Inspection on 06/07/06 for Maple Lodge Care Centre

This inspection was carried out on 6th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 but made no statutory requirements on the home.

Other inspections for this house

Maple Lodge Care Centre 30/04/08

Maple Lodge Care Centre 02/05/07

Maple Lodge Care Centre 23/11/06

Maple Lodge Care Centre 14/02/06

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Maple Lodge Care Centre (Scotton Gardens) Scotton Richmond North Yorkshire DL9 4LZ Lead Inspector Jo Bell Key Unannounced Inspection 6th July 2006 09:30 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 Care Centre DS0000066447.V298988.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 Care Centre DS0000066447.V298988.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Maple Lodge Care Centre Address (Scotton Gardens) Scotton Richmond North Yorkshire DL9 4LZ 01748 834029 01748 831008 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) www.fshc.co.uk Four Seasons (DFK) Limited (wholly owned subsidiary of Four Seasons Health Care Limited) Mrs Susan Margaret Alderson Care Home 60 Category(ies) of Dementia - over 65 years of age (10), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (10), Old age, not falling within any other category (50) Maple Lodge Care Centre DS0000066447.V298988.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users to include up to 50 (OP), up to 10 (DE(E)) and up to 10 (MD(E)) up to a maximum of 60 Service Users 14th February 2006 Date of last inspection Brief Description of the Service: Maple Lodge is a large care home providing nursing and Social care for up to 60 elderly people. There is a separate 10-bedded unit providing nursing care for people suffering from dementia. The home was purpose built in 1991 and comprises three single storey wings with level access by wheelchair users throughout. The fees vary from £430 upwards. There are additional charges for chiropody, hairdressing, papers and toiletries. The home is located near the Garrison base of Catterick and has extensive grounds to the rear with car parking at the front. Maple Lodge Care Centre DS0000066447.V298988.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key inspection of the service took place on Thursday 6th July 2006. The site visit took one inspector eight hours during which time the deputy manager was available to assist. All the key standards were looked at and the previous issues highlighted were discussed. Thirty seven service users were residing in the home at the time of the site visit. The pre-inspection questionnaire was returned prior to the site visit, three GP comment cards, one health care professional comment card and four relatives comment cards were received. A tour of the premises took place, service users were spoken with throughout the visit and documentation relating to their care, activities provided, risk assessments, finances and staffing issues were discussed. The lunchtime and evening meals were observed and care practices including administration of medication, moving and handling and maintenance of privacy and dignity were monitored. A range of records were inspected which included health and safety, complaints and adult protection, recruitment and staff training. The standard of care provided in the home was good, a review of the meals provided needs to take place and issues relating to adherence of fire procedures and general security need to be addressed. What the service does well: What has improved since the last inspection? What they could do better: Maple Lodge Care Centre DS0000066447.V298988.R01.S.doc Version 5.2 Page 6 The home does not adhere to fire safety, service users are at risk because fire doors are not fitted to their rooms. The home have been aware of this for two years and no action has been taken to address this. A letter of serious concern was issued. Service users are at risk of harm through sluice doors been left open, soiled linen left on the floor and exposure to ‘sharps’ which are not dealt with properly. A letter of serious concern was issued. The medication procedure is not consistently adhered to which puts service users at risk. This was evident through the medication room door been left wide open and windows in this room again wide open. This is on the ground floor where easy access to this room is available. A letter of serious concern was issued. Service users are not offered a range of fresh vegetables or home baking at mealtimes. There is a poor choice of food which service users found unappetising. The dementia unit does not have a phone for the staff to use which is connected to the rest of the home. Service users may be put at risk if access to help is not accessible via the phone. This is needed especially overnight when there is one registered nurse on duty. During the day relatives cannot directly speak to the staff on the dementia unit they have to either have their call returned or a member of staff has to walk to the phone in another area of the home. This is not acceptable and needs to be resolved. Service users currently do not have any proof that they have deposited valuables with the home, this could cause concern especially for those service users with impaired memory. 