Inspection on 07/09/05 for Maple Lodge

This inspection was carried out on 7th September 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 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 24/06/08

Maple Lodge 22/08/07

Maple Lodge 21/03/06

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Maple Lodge Arncliffe Road Halewood Liverpool L25 9PA Lead Inspector Natalie Charnley Unannounced 7 September 2005 th 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 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 F53 F03 Maple Lodge S5463 V248552 07.09.05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Maple Lodge Address Arncliffe Road Halewood Liverpool L25 9PA 0151 448 1621 0151 448 0713 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) Exceler Healthcare Services Ltd Ms Eileen Geraghty PC - Care Home Only 45 Category(ies) of DE - Dementia (55 Years and over) - 24 Places registration, with number DE(E) - Dementia - over 65 - 20 Places of places OP - Old age - 25 Places Maple Lodge F53 F03 Maple Lodge S5463 V248552 07.09.05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 25 OP, and up to 24 DE and up to 20 DE(E). 2. Service Users in the DE category only can be in the age range 55 years and over. 3. The manager to provide the inspector with 3 monthly accident evaluations for the DE Unit whilst evaluating staffing levels. 4. The manager must provide all staff working on this unit with dementia care training within 3 months. 5. A maximum of 45 service users may be accommodated. 6. The Service should, at all times, employ a suitably qualified and experienced manager who is registered with the CSCI. Date of last inspection 1st December 2005 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 approximatly 3 miiles 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 easilly 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. Maple Lodge F53 F03 Maple Lodge S5463 V248552 07.09.05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out over a period of one day. The inspector arrived at the home at 07.05 and left at 13.30. The inspector intended to speak with night staff, however they had already gone home as their shifts end at 7am. The inspector spoke with 2 care staff, 2 care managers, 1 administrator, 1 domestic, 7 residents from the elderly care unit and 2 from the dementia unit. A visiting District Nurse was also spoken with. No visitors were available for the inspector to speak with. The inspector completed the inspection by looking at the homes records, a tour of the building, formal and informal interviews and information from previous inspection reports. The inspector followed an inspection plan written before the start of the inspection to ensure that all areas that needed covering were done so. The inspector had been informed prior to the inspection by telephone, that the home manager was no longer working at the home and that a replacement was now in post. No written confirmation has been received by the inspector in relation to this change. The new manager was not available during this inspection as she was on holiday. What the service does well: The staff team working at the home work well together and receive strong leadership from the care managers. Residents were complimentary about staff stating they are helpful and enthusiastic. Staff have good in house training in all key areas of care and the home run an good monitoring system to ensure all training remains up to date. Staff were observed interacting well with residents on both units and a homely atmosphere was evident throughout the home. The atmosphere is supported by the good standard of decoration, especially within the elderly care unit. The home have two large lounge areas which have an interlocking door which enables activities to be attended by residents on both units. The home has ample communal area for those who wish to smoke and for those who don’t. Visitors are welcome at any time and residents stated that staff are very supportive and helpful during these times. Maple Lodge F53 F03 Maple Lodge S5463 V248552 07.09.05 Stage 4.doc Version 1.40 Page 6 Care plans at the home are reviewed on a monthly basis and contain both long and short-term goals. There are extensive life biographies showing the past lives and hobbies that residents had. These help staff to have a basic knowledge of residents likes and dislikes. Any risks that are taken by residents such as smoking and moving about the home are clearly recorded and updated in their files. The upkeep of the home is generally good, with a full time maintenance person employed. There are gardens to the rear and centre of the home with easy access for residents. Décor in the home is tasteful and of a good standard. A tour of the building showed that private and communal areas were tidy and clean with exception to a few areas highlighted in the main body of the report. What has improved since the last inspection? What they could do better: The home needs to make sure that the care planning process and review of this document is done with the residents or their representatives. This will help residents to feel that they are contributing to how they will be looked after and to