incident. Staff members monitor service user’s health and maintain up to date records. Some of the staff team including the night staff have undertaken medication training. A requirement from the last inspection that the wishes of service users regarding death and dying are recorded has still not been complied with. Given Maple Lodge G53-G53 S13393 MapleLodge unann V221916 180805 Stage 0.doc Version 1.40 Page 16 this leaves the potential for making incorrect funeral arrangements to be made for service users the registered person must ensure this requirement is met without further delay. Maple Lodge G53-G53 S13393 MapleLodge unann V221916 180805 Stage 0.doc Version 1.40 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 Arrangements for protecting service users are not satisfactory at this home and place them at possible risk of harm and abuse. EVIDENCE: The home has a detailed complaints procedure. A pictorial format of this procedure has been developed and provided to service users. However it is of concern to note that the homes complaints forms are not being used. Instead accident and incident forms are being used which are quite inappropriate. The registered person must ensure the correct forms are used. In addition it was not possible to evidence how complaints had been resolved and, if so timescales for resolution were not clear. Complaints were kept in a buff envelope and it was not possible to establish if there had been any complaints since the last inspection. The registered person must develop a clear and transparent complaints process, enough that all complaints are monitored and record complaints in an appropriate format. There are also policies and procedures in place regarding the protection of vulnerable adults. However the homes Vulnerable Adult Procedure could not be found which is of serious concern. The team leaders stated that the staff team had completed a course on adult protection issues. Although in discussion with staff on duty it was evident that they would take appropriate action to report an accident or incident policies and procedures of the home must be available for all staff at all times for the welfare of the service users. Maple Lodge G53-G53 S13393 MapleLodge unann V221916 180805 Stage 0.doc Version 1.40 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 27, 28, 29, 30. Service user’s bedrooms provide privacy and reflect individual interests and preferences. The home is homely, bright and clean with the necessary adaptations in place, thus providing the service users with safe, comfortable surroundings that meet their needs. The homes laundry floor finishes are not impermeable and these and wall finishes are not easily cleanable possibly leading to infection. EVIDENCE: The home is a two story building in a quiet residential road. It is situated in Surbiton and is close to local shops and amenities. There is a large communal lounge on the ground floor as well as a spacious kitchen and dining room. The furniture is domestic, flame retardant, and of good quality. There has been some improvements in the décor of the home since the last inspection although some areas look shabby and in need of decoration. The team managers stated that a programme of redecoration is due to be implemented. In addition new furnishing, fixtures and fittings are to be purchased as required. Maple Lodge G53-G53 S13393 MapleLodge unann V221916 180805 Stage 0.doc Version 1.40 Page 19 There is also a pleasant garden at the rear of the home. Bedrooms viewed provided sufficient and suitable furniture. All areas of the premises viewed were clean and free from offensive odours. Systems are in place for controlling the spread of infection. This includes staff training in this area. The home does not have enough baths/showers to meet the needs of the service users. A previous requirement that the home provide an additional shower is still outstanding. In addition the laundry floor requires renewal to make it impermeable and the walls should be readily cleanable. The home has thermostatic valves fitted to each of the baths to avoid any scalding accidents. The temperature of the water is taken and duly recorded. Maple Lodge G53-G53 S13393 MapleLodge unann V221916 180805 Stage 0.doc Version 1.40 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35. The staff team at the home have a range of skills and ability, which appear to meet the needs of the service users. The staff team have all had Criminal Records Check, as a safeguard to offer protection to the homes service users. EVIDENCE: Maple Lodge G53-G53 S13393 MapleLodge unann V221916 180805 Stage 0.doc Version 1.40 Page 21 The home offers training opportunities to staff at all levels within the home. New members of staff complete an induction programme covering various subjects including health and safety, fire drills, and introductions to service users and other staff. The induction programmes are signed, dated and kept on staff files. Criminal Records Checks are completed before a new member of staff can begin work in a home. The home has a very stable staff team consisting of manager, team leaders and support workers. The manager is qualified and two of the team leaders are currently completing NVQ level 3. The manager and team leaders offer professional support and guidance to the support workers in addition to bank staff. They are currently responsible for the supervision of junior staff which is now in line with the standard. The team leaders advised that staff meetings usually take place every fortnight, although minutes evidenced suggested they were more likely to be held each month. They are used as a communication tool, where information is shared and common themes are addressed. Staff meetings minutes evidenced were clear and focused on service users needs. There are three staff members on duty on each shift, plus one member of staff sleeping-in. There are suitable on call arrangements in place in case of an emergency. Maple Lodge G53-G53 S13393 MapleLodge unann V221916 180805 Stage 0.doc Version 1.40 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39 and 42 The management of the home appears to be open and transparent with clear lines of accountability, which is aimed at ensuring the well being of the service users. The overall management of Health and Safety within the home is extremely poor and potentially dangerous placing service users and visitors of risk of injury or harm. EVIDENCE: The managing company has recently been served with an enforcement notice by the London Fire and Emergency Planning Authority. This was due to the fact that there were deficiencies relating to fire safety. These deficiencies had been outstanding for over twelve months hence the issue of an enforcement notice. At the time of this inspection there was no evidence to suggest that suitable arrangements had been made to complete the outstanding works. Fire drills are now up to date and a fire risk assessment had now been completed. There were good support mechanisms in place and the manager meets with the chief Maple Lodge G53-G53 S13393 MapleLodge unann V221916 180805 Stage 0.doc Version 1.40 Page 23 executive of the trust to discuss any issues concerning the home, efforts are made to meet any concerns or improve the service. The annual development