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 Care Centre DS0000066447.V298988.R01.S.doc Version 5.2 Page 7 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 Care Centre DS0000066447.V298988.R01.S.doc Version 5.2 Page 8 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 the following standard(s): 3 (Standard 6 is not applicable) Quality in this outcome area is good. Service users have their needs fully assessed prior to admission. This judgement has been made using available evidence including a visit to this service EVIDENCE: The manager and deputy carry out initial assessments on service users. This occurs if the service user is care managed or self funding. Three assessments were inspected, they had detailed social assessments in place and information relating to all aspects of personal and nursing care. Personal information was detailed and the documentation was user friendly. One service user on the dementia unit was able to confirm an assessment had taken place, this was confirmed by the relatives. In general discussions with service users in the lounge four people stated they had been assessed before coming into the home. The home is aware of the categories of registration and the necessity to apply to the CSCI if any service users are outside the age group or category specified. This was discussed with the regional manager as this affects one current service user. Maple Lodge Care Centre DS0000066447.V298988.R01.S.doc Version 5.2 Page 9 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 the following standard(s): 7,8,9 & 10 Quality in this outcome area is adequate. Whilst health and personal care is delivered in a dignified manner with care staff understanding service users needs, service users are put at unnecessary risk due to the poor safekeeping of medications. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The standard of care provided by the staff is good. Access to health care provision was evident and care plans reflected this. Three care plans were inspected, one from the dementia unit, one from the residential and one from the nursing area. All care plans inspected had a detailed history, assessments for moving and handling, nutrition, prevention of pressure sores and the use of bed rails were in place. A progress sheet clearly identified any changes and plans were reviewed and evaluated on a monthly basis. Some care plan auditing takes place and staff in discussion were aware of how to meet individual needs. One service user confirmed who the key worker was and that an increase in weight had occurred since admission, which was a positive change. Cognitive assessments take place on the dementia unit and each care plan is clearly identifiable. Maple Lodge Care Centre DS0000066447.V298988.R01.S.doc Version 5.2 Page 10 Three GP comment cards were received which were all positive. One GP was spoken with at the site visit who again confirmed how good the care was and the positive relationship the home have with the GP surgery. Access to the community mental health team was recorded, and the motor neurone disease specialist had been contacted for a specific service user. The chiropodist and dentist visit and there is a hospital in Northallerton and Richmond which are used when needed. The home is aware of how to complete accident forms along with Regulation 37 notifications to the CSCI. One service user who has resided in the home for a number of years has specific mental health needs, this was discussed and it was clear staff knew how to care for this person. Observation confirmed staff treating service users in a professional and dignified manner. Staff were viewed knocking on doors and healthcare professionals guided service users into a private room prior to consultation. The home have medication procedures in place and whilst the areas of administration of medication, use of controlled drugs and ordering and disposing of medication was acceptable. It was evident that service users were put at risk because the medication room door was left wide open. After the first time the inspector discussed this with the deputy manager. This then occurred for a second time later on in the day. The windows in the medication room were wide open without window restrictors again posing a risk to service users. Access into this room and the rest of the home was available as the room is located on the ground floor. A letter of serious concern was issued. Maple Lodge Care Centre DS0000066447.V298988.R01.S.doc Version 5.2 Page 11 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 the following standard(s): 12,13,14 & 15 Quality in this outcome area is poor. Though service users social needs are generally met and contact with family and friends is encouraged, there is a shortfall in the quality of meals provided which service users were concerned about. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users have access to an activities organiser who works twenty five hours per week. Activities offered include bingo, quizzes, trips to the local garden centre, exercises and visits to the coffee shop. Religious needs are catered for through church services both in the home and externally. During the site visit it was evident that the general nursing/residential area has access to board games and dominoes. Extra large dominoes were available for those service users who had difficulty seeing and for those with problems holding small objects. The inspector joined in with a game of dominoes and chatted to four service users about the activities provided and friends and family visiting. The visitors book confirmed relatives are welcome anytime, this was also observed. Service users stated how nice the gardens were and how they enjoyed going outside. They stated they had a choice about what they do each day, they can go to bed when they want and get up when they want. Maple Lodge Care Centre DS0000066447.V298988.R01.S.doc Version 5.2 Page 12 A discussion took place with the activities organiser who was aware that more time is needed on the dementia unit, though no specific training in this area has taken place. Suggestions were given as to where support and help could be sought regarding the appropriate activities for people with mental health problems. Mealtimes in the home were observed at lunchtime and during the evening. The dining areas were pleasant, light and airy. Napkins and glasses were available and service users were aware of the menu prior to sitting down at the table. The menu is on a rolling three week programme, and whilst the menu looked appetising the food observed at the site visit looked unappealing. Service users commented that the food is poor, this was echoed by staff and relatives. The cook was spoken with, he confirmed he was not a chef and had not received any formal training. No fresh vegetables were served at either the lunch or the evening meal, tins of ravioli were served for a main course with tinned peaches for desert. Service users felt more home cooked food was needed. In the kitchen no fresh produce was evident and the fridge was not stocked. There was also no evidence of home baking. Service users were observed having tea and coffee to drink in the morning and afternoon though no home made biscuits or cakes were available as a snack. A review of the meals must take place which includes views of service users, relatives and staff. Maple Lodge Care Centre DS0000066447.V298988.R01.S.doc Version 5.2 Page 13 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 the following standard(s): 16 & 18 Quality in this outcome area is good. Service users concerns are listened to by the care staff, and the risk of harm is minimised through staffs understanding of adult protection issues. