Inspection on 24/06/08 for Maple Lodge

This inspection was carried out on 24th June 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Maple Lodge 22/08/07

Maple Lodge 21/03/06

Maple Lodge 07/09/05

Maple Lodge 01/12/04

Maple Lodge 07/06/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Maple Lodge Arncliffe Road Halewood Liverpool Merseyside L25 9PA Lead Inspector Mrs Lynn Paterson Key Unannounced Inspection 24th June 2008 10:00 X10015.doc Version 1.40 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 DS0000005463.V363690.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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 DS0000005463.V363690.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Maple Lodge Address Arncliffe Road Halewood Liverpool Merseyside L25 9PA 0151 448 1621 0151 448 0713 maple.lodge@schealthcare.co.uk The.willows@ashbourne.co.uk Exceler Healthcare Services Limited 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) Miss Lorraine Sharpe Care Home 45 Category(ies) of Dementia (24), Dementia - over 65 years of age registration, with number (20), Old age, not falling within any other of places category (25) Maple Lodge DS0000005463.V363690.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Service users to include up to 25 OP, and up to 24 DE and up to 20 DE(E). Service Users in the DE category can only be in the age range 55 years and over. A maximum of 45 service users may be accommodated. The Service should employ a suitably qualified and experienced manager who is registered with the CSCI. The service may admit one named service user under pensionable age. 22nd August 2007 Date of last inspection Brief Description of the Service: Maple Lodge is a large, single storey building located in the Halewood area of Liverpool. It is close to local shops and has good links to motorways and buses. The home is approximately 3 miles from the city centre. The home is registered for 24 people with dementia and 25 people who are elderly. Within the home, there are two units, each looking after people with different care needs. The units have security locks to ensure the safety of those who live there. The home is easily accessible from the front and back of the building and has plenty of car parking spaces. There is suitable access for people using wheelchairs. Garden areas are located to the front and rear of the home and a small communal garden in a central courtyard and accessed from the main building. Fees are currently charged between £300 - £500 per week. Maple Lodge DS0000005463.V363690.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two stars. This means that people who use the service receive good quality outcomes. An unannounced visit was carried out over a seven - hour period and the methods used to assess the service, included discussions with the people who live in the home, their representatives, the home manager and staff. A tour of the building was also undertaken to assess the environmental standards of the premises and activities of daily life for the people living in the home were observed. Six care plans were selected on a random basis and assessed in detail to ensure that the people living in the home are receiving the care and support they need. Records on staffing and health and safety were looked at to ensure that residents are safe in Maple Court. The manager completed the Annual Quality Assurance Assessment (AQAA) and returned it before the visit was carried out. The AQAA is a self assessment document which gives much information about any changes to the services provided, how the home has improved in the last twelve months, development plans and any barriers to improvement. This information is referred to in this report. Surveys were sent to staff and residents some of which have been returned comments of which are contained in this report. What the service does well: Staff and residents say the manager has an open door policy in which they are always welcomed to pop in and speak with her about anything that is on their mind. Staff said the manager is very good at what she does, she runs the home well and everyone respects her. Staff are supported and receive ongoing training to ensure they have the necessary skills to look after the people living in the home. Pre admission assessments are detailed and hold clear details of individual need. Residents said they were even asked what newspapers they liked to read to ensure that the home could provide them when they “came to live in the home”. Maple Lodge DS0000005463.V363690.R01.S.doc Version 5.2 Page 6 The activities are clearly structured around the choices and capabilities of the people living in the home and as a consequence most residents participate. Residents said that staff are kind and caring and go the extra mile to make sure residents are happy. Comments included: “These people who work here are great. They are always happy and look after us so well”, “The staff are so good to us, I don’t know what we would do without them” “The staff seem to know what we want although they always ask us. They can’t do enough for us”. “The staff put themselves out for us to make sure we get what we want. For example if I want a magazine, someone will run out for it for me. I wanted something the other day and before I knew it, it was here. They are kind caring and very good at what they do. We could not get better anywhere” What has improved since the last inspection? Care plans have been updated and now hold more detail about residents past lives. Staff, say this enables them to speak with the people living in the home about places and people that have special meanings to them. The home continues to carry out a continuous refurbishment programme to ensure that the premises are safe and well maintained. The administration has been improved with updating of company policies and has clear financial management records for residents. The home has also developed a meeting and greeting process in which the manager and the administrator meet with the person to be admitted and or their families and make them feel welcome in the home. Contacts and other administrative documentation are signed to ensure that the new resident has full details of what the home should provide. A resident who had recently been admitted to the home said this meeting made her feel very good and reassured her that “everything would be alright” The manager has recruited a committed and dedicated activities co-ordinator who has introduced innovative activities and developed strong links within the local community. Maple Lodge DS0000005463.V363690.