make sure that all their individual needs are met by staff. The home must make sure that all medications given to residents are as the prescription states. If the prescription needs changing, this must be done by a Doctor. The home could lower the risk of medication errors by removing the second controlled drug check list, which is nor needed. Maple Lodge F53 F03 Maple Lodge S5463 V248552 07.09.05 Stage 4.doc Version 1.40 Page 7 The home must make sure that all residents are consulted on matters arising in the home and that they are aware and happy with the menus. Menus need to show the correct choices and be in a place where all residents can see them. Complaints procedures should easy and clear for residents to understand. They should be discussed directly with residents so they are clear as to how to use them. The home must get rid of the smell to the dementia that is strong in the corridor and lounge areas. The carpet to the lounge needs urgent replacement as it is warn and has been soaking up smells for some time that will now not be able to be cleaned out. The use of a air conditioning system may be useful in these areas. The home must ensure that abuse training is revisited to enable staff to be clear on all aspects of dealing with this issue and to protect the residents of the home. 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 F53 F03 Maple Lodge S5463 V248552 07.09.05 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Maple Lodge F53 F03 Maple Lodge S5463 V248552 07.09.05 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3,4 The homes service user guide is misleading and contains information that is not accurate. This means that prospective residents are not clear about the services and support offered by the home and if it can meet their specific needs. EVIDENCE: The care plans at the home showed that the home have some details about residents before they move in. Details are recorded regarding brief medical history, likes and dislikes and daily routines. These also showed that emergency admissions to the home did not occur. Residents told the inspector that they were able to come and visit the home before moving, those who were unable to do this stated that relatives came to view the home and meet the staff on their behalf. One resident showed the inspector a copy of a booklet he ad been given when he first moved to the home. This was called a ‘service user guide’. The inspector was able to read this document and found that it contained some information which was out of date and misleading. Maple Lodge F53 F03 Maple Lodge S5463 V248552 07.09.05 Stage 4.doc Version 1.40 Page 10 The booklet had not been updated since the manager had left and stated that the home have a ‘residents council’ which in discussion with residents, they confirmed these meetings do not occur. The booklet contains details about the staff at the home and has details about advocacy services and activities which some residents had found helpful. Not all residents spoken to were aware that the home has such a document and did not know how they would make a complaint. Residents had not seen a copy of any previous inspection reports and the inspector was unable to find a copy of these reports anywhere in the home on the day of the inspection. The home had information available for staff on specialist dementia care and some training had been offered in this area. Staff spoken with and observed during the inspection showed that they had the necessary skills and experience to care for the residents living at Maple Lodge. Maple Lodge F53 F03 Maple Lodge S5463 V248552 07.09.05 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8 and 9 The home has failed to improve their record keeping for administering medications and are placing residents at risk. The health needs of residents are well met and there is evidence of a variety of health professionals being consulted and included. There is a clear and consistent care planning process in place that is regularly reviewed, however plans did not reflect that residents had been involved in this process. EVIDENCE: Residents at the home all have individual plans of care. 5 plans were looked at from each unit and were found to be reviewed by staff on a monthly basis and earlier if needed. Information contained in these plans was detailed and showed that the home involve a wide range of other health workers in the care of residents such as nurses, social workers, opticians and dementia specialists. Those residents, who have nursing input for wound care, have separate specialist documentation which is kept in the office for review by staff. The home service user guide states in it that ‘staff will draw up your care profile with your involvement… we encourage you to include your views and agree to the plan wherever possible’. Maple Lodge F53 F03 Maple Lodge S5463 V248552 07.09.05 Stage 4.doc Version 1.40 Page 12 From discussions with all the residents at the home, no one knew what their plan of care was and stated that they had not been involved in the planning or reassessment process. The inspector found no signatures on care plans sampled to say a resident had agreed to a plan of care. Medication