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users and relatives spoken with said if they had any concerns they would speak to the person in charge. One service user said ‘I have no complaints at all’. Though when questioned regarding mealtimes service users did feel an improvement was needed. The home have a complaints procedure in place. This is displayed in the entrance of the home and has set timescales when complaints will be dealt with and by whom. One complaint was previously received and this was dealt with effectively by the home. The CSCI has not received any formal complaints. The home have an adult protection procedure in place. Adult protection training takes place which was confirmed by the pre-inspection questionnaire and the training records. During the site visit service users were handled in a dignified and pleasant manner. Service users spoken with said the staff have a nice kind manner and always treat them with respect. The deputy manager was aware of the procedure to follow if an incident occurs regarding adult protection. Maple Lodge Care Centre DS0000066447.V298988.R01.S.doc Version 5.2 Page 14 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 the following standard(s): 19 & 26 Quality in this outcome area is poor. Whilst the general environment is satisfactory, areas of refurbishment are needed. Service users are also being put at risk through staff not adhering to the infection control procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is purpose built and set in its own grounds near Catterick Garrision, there is a plan of routine maintenance which is adhered to and service users said they enjoyed living in this environment. The home had no unpleasant odours except in the sluice rooms. The garden area is pleasant with views across the fields with an area to sit out in which is very welcoming. There are sufficient facilities for service users which include bathrooms, showers and toilets. The bathroom on Laurel Wing is in need of refurbishment, this was highlighted at the previous inspection. The home have a robust infection control procedure in place, and staff have received infection control training, though this is not fully implemented. During Maple Lodge Care Centre DS0000066447.V298988.R01.S.doc Version 5.2 Page 15 the morning it was evident that the 3 sluice rooms on the general side were left open. One sluice door was being propped open with a bag of soiled linen. On the side was a open sharps bin with razors, syringes and needles and a light bulb. Service users were mobile in this area and were being put at risk because of poor practice by the staff. This was discussed with the deputy manager and later on in the day these three rooms were checked again to identify if they were being kept locked when not in use. All three were left open though staff had been informed of the correct practice. A letter of serious concern was issued. Maple Lodge Care Centre DS0000066447.V298988.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality outcome in this area is adequate. Service users are cared for by skilled and experienced staff who are recruited correctly and trained in a range of areas. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels throughout the home were adequate. Currently there are 37 service users resident in the home. At the site visit there was a senior sister with six carers for the general nursing and residential area, with one registered nurse and a carer for the ten service users on the dementia unit. A discussion took place regarding the lack of RMNs on the dementia unit. However, it is evident that the general nurse in this area is knowledgeable, skilled and motivated to care for service users with dementia needs. She is starting an RMN course in September which will make her aware of how to meet needs effectively with this client group. Service users relatives spoken with were clear that their needs were being met, much of this was credited to the Head of Unit. One service users said ‘I love it here, I have everything I want’. Two relatives said ‘the care is excellent’. The home have ensured that over 50 of care staff have achieved an NVQ Level 2 or equivalent, they are committed to developing training and ensuring needs of service users are met. Maple Lodge Care Centre DS0000066447.V298988.R01.S.doc Version 5.2 Page 17 One issue which was discussed related to the lack of phone access for staff on the dementia unit. Currently relatives or staff cannot phone the unit direct. Staff have to go to the area of the home where the phone is. In an emergency the call bell system can be used. However, overnight when there is one registered nurse on duty phone access is extremely important and it is not always appropriate to leave the unit to speak to another member of staff. This has been discussed with the regional manager who is aware of the problem and has given the CSCI assurances that this is being dealt with. Clearly, service users must not be put at risk if the unit is left understaffed. Recruitment practices were discussed following a previous complaint which related to storage of CRBS, this has been dealt with effectively by the manager. All staff have enhanced CRB checks, two references are obtained prior to employment and checks take place regarding the authenticity of identification numbers for registered nurses. Staff spoken with confirmed they receive induction training, initial supervision of staff takes place then when they are competent they are allocated a group of service users to look after as a key worker. Care practices including eating and drinking, communication, care of ageing skin, customer care and specific nursing care training has been attended and documented. Maple Lodge Care Centre DS0000066447.V298988.