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Maple Lodge DS0000005463.V363690.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Maple Lodge DS0000005463.V363690.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1.2.3.5.6. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Prospective residents are confident the home can meet their identified care needs and personal aspirations. EVIDENCE: The service user guide and statement of purpose is provided to all new residents and is also assessable to any visitors to the home. Any person considering moving into the home is encouraged to visit the premises and stay for a while to gain some insight into how the home runs. A full assessment of need is carried out in the persons own home or hospital setting and staff will then see if the persons needs can be met by the staff and Maple Lodge DS0000005463.V363690.R01.S.doc Version 5.2 Page 10 facilities provided. If so, a placement is offered and the new resident is admitted on a four- week trial basis. Staff revealed on admission the manager or member of staff who has carried out the initial assessment is on duty and along with the administrator they meet and greet the person and provide a contract and other documentation to ensure the resident knows what the home should provide. Observations of a new admission showed that this process assists the resident to “move in” and reassures them about what to expect. A resident who was a fairly new admission said that the manager and administrator had followed this process when s/he was admitted. S/he said that it make her/him feel very reassured that everything was going to be allright. Six care files viewed showed that full details of assessed needs were recorded together with capabilities and choices. Details of diversity were well recorded to include religion; heritage, sexuality, diet, nutrition, hobbies, interests and details even included their choice of daily newspaper. The home does not currently provide intermediate care. Maple Lodge DS0000005463.V363690.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7.8.9.10. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Care planning and risk management strategies used by the home accurately reflect the social, health care and support needs of residents EVIDENCE: Six care plans were randomly selected and examined in detail and several other care plans were looked. All care plans held detailed information about residents changing needs and also show that each person is supported to make decisions about their lives and choices are given and risks assessed and managed. Care plans show that the comprehensive assessments details are added to as an ongoing process once the resident moves into the home. The care plan Maple Lodge DS0000005463.V363690.R01.S.doc Version 5.2 Page 12 details health and personal care needs and promotes individual diversity and independence. There was evidence that people who live in the home are consulted and involved in their care planning and with the risk assessment process. An example of the risk assessment was recorded in respect of a resident who liked to go shopping and needed the assistance of a staff member to enable him/her to do this. Other risks assessed included money management, personal safety and mobility issues. In general care planning and reviewing documents held signatures of all the people who had been involved in drawing them up. However the home is in the process of updating care plans and it was noted that three updated plans were awaiting signatures of the residents to confirm they had been drawn up in full consultation. The manager addressed this as a matter of urgency. Care plans identified that GP, District Nursing, chiropody, aromatherapy and other paramedical services regularly visit the home. Staff said they were provided with detailed care plans to identify what level of care and support they should provide. However they said that they always ask a person what they want and said that this assists them to maintain the persons dignity. One staff member said that the home use a key worker system which further helps staff to really get to know the residents and enjoy effective communication about their past. Another staff member said that in the case of providing care and support she waits for the resident to lead and she will follow that lead, wherever possible. In discussions staff identified that they had received and understood the dementia care training they had been provided with to include training on Yesterday, Today and Tomorrow. They said that this training enabled them to observe resident’s mood swings and actions and provide appropriate interventions to deescalate situations. Discussions with people living in the home revealed that they are content with all aspects of the health and social care provision. Residents said that staff are kind and caring and go the extra mile to make sure residents are happy. Comments included: “These people who work here are great. They are always happy and look after us so well”, “The staff are so good to us, I don’t know what we would do without them” Maple Lodge DS0000005463.V363690.R01.S.doc Version 5.2 Page 13 “The staff , seem to know what we want although they always ask us. They can’t do enough for us”. “The staff put themselves out for us to make sure we get what we want. For example if I want a magazine, someone will run out for it for me. I wanted something the other day and before I knew it, it was here. They are kind caring and very good at what they do. We could not get better anywhere” Comprehensive medication policies are in place and all medications are safely stored and correctly administered. Staff, are provided with training from a local pharmacist. Medication systems are audited weekly and action is implemented if staff, have not strictly adhered to the company medication policy. Records show that a medication audit identified a discrepancy in the administration of medication and appropriate action was taken to ensure this did not happen again. Medication record sheets examined were well managed. However some held front sheets that held hand written details of changes of medication. When questioned, staff said that GP’s would ring up and tell them to change medication for some residents. None of the amendments held signatures of the person who had prescribed these changes although 2 staff members of the home signed the record sheet to say they had received verbal instruction. Discussions were held about how instructions were currently recorded in respect of changes of medication as prescribed by General Practitioner. It was recommended that this system be modified to include the GP’s faxinated signature if the medication change had been prescribed by telephone. Maple Lodge DS0000005463.V363690.