records were reviewed for both units during the inspection. The inspector also viewed the treatment room where medications are stored. Not all records were completed correctly and some medication doses had been given at the wrong time resulting in too much or too little medication being administered. These serious issues were feedback to the care managers at the time of the inspection for them to address. Some handwritten entries had been made on medication records but had not been correctly documented, as two signatures are required to ensure no mistakes are made. Those medications such as painkillers that have variable doses where one or two tablets can be given were not always recorded correctly. Staff at the home had received training in medication administration and there were accurate records regarding controlled drugs and how much medication was coming in and out of the home. The home has an extra controlled drug record, which has the potential for error, as it is very confusing and not needed. The inspector recommended that the home stop using this as soon as possible. Records in relation to the drug ‘wafarin’ which requires special documentation charts was accurate and available for staff. Those residents who give themselves medication had appropriate paperwork to demonstrate the home had looked at all the risks involved. All residents had photographic identification on their medication records to help new or agency staff. All medication was stored in appropriate trolleys. Maple Lodge F53 F03 Maple Lodge S5463 V248552 07.09.05 Stage 4.doc Version 1.40 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 and 15 The home has a menu system however it was not clear to residents as to what choices were on offer on a daily basis and was therefore not allowing any choices to be made. Residents are provided with a variety of daily activities, flexible to their specific needs. They are supported to keep up links with the local area. EVIDENCE: The inspector sat with residents during breakfast time on the elderly care unit. This was a sociable occasion with residents chatting among themselves. The inspector found a copy of the home menu in the corner of the lounge and in the main reception of the home, however neither contained the correct information about the meals for that day. Residents spoken with during breakfast stated that they always had some form of cooked breakfast which was ‘fantastic’ but non were aware of the formal menu and the choices on offer for that particular day. Two residents stated that they felt that they would like to have more choices of meals, stating that ‘there is not much variety’. One resident was particularly complementary about the soup at the home stating it was ‘wonderful’. Maple Lodge F53 F03 Maple Lodge S5463 V248552 07.09.05 Stage 4.doc Version 1.40 Page 14 The inspector noted that some residents had been sitting in the lounge from 7am and that breakfast was not served until 09.15 and felt this was a long period of time to sit and wait, residents also commented on this stating it was the normal routine and also felt it was a long time to wait. Residents stated they had never been consulted regarding what they would like to have on the menu. Care plans for residents contained very good social histories, sometimes completed by families and others completed by staff and residents together. Details of resident’s social interests and hobbies were also noted. Residents spoke about bingo and sing a long sessions held at the home however all stated that they would like to go out on trips out and that the home had not arranged these for twelve months or more. Activity plans were on display throughout the home and residents were aware of what was due to take place. Those living in the dementia unit had specialist activities planned, however they also join in with some activities with the other units. Activities primer ally take place in the lounge areas. One resident stated that he visits local shops by himself and when needed, is supported by staff. Residents discussed with the inspector about the religious visitors that support them at the home and stated that this was an enjoyable event for them. Residents told the inspector that their daily routines were flexible and varied on most days. They confirmed that visitors come at any time during the day and that they can visit in either communal or private areas of the home. The home has a security bell and signing in book at the main reception to safeguard residents and for fire purposes. Maple Lodge F53 F03 Maple Lodge S5463 V248552 07.09.05 Stage 4.doc Version 1.40 Page 15 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The home has a clear complaints procedure. Arrangements for protecting service users is not satisfactory placing them at risk from harm or abuse. EVIDENCE: Residents spoken with during the inspection stated that they were not aware of the homes complaints procedure and many did not know that there was a new home manager. The inspector found this procedure at the main entrance to the home and in the service user guide, however staff must ensure that residents are aware of how to use it and whom to go to if they need help or advise. The