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 Quality in this outcome area is poor. Whilst the staff in the home have the best interest of the service user in mind, the quality assurance system needs to be more robust, and the service users being put at risk of harm through the home not adhering to fire safety procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager was not available at the site visit, the deputy and staff assisted with any information needed. Positive comments were received from the service users and relatives regarding the effectiveness of the manager. Although, the issues regarding security and safety should have been addressed sooner by the home. Maple Lodge Care Centre DS0000066447.V298988.R01.S.doc Version 5.2 Page 19 Staff in the home were unsure of the quality assurance system that Four Seasons have developed, staff and service users meetings take place and some auditing is evident though this could not be clarified as the manager was not available. Service users did confirm that a questionnaire had been sent out to them recently asking for their views, and the person in charge on the dementia unit was keen to develop this area further. Service users finances were checked, a policy was in place detailing how finances are dealt with and a personal allowance account was available which had detailed information regarding the individual money deposited. There were a number of valuables in the safe and whilst these had a description of the item in an envelope in the safe, the service user who had deposited the item had no record of this. It was suggested this needs to be reviewed. The home have now started to obtain lockable spaces for service users if they wish to keep any valuables/medication in their own rooms. This was observed in some rooms. Health and safety in the home was observed and discussed with the maintenance person all records were well maintained. Radiator guards are evident, checks on the emergency call bells, lighting and central heating take place on a regular basis. One water temperature checked was high but this was immediately adjusted, records relating to legionella testing, electrical wiring and gas safety certificate were in place. Contracts to check the baths, hoists, wheelchairs and sluice machines were evident and all the information supplied was easily accessible and clearly documented. Fire safety in the home was discussed, whilst service users felt safe in their environment it was evident through the previous fire risk assessment and recommendations made by the fire officer that aspects of fire safety were not being adhered to. Service users room doors were not fire proof. This had been identified two years ago and no action had been taken to resolve this. This clearly has put service users at risk and must be addressed, for this reason a letter of serious concern was issued. Maple Lodge Care Centre DS0000066447.V298988.R01.S.doc Version 5.2 Page 20 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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 1 x x x x x x 1 STAFFING Standard No Score 27 1 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x 2 x 2 x x 1 Maple Lodge Care Centre DS0000066447.V298988.R01.S.doc Version 5.2 Page 21 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 OP9 Regulation 13 Requirement Timescale for action 07/07/06 2. OP15 16 3. OP19 23 The medication room door must be kept locked when not in use. The windows in the medication room must not be left wide open, window restrictors need to be in place. Immediate requirement issued. A review of the meals provided 07/08/06 must take place to ensure service users are receiving a nutritious varied diet. The bathroom in Laurel Wing 07/09/06 should be refurbished with the aim of providing a safer environment for the residents and staff (Previous timescale of 01/04/06 not met) The sluice rooms must be kept locked when not in use. Sharps bins must be maintained and stored correctly. Soiled linen in red bags must be disposed of correctly and not left on the floor. Immediate requirement issued. Staff on the dementia unit must have access to a telephone which is situated on the unit. DS0000066447.V298988.R01.S.doc 4. OP26 16 07/07/06 5. OP27 13 07/08/06 Maple Lodge Care Centre Version 5.2 Page 22 6. OP31 26 7. OP38 23 This is especially relevant when there is one registered nurse on the dementia unit overnight. The Home must ensure any health and safety issues are dealt with promptly when identified to reduce the risk of harm to service users. Fire doors must be fitted to rooms occupied by service users (in line with fire safety risk assessment) within one month. Unless evidence is supplied to the CSCI by 10th July confirming this is not required. Immediate requirement issued. 07/07/06 10/07/06 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. 2. 3. Refer to Standard OP12 OP33 OP35 Good Practice Recommendations Consideration should be given to having specific activities for service users on the dementia unit. The home should be aware of the quality assurance system that Four Seasons have developed. Service users should be given a receipt when they have deposited valuables with the home. Maple Lodge Care Centre DS0000066447.V298988.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Care Centre DS0000066447.V298988.R01.S.doc Version 5.2 Page 24 - 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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