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12.13.14.15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s views and wishes are valued and form the basis of social and leisure activites provided in the home. This results in the home proving a flexible lifestyle to suit all individual needs. EVIDENCE: Observations of the general interactions in the home identify that the home provide a safe and nurturing environment that promotes a general family feeling. Staff, say they like to think that the residents are happy, content and at peace with themselves and staff were seen to go about their business creating a feeling of wellbeing. Daily records show the home has flexible routines that are resident led. Staff said that residents are encouraged to decide what they want to do and when they want to do it. Maple Lodge DS0000005463.V363690.R01.S.doc Version 5.2 Page 15 The manager said she had recruited an excellent activities co-ordinator who is committed and dedicated to providing innovative activities to suit the capabilities and preferences of the residents. Discussions with the co-ordinator reinforced the manager’s comments and it was apparent that the co-ordinator has met with each resident to ensure that they have told her about what they would like to happen in the home. The coordinator has developed stronger community links and the home have arranged fund raising events that have increased the residents funds and has enabled them to “buy in” entertainment for the residents. The activities board showed that games, quizzes, musical events, shopping trips, community outings, and entertainment -evenings were all part of the daily life at Maple Lodge. It was noted however that the activity of the day of the inspection visit included some baking. Residents told us that they did not want to bake when the inspector was there as “they were afraid of missing something” so had put this activity off until tomorrow. They said that when we had “seen them” they would join in with a quiz. The AQAA details that the home has a nutritionally balanced menu using fresh products and home baking. Residents said the food is always good and they can have what they want, when they want. Staff said “finger foods” were on offer throughout the day for the people who may be experiencing weight loss or prefer to eat as they go opposed to sitting at a dining table. Some residents were seen to be eating as they walked but appeared to be fully enjoying the food. Residents said they have birthday parties and other celebrations and the chef home bakes wonderful cakes and provides buffets. Residents observed at lunch -time appeared to be thoroughly enjoying varied meals in a pleasant ding room setting. The chef said that people are fully consulted about their meals and many choices are available. Comments from residents about the meals included: “Good”, ”Very nice”, ”Plenty of it” “Nice and hot” “Very tasty” “Never had a bad meal here yet”. Maple Lodge DS0000005463.V363690.R01.S.doc Version 5.2 Page 16 Maple Lodge DS0000005463.V363690.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16.18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ views and opinions are sought and acted upon. The homes policies and procedures protect residents from abuse and neglect. EVIDENCE: The home has a complaints procedure, which residents say is clear and easy to understand. Details of the complaints procedure are displayed in the reception area of the home and copies of the complaints policy are given to all residents on admission. Minutes of residents meetings and feedback from the people living in the home and their representatives indicate that the manager and staff of the home promote and encourage “customer feedback” and listen and respond. The manager said that all complaints are treated with respect and assurances given that the matter will be thoroughly investigated and the outcome fed back within the timescales stated. Maple Lodge DS0000005463.V363690.R01.S.doc Version 5.2 Page 18 Records show that the home have received five complaints in the past twelve months all of which had been resolved within twenty-eight days. The manager also advised that the home operates an open policy in which all health and social care professionals together with relatives are made aware of any issues/areas of concern that are received and they are asked if they may have any input that may be useful to the investigation. Minutes of meetings show that the manager has requested “professionals” meetings to discuss areas of concern and seek positive outcomes for the people living in the home. Staff records show that they attend Protection of Vulnerable Adults training on a yearly basis. The training includes the identification of various types of abuse and how to report concerns. The home has procedures in place on how and when to respond to any suspicion of abuse or neglect and records show that they have utilised their procedures to ensure the safeguarding of people living in the home. The manager said that the homes stringent recruitment and section procedures to include police checks, past working life and reference checks also serve to protect the people living in the home. Maple Lodge DS0000005463.V363690.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19.26. Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. The home is well maintained and provides a homely, comfortable and safe environment for residents to live in. EVIDENCE: A tour of the premises and feedback from staff and people living in the home revealed that the home is well maintained, warm and comfortable. Records show that maintenance contracts are in place and active for all equipment in the home. The AQAA states the home provide effective systems to provide early alarms to major incidents, for example, Fire systems. There Maple Lodge DS0000005463.V363690.R01.S.doc Version 5.2 Page 20 are strict fire safety systems in place to include fire doors and early warning systems. Moving and handling equipment such as hoists, stand aids and bath hoists are serviced and checked as an ongoing process and the home has good wheelchair access. Bedrooms appear cosy and personalised. Bathroom and toilets presented as clean and well equipped. Nurse call systems were checked and appeared to be in good order. The communal parts of the home have benefited form a refurbishment to include carpets and furnishings and the home has plans to install a sensory room for the use of the residents. The home has large well- kept open gardens and three secure well maintained garden areas to ensure residents and their families to enjoy sitting outdoors. The kitchen and laundry areas of the home appeared well managed. The premises appeared clean, tidy and free from unpleasant smells at the time of my visit. Maple Lodge DS0000005463.V363690.