Inspection on 23/05/06 for Maple Lodge

This inspection was carried out on 23rd May 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 10 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 03/01/06

Maple Lodge 18/08/05

Maple Lodge 12/10/04

Maple Lodge 22/04/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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 Key Unannounced Inspection 23rd May 2006 09:30 Maple Lodge DS0000013393.V294189.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 Maple Lodge DS0000013393.V294189.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. Maple Lodge DS0000013393.V294189.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Maple Lodge Address 10 Southborough Road Surbiton Surrey KT6 6JN 020 8399 4356 020 8287 1950 richard@maplelodge.charityday.co.uk 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) The Fircroft Trust Mr Richard Weir Care Home 13 Category(ies) of Learning disability (13) registration, with number of places Maple Lodge DS0000013393.V294189.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been agreed to allow one specified service user over the age of 65 to be accommodated. 3rd January 2006 Date of last inspection 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 key working 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 DS0000013393.V294189.R01.S.doc Version 5.2 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 23rd May 2006. The home was represented by the Registered Manager, Mr. Richard Weir and support staff who all contributed to the inspection process. The manager is supported by Kay Harris the Chief Executive of the Fircroft Trust the company that manage the home. She too is very experienced and well qualified to support the manager in his day to day management of the home. 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 registered manager who will be sending an action plan to the commission as agreed at the time of the inspection. 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. The home encourages all service users to make decisions in all aspects of their lives; this includes what to eat, where to go on holiday, day trips out and what clothes to buy. The home is aware of the importance of marking significant life events and recently helped a service user’s family in planning a surprise 60th birthday party. 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 Maple Lodge DS0000013393.V294189.R01.S.doc Version 5.2 Page 6 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. What has improved since the last inspection? Since the last inspection the organisation has changed its name from Mental Aid Projects to The Fircroft Trust. It was felt that this new name is more in line with current thinking of how people with either learning disabilities or mental health are viewed. The home has also been involved in a pilot project “Total Communication” The staff at the home who are involved in the project have worked in conjunction with the speech and language therapy service. The project looked at various communication strategies within the home and identified specific service users who had particular support needs with their communication as well as looking at other areas of communication within the home. After the initial training day various agreed objectives were set: a. To Develop a resource of useful photographs for reviews, meetings and of important places and activities b. To Learn more about makaton signs and to use them on a daily basis c. Devise and draw up important signs and put them on the wall to remind staff d. Introduce an activities board for the weekly social club e. Develop a chat book for three service users f. Develop a communication passport for two service users g. To create a photographic board for the staff rota Maple Lodge DS0000013393.V294189.R01.S.doc Version 5.2 Page 7 h. Develop a new visual timetable for one service user i. Assess the understanding and communications skills of five service users This project has proved to be enormously beneficial to the service users involved and has enabled the staff team to look at various communication strategies within the home. The home has been visited by two Registered Managers within the borough who plan to introduce this project to their service. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Maple Lodge DS0000013393.V294189.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Maple Lodge DS0000013393.V294189.R01.S.doc Version 5.2 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 the following standard(s): 1, 2, 4 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 contain all the information required under standard five thus ensuring the rights of the residents of Maple Lodge. Staff at the home have access to a range of training programmes thus enabling them to offer an effective care programme for service users. EVIDENCE: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has produced a Statement of Purpose. However this still needs to be amended to clearly state the experience of the staff at the home and the needs of the service users the home can meet. 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. Senior staff at the home can visit the prospective Maple Lodge DS0000013393.V294189.R01.S.doc Version 5.2 Page 10 service user in their current placement or own home, if appropriate. The importance of any service user coming to the home and relating to those already living at the home was clearly emphasised. A number of introductory visits are planned; this may include an activity and a meal at the home. In addition overnights stays can be arranged to ensure the service user is at ease when they come to their new home. It is clear that although this admission process takes some time it does give every chance for the new service user to settle in to their new surroundings and thus give a solid grounding to any placement. All of the service users at Maple Lodge have lived at the home for some time 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 based on the home’s individual system which is an in depth assessment of all aspects of service users personal care, social, recreational and emotional needs. The home monitors service users care plans on a monthly basis when 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 manager advised that all service users have access to an advocate has and when necessary, although the majority of service users were supported by their families and relatives. The home has a training programme that has been well developed and staff at the home have clearly benefited from being involved in the “Total Communication” Project that has enabled them to improve their communication skills with the service users. Contracts inspected now contained all the information as required under standard 5.2. thus ensuring service user’s rights. Maple Lodge DS0000013393.V294189.R01.S.doc Version 5.2 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 the following standard(s): 