inspector watched good interaction on both units between staff and residents and communication was clear and effective. Staff interviewed stated that they had received minimal training on abuse and POVA (Protection of Vulnerable Adults). This was part of the homes internal training on resident welfare. When questioned by the inspector, staff did not know where to find the POVA policy and they were unclear about what information it contained. The inspector found that complaints dealt with by the home had been done so in accordance with their policy. Maple Lodge F53 F03 Maple Lodge S5463 V248552 07.09.05 Stage 4.doc Version 1.40 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25 and 26 The layout, facilities and location of the home are suitable for the residents who live there. The home is safe and clean, however the dementia unit has areas that are not hygienic which may impact on residents health and comfort. EVIDENCE: The home offers single room accommodation to all residents. Rooms examined by the inspector were well decorated and contained personal belongings that helped create a homely atmosphere. Residents stated that they were encouraged to bring these items prior to moving into the home. Both units have large lounge areas that are also used for residents to eat meals. The lounge on the dementia unit was found to have an unpleasant smell and the carpet was in need of replacement. The corridor areas in the dementia unit also had unpleasant smells that needs addressing. The two unit lounges have a partition door that is opened when communal activities are taking place. This promotes good interaction between residents. Maple Lodge F53 F03 Maple Lodge S5463 V248552 07.09.05 Stage 4.doc Version 1.40 Page 17 There are sufficient numbers of bathrooms and toilets located throughout the home to meet the needs of the residents who live there. Bathroom and toilets are in easy reach from bedroom and communal areas. These areas were clean and tidy on the day of the inspection. The home was warm and well lit. The home has a maintenance person who works daily to maintain the home and address repairs. Staff and residents confirmed that the home is cleaned by domestics on a daily basis and to a good standard. One resident stated that ‘the home is always clean and tidy. The cleaner always works hard when she does my room’. Residents can have a lock and key to their room if they want providing there is no risk identified by the home. This was confirmed by service users. Room 4 was identified as needing a replacement easy chair as it had very dirty arms which could not be cleaned to a good standard. The home have a variety of specialist equipment including beds, hoists (machines used to lift residents) and grab rails. Both units also have a nebuliser machine which is used for residents who need special medication to help their breathing. Residents confirmed that they have access to call bells which work when they need to call staff. Maple Lodge F53 F03 Maple Lodge S5463 V248552 07.09.05 Stage 4.doc Version 1.40 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 and 30 Sufficient numbers of staff are employed by the home to meet the needs of the residents who live there. Training records are comprehensive but staff showed poor knowledge in the area of abuse and protection of vulnerable adults. This could leave residents at risk from harm or abuse. EVIDENCE: The home has two care managers who are responsible for all the day-to-day hands on care of residents. The home use occasional agency staff to cover shifts however try to use the same staff for continuity of care. Residents stated that staff were warm and friendly. They felt well cared for and supported. One resident stated ‘staff are attentive to my needs’ and one commented that ‘staff are friendly and caring’. The district nurse commented that staff were always helpful. The rota for the home showed that there are adequate numbers of staff on duty at all times of the day and night on both units. Staff and residents interviewed stated they have no concerns over staffing numbers. Staff are all allocated specific residents for whom they have responsibility to complete their paper work and ensure they are kept happy and content. This is called a ‘key worker’ system. Apart from care staff, the home employs an activity coordinator (who is also a carer), an administrator, domestics to work in the laundry and on cleaning, a handyman and a chef. These staff all support care staff and the manager in the smooth running of the home. Maple Lodge F53 F03 Maple Lodge S5463 V248552 07.09.05 Stage 4.doc Version 1.40 Page 19 Individual staff have personal files held in the office containing information such as qualifications and experience. The also all undergo a Police check. The home offer staff a wide variety of basic training in the areas of moving and handling, fire safety, food hygiene, health and safety and first aid. These are well recorded in training records. Staff stated that training is of a good standard, however some were disappointed in the dementia training and stated that it wasn’t sufficient to enable them to care for the residents on the dementia unit. Some staff had undertaken