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27.28.29.30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by a well -trained and skilled work force resulting in positive outcomes with regard to individualised care and support. EVIDENCE: Records show that staff retention is very good at Maple Lodge. Rotas show that staff, are provided in sufficient numbers and skill mix to meet the needs of the people living in the home. Observations of staff working together as a team indicated that they worked very well together and comments from staff included: “The staff group all know each other well and we like and respect each other” “We work well together as we know each other and no one is precious about themselves” “We get great training and support, I love it here” “The manager and other staff are very good at what they do and we all just love the residents and will do anything to make them happy and comfortable”. Maple Lodge DS0000005463.V363690.R01.S.doc Version 5.2 Page 22 The AQAA details that all staff mandatory training is completed each year and over 55 of staff, have achieved between Levels 2 and 4 in their NVQ qualifications. Staff who work on the EMI unit have received training in dementia care to include “Yesterday, Today and Tomorrow” (YTT). Staff said this training was very thought provoking and they learned a lot from it in respect of their understanding of dementia. Staffing records show that in addition to their permanent staff, the home has a small bank of staff that they can call upon in and emergency. The manager advised that the bank staff undergo the same recruitment and training process as the permanent staff to ensure they are fit to carry out their roles. Staff recruitment policies are clear and examination of four staff files revealed that Criminal Records Bureaux (CRB) checks are undertaken ad references and past work history provided prior to an offer of employment being made. Staff said they have their own personal file that is kept in a, lockable unit, there own training file and received job descriptions, contracts of employment staff handbook and work uniform when they started work at Maple Lodge. Staff said they have good structured supervision and appraisals and have regular staff meeting throughout the year. They said that they are never afraid to raise issues at staff -meetings, as they know the manager listens and if there is a problem she will deal with it. Discussions with staff revealed that they feel empowered by the manager, whom they say provides them with excellent development opportunities and encourages them to believe in themselves. A staff comment made during discussions “we let the residents lead and we follow, wherever possible” and observations of staff and resident interactions, clearly demonstrated that staff work hard to ensure they carry out their roles in the very best interests of the people living in the home. Maple Lodge DS0000005463.V363690.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31.33.34.35.36.38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The mangement systems within the home promote the health, safety and welfare of residents. EVIDENCE: The home manager has twenty - nine years experience of working in care homes and has qualifications to include Management and Residential Social Work. Maple Lodge DS0000005463.V363690.R01.S.doc Version 5.2 Page 24 The home arranges many resident and family meetings in which everyone is encouraged to speak their mind. Minutes of meetings show that the agenda is clear and any issues are quickly dealt with. Residents personal allowance records have been amended and are easily accessible to each individual on request. The home administrator manages resident’s finances in a way that details every item of their expenditure and shows any interest accrued. Records show that personal allowances are reconciled every week to ensure accuracy. Health and safety meetings are held quarterly. However the maintenance person deals with daily heath and safety issues. All health and safety policies and procedure are in place to give guidance to bets practice and health and safety training provided to all staff as an ongoing process. The management structure of the home is clear and consists of manager deputy home manager, team leaders and heads of department departments and they meet monthly to share information. All staff receives structured supervision via their line manager. In the wider organisation there are operational managers, human resources managers and ancillary support. The homes quality assurance system is carried out both internally by the manager and externally by the wider organisation for the purpose of monitoring and improving the service provision. Feedback from these sources indicated that people living in the home and their representatives are more than happy with the staff and service provision of the home. Maintenance of the building and equipment was discussed with the manager who advised that the home ensures essential -services are maintained by external- contractors who provide relevant certificates and servicing records. She revealed that in- house staff also carries out health and safety maintenance. Maple Lodge DS0000005463.V363690.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 Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 4 3 4 X 4 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 3 3 3 X 3 Maple Lodge DS0000005463.V363690.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations Updated care plans should hold the signatures of people who have been involved in their update to ensure that choices of daily life and risk assessments have been agreed. Instructions for changes to medication should hold the signature of the person who is responsible for making the changes. 2 OP9 Maple Lodge DS0000005463.V363690.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Central Contact Team Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries.northwest@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 DS0000005463.V363690.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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