6, 7 and 9. Service user care plans contain all the information required as per standard six. Staff at the home has 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 thus enabling them to participate in activities in the home and in the community with appropriate support. EVIDENCE: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user individual care plans are comprehensive and contain all the elements of standard six. Care plans contain a pen portrait of the service user, weekly activities, health needs and communication skills. Service users and their respective families are involved in drawing up such plans as outlined in standard 6.6. In addition service users have a key worker who writes a monthly report on his/her service user. It is suggested that service user’s could Maple Lodge DS0000013393.V294189.R01.S.doc Version 5.2 Page 12 have their own personal file written in a format they understand which they keep could and refer to. The home is beginning to be far more service user focused. Service users are encouraged to become far more involved in the home. House meetings that take place every week are used as a communication tool to empower service users. Service users files sampled at random during this inspection all had individual risk assessments and risk management strategies. Risk assessments inspected during the course of this inspection were for the most part found to be up to date. 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. Maple Lodge DS0000013393.V294189.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 14, 15, 16 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: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 Maple Lodge DS0000013393.V294189.R01.S.doc Version 5.2 Page 14 staff team are available to support service users while accessing community resources. Service users spoken to during the course of this inspection stated that they enjoyed the activities on offer at the home. In addition all of the service user’s have an annual holiday with support from staff which is paid for by 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. Weekly menus were constructed with the aid of the service user’s personal choice, advice from service user’s families and the experiences of the staff. Service user’s spoken to during the cause of this two inspection stated they enjoyed what they had to eat at the home. Service user’s weight is monitored and appropriately recorded. Any significant loss or weight gain to discussed with the homes GP. In addition the home seeks the advice and guidance of a dietician to ensure a healthy and well balanced diet. Staff encourage service user’s to help with the shopping, preparation of meals and other chores wherever possible. The manager has drawn up a pro forma which clearly indicates that the service user is involved in planning such activities and that all chores are completed with the agreement of the service user. Service users now have access to a lap top computer although the manager advised the Fircroft Trust were fundraising for a touch screen computer. The Inspector, in discussion with the manager suggests it might be prudent for service users to have access to the internet to enhance there social and educational skills. Any software would clearly need to be suitable and accessible to those with a disability. In discussion with some of the service users and the manager it became apparent that not all service users had been offered a front door key. One service user commented that he would like a key to the front door as this was ‘his home’ In addition it was noted that service users were not able to lock their own bedrooms as outlined in Standard 16.2 The home has its own mini-bus and the use of other vehicles. Maple Lodge DS0000013393.V294189.R01.S.doc Version 5.2 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 the following standard(s): 18, 19, 20 and 21. Personal care is carried out in a way that residents prefer so that dignity and choice are maintained. Residents’ medication is well managed to ensure good health. 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: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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. The staff team at the home keep a central record of incidents as well as an individual record on service user’s files. Staff members monitor service user’s health and maintain up to date records. Maple Lodge DS0000013393.V294189.R01.S.doc Version 5.2 Page 16 All of the staff team have now completed accredited medication training. The pharmacist visits the home on a regular basis. All requirements and recommendations from the inspection of 6th March 2006 have been complied within laid down timescales. All requirements from the last inspection by the Commission Social Care Inspection have also been complied with. The manager has introduced a weekly medication audit following serious concerns expressed by the Inspector at the last inspection. This form has been commended by the pharmacist from Boots the chemist and is now being used in other registered homes in the area. All other medication records, including MAR sheets and service user profiles were correct at the time of the inspection. In addition the home keeps a list of specimen signatures for those staff that administer medication. A requirement from the last announced inspection that the wishes of service users regarding death and dying are recorded has still not been complied with. The manager advised that he had drawn up a template for this to be recorded although the home was finding this to be an extremely sensitive matter to deal with. It is suggested the home contact families, relatives and advocates so that they are involved in drawing up such arrangements with service users at the home. At present as there are no funeral arrangements held on file there is the potential for making incorrect funeral arrangements for service users. The registered person must ensure this requirement is met without further delay. Maple Lodge DS0000013393.V294189.R01.S.doc Version 5.2 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 the following standard(s): 22 and 23. There is a complaints policy and procedure, which facilitates good access to the complaints system for the residents, their family or their representatives. The home has the appropriate policies in place to ensure the protection of vulnerable service users. EVIDENCE: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a detailed complaints procedure. A pictorial format of this procedure has been developed and provided to service users. The Inspector noted that any complaints appeared to centre around one particular service user and his unacceptable behaviour. The manager advised how he dealt with these situations including meeting the service user with his key worker. All concerns were managed appropriately. The complaints book gives details of any investigation, actions taken (if any) and the outcomes. There are also policies and procedures in place regarding the protection of vulnerable adults. The home has drawn up a flow chart to ensure that all staff is aware of the action to be taken in regard to adult protection. The staff team are aware of the action they must take if they need to report an incident. The Inspector noted that not all of the staff team had undertaken adult protection training. The manager agreed to arrange such training within agreed timescales. Maple Lodge DS0000013393.V294189.R01.S.doc Version 5.2 Page 18 Maple Lodge DS0000013393.V294189.