plan and business plan for 2005-06 were not available for inspection at the home. Records required for the safety and well being of service users were not available or were out of date. These included Portable Appliance Testing which was out of date. Certificates in respect of legionella and the five yearly electrical certificate could not be found. However other records inspected were generally found to be in order including accidents, water temperatures, incidents, food records, fire records, staff and service user’s case files. The residents are beginning to see the benefits of a stable staff team and a continuity of approach this generates. However for residents and their stakeholders these developments need to be consolidated and built on in order for them to be confident that their best interests are safeguarded, their views are taken into account and the home is well managed. The system for consultation with service users, families, stakeholders and other interested parties is reasonable although the quality assurance system which has yet to be developed should include service user, relatives, staff and outside professional questionnaires. In addition there was no evidence of an annual audit Maple Lodge G53-G53 S13393 MapleLodge unann V221916 180805 Stage 0.doc Version 1.40 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. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 3 x 2 Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 x 2 3 3 2 Standard No 11 12 13 14 15 16 17 x 2 3 3 2 x 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Maple Lodge Score x 3 2 2 Standard No 37 38 39 40 41 42 43 Score 3 x 3 x x 1 2 G53-G53 S13393 MapleLodge unann V221916 180805 Stage 0.doc Version 1.40 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4 Requirement The Registered Provider must ensure that the Statement of Purpose is reviewed to describe staff skills and experience and how these meet the needs of service users, and the specific needs the service can meet and those it can’t, in consultation with service users, and a copy supplied to the Commission for Social Care Inspection (CSCI). The Registered Provider must ensure that the contract/statement of terms and conditions includes the rooms to be occupied, rules in place at the home (in agreement with the purchasing authority), arrangements for the review of the Service Users Plan, and makes clear the ninety day trial period. The Registered Provider must ensure that service users care plans are drawn up after consultation with the service user, familiy, friends and an advocate where appropriate. Service User Plans must show how service users current and changing needs and aspirations G53-G53 S13393 MapleLodge unann V221916 180805 Stage 0.doc Timescale for action 31/10/05 2. YA5 5 31/10/05 3. YA6 15 30/10/05 Maple Lodge Version 1.40 Page 26 4. YA 16 18 12 24 5. YA19 12 6. YA20 12 7. YA20 12 8. YA21 12 9. YA23 13 20 will be met, and goals achieved, in sufficient detail for a new staff member and other stakeholders to understand. The Registered Provider must ensure that the home can demonstrate the benefit of discussing the completion of agreed chores with service users at their meeting, ensure that the privacy and dignity of service users is respected, support service users to influence key decisions at the home including the recruitment of staff, and that service users receive clear information about the outcome of involvement and participation at meetings. The Registered Provider must ensure that the service user described is assessed by their GP, and necessary action taken. Such action should be recorded and placed on service users file. The registered persons must ensure where medication is signed as given by a staff member of the MAR sheets it is actually given to the service user. The registered person must ensure that outdated creams and tubes are disposed of within laid down timescales after they have been opened. The Registered Provider must ensure that the wishes of service users regarding death and dying are recorded, with the involvement of other stakeholders including friends and family members as appropriate. The Registered Provider must ensure a contract is drawn up between the organisation and the service users in respect of 31/10/05 31/10/05 31/10/05 31/10/05 31/10/05 31/10/05 Maple Lodge G53-G53 S13393 MapleLodge unann V221916 180805 Stage 0.doc Version 1.40 Page 27 10. YA22 17 11. YA23 13 12. YA24 13 13. YA27 13 23 14. YA30 16 23 15. YA39 24 the house vehicle. Among other things, this contract must detail ownership and the procedures in event of a service user leaving the home or not wishing to be part of this contract for any reason. The registered person must ensure a written record is kept and available for inspection of all complaints made about the operation of the care home and action taken is appropriately maintained from now on. Complaints must be recorded on the complaints form and not on theaccident and incident form. The registered person must ensure that the homes Vulnerable Adults Procedure is available in the home for staff use at all times. The Registered Provider must ensure that ensure that the patio is even and does not present a hazard. The Registered Provider must ensure that a further shower is provided at the home, or demonstrate that current provision meets the needs of service users, and respects their wishes. The registered person must ensure the laundry floor finishes are impermeable and these and wall finishes are readily cleanable. A quality audit system, including an annual development plan must be in place to assess whether the aims and objectives of the home have been met and:The home must implement a professionally recognised quality assurance or ‘join up’ their own quality assurance tools into a cyclic quality assurance system. 31/10/05 31/10/05 31/10/05 31/10/05 31/10/05 31/10/05 Maple Lodge G53-G53 S13393 MapleLodge unann V221916 180805 Stage 0.doc Version 1.40 Page 28 16. YA42 12 17. YA42 12 18. YA42 23 19. YA43 25 The registered provider must send to the CSCI, local office a copy of the current legionella certificate, five yearly electrical certificate and a current portable appliance testing certificate. The registered provider must ensure that risk assessment are carried out for all safe working practise topics in Standard 42.3 and 42.4. In addition all generic and individual service user risk assessments must be reviewed. The registered persons must complete all outstanding works detailed in an enforcement notice issued by the London Fire and Emergency Planning Authority on 28th July 2005 and confirm in writing to CSCI when it has been completed. The Registered Provider must ensure that a business plan is available for inspection, demonstrating the financial viability and accountability of the home and send copies to CSCI. 31/10/05 31/10/05 28/10/05 31/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Maple Lodge G53-G53 S13393 MapleLodge unann V221916 180805 Stage 0.doc Version 1.40 Page 29 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor, Grosvenor House 125 High Street, Croydon CR0 9XP 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 Maple Lodge G53-G53 S13393 MapleLodge unann V221916 180805 Stage 0.doc Version 1.40 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!