a more comprehensive course, which had very positive feedback. When staff start work at the home they receive a full induction and work closely with a more senior carer. Staff also confirmed that a daily hand over takes place from shift to shift and that important information is recorded in the communication book. The inspector saw samples of this good practice in the office. Details of meetings held within the home were noted and staff stated that they found these a useful way of letting the management of the home know of any difficulties they are having. Maple Lodge F53 F03 Maple Lodge S5463 V248552 07.09.05 Stage 4.doc Version 1.40 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,35,36 and 38 The home does not have a registered manager who is approved by Commission for Social Care Inspection. This will impact on the care of the residents and the morale of staff. EVIDENCE: The home must ensure that the new manager makes an application to Commission for Social Care Inspection to become the homes registered manager as soon as possible. Staff informed the inspector that the new manager presently runs another home as well as Maple Lodge and is not in the building at all times. It is not acceptable for a manager to run two homes at once. Residents spoken to were not aware that there was a new manager at the home. Maple Lodge F53 F03 Maple Lodge S5463 V248552 07.09.05 Stage 4.doc Version 1.40 Page 21 All staff spoken to were able to show the inspector where all the policies and procedures to the home were kept. They confirmed that these were accessible at all times. Accident recording at the home was of a good standard and maintained the confidentiality of all residents by keeping reports in care files and not in communal areas. Certificates in relation to the health and safety of the home such as gas and electric checks were up to date. All risks undertaken by staff and residents were well recorded and updated on a regular basis. Staff confirmed to the inspector and records showed that staff were receiving 1:1 supervision from the manager on a regular basis. This allows staff to discuss any concerns they may have and develop a plan of development for themselves. Discussions with residents showed that the home do not seek the views of the residents who live there with regard to the running or development of the home. One resident stated that he would like to be involved with this type of work and had some clear ideas and suggestions. The administrator stated that the home has feedback cards available in reception but was unable to produce any results that had been achieved using this method of quality assurance. No annual development plan was available at the home at the time of the inspection. Maple Lodge F53 F03 Maple Lodge S5463 V248552 07.09.05 Stage 4.doc Version 1.40 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 2 x 2 x x 3 x 3 Maple Lodge F53 F03 Maple Lodge S5463 V248552 07.09.05 Stage 4.doc Version 1.40 Page 23 NO 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 1 Regulation 4(1) 5(1) Requirement The home must ensure that the statement of purpose and service user guide are accurate and up to date. Residents must be able to access this information The home must ensure that all care plans are drawn up with the service user and or their representative The home must ensure that all medication is given as prescribed on the prescription and that all variable doses are accounted for. The home must ensure that all service users are able to have a chioice of meals and that menus displayed are accurate The home must ensure that all service users are aware of how to make a complaint The home must ensure that all staff undertake suitable training to enable them to be competent regarding the handling of alledged abuse at the home The home must ensure that all areas within the home are kept free from offensive odours. The carpet in the dementia unit and easy chair in room 4 must be Timescale for action By 1st December 2005 2. 7 15(1)(2) By 1st January 2006 By 1st October 2005 By 1st October 2005 By 1st October 2005 By 1st December 2005 By 1st October 2005 3. 9 13(2) 4. 15 16(2)(i) 5. 6. 16 18 22(1)(2) 18(1) 7. 26 16(2)(k) Maple Lodge F53 F03 Maple Lodge S5463 V248552 07.09.05 Stage 4.doc Version 1.40 Page 24 replaced 8. 31 8,9,10 The registered provider must ensure that an application is made to register the new manager and that she is only responsible for the running of one home The home must ensure that a system for monitoring quality and the views of service users is in place By 1st October 2005 9. 33 16(2)(m) By 1st December 2005 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 9 Good Practice Recommendations The inspector reccomends that the home discontinue the second controlled drug record Maple Lodge F53 F03 Maple Lodge S5463 V248552 07.09.05 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Burlington House, 2nd Floor, South Wing Crosby Road North Liverpool L22 0LG 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 F53 F03 Maple Lodge S5463 V248552 07.09.05 Stage 4.doc Version 1.40 Page 26 - 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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