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 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. EVIDENCE: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 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 have been some improvements in the décor of the home since the last inspection although there is some damp in the lounge and some external decoration is needed. The laundry has been decorated since the last inspection Maple Lodge DS0000013393.V294189.R01.S.doc Version 5.2 Page 20 however a number of environmental requirements are still outstanding from previous inspection. In addition new furnishing, fixtures and fittings have recently been purchased. However there is know external lighting whatsoever to the front of the building which could not only cause service users difficulty in accessing the building during the dark but cause difficulties for staff at night. 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. 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 DS0000013393.V294189.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. 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. The staff team have access to a wide range of training programmes which enhance their personal and professional development. EVIDENCE: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers reasonable training opportunities to staff at all levels within the home, although staff would benefit by taking specialist training courses such as that offered by BILD for staff who work with service users who have a disability. 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. Maple Lodge DS0000013393.V294189.R01.S.doc Version 5.2 Page 22 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 three other staff are completing NVQ training including the two team leaders who are completing NVQ level 3. While this is to be commended the home must ensure that 50 of the staff will achieve as a minimum an NVQ level 2 qualification without further delay. 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 manager advised that staff meetings usually take place weekly. 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 DS0000013393.V294189.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 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. EVIDENCE: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager and two team leaders offer support and supervision to the support workers at the home. There were good support mechanisms in place and the manager meets with the Chief Executive to discuss any issues concerning the home, efforts are made to meet any concerns or improve the service. The draft annual development plan and business plan for 2006-07 was evidenced during the course of this inspection. Records required for the safety and well being of service users are in place including accidents, water temperatures, complaints, incidents, food records, Maple Lodge DS0000013393.V294189.R01.S.doc Version 5.2 Page 24 fire records, staff and service user’s case files, medication records. Fire drills are now up to date and a fire risk assessment has now been completed, although Fire Training needs to be updated for all new and existing staff. All certificates in respect of Health and Safety were evidenced during the course of this inspection and found to be in order. The residents are beginning to benefit from 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 has been reviewed. The quality assurance system includes service user, relatives, staff and outside professional questionnaires. The home is shortly to complete a survey for service users, care managers, families and other stakeholders. The home will need to collate the results of these surveys and ensure the outcomes will need to evidence that the results of the surveys are acted on for the benefit and wellbeing of the service users at the home. The home has also recently completed a ‘SWOT’ analysis to identify its Strengths, Weakness, Opportunities and Threats. This is being used to identify and review the aims and objectives of the home. Maple Lodge DS0000013393.V294189.R01.S.doc Version 5.2 Page 25 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 2 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 2 27 2 28 3 29 2 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 2 3 X 2 X X 2 X Maple Lodge DS0000013393.V294189.R01.S.doc Version 5.2 Page 26 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 YA1 Regulation 4 Requirement Timescale for action 30/06/06 2. YA16 13 3. YA21 12 4. YA24 23(2)(b) 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 cant, in consultation with service users, and a copy supplied to the Commission for Social Care Inspection. (Not met at 31/10/05) The registered person should 31/08/06 ensure service users are offered a key to their own bedroom and front door. Where this is declined it should be appropriately recorded. The Registered Provider must 31/08/06 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. (Not met at 31/10/05) The registered person must 31/08/06 ensure that the damp in the lounge is investigated and made DS0000013393.V294189.R01.S.doc Version 5.2 Maple Lodge Page 27 5. 6. YA24 YA26 23(2)(o) 13 7. YA27 13 & 23 8. YA29 13 9. YA39 24 10. YA42 12 good in order to ensure the Health and Safety of service user’s. The registered person must ensure there is adequate lighting to the front of the building. The registered person should ensure service user’s bedrooms are lockable. Staff use an override device only as indicated by a service users risk assessment. 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. (not met at 31/10/05) The registered person must ensure the home as an up to date assessment for aids and adaptations undertaken by an Occupational Therapist or other suitably qualified specialist. 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. (partly met at 31/10/05) The registered provider must ensure that risk assessment is 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. (partly met at 31/10/06) 31/08/06 31/08/06 31/08/06 31/08/06 31/08/06 31/08/06 Maple Lodge DS0000013393.V294189.R01.S.doc Version 5.2 Page 28 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 Maple Lodge DS0000013393.V294189.R01.S.doc Version 5.2 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 DS0000013393.V294189.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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