Inspection on 18/12/06 for Maple Lodge Nursing Home

This inspection was carried out on 18th December 2006.

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 Nursing Home 04/12/08

Maple Lodge Nursing Home 22/02/06

Maple Lodge Nursing Home 07/09/05

Maple Lodge Nursing Home 24/02/05

Maple Lodge Nursing Home 09/09/04

Maple Lodge Nursing Home 23/03/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Maple Lodge Nursing Home Woolwich Road Witherwack Sunderland SR5 5SF Lead Inspector Sam Doku Key Unannounced Inspection 18 & 19 December 2006 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 Nursing Home DS0000018201.V304174.R02.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 Nursing Home DS0000018201.V304174.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Maple Lodge Nursing Home Address Woolwich Road Witherwack Sunderland SR5 5SF 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) 0191 549 3672 0191 549 3687 www.fshc.co.uk Tamaris Healthcare (England) Limited (wholly owned subsidiary of Four Seasons Health Care Limited) Mr Anthony Duggan Care Home 54 Category(ies) of Dementia (30), Dementia - over 65 years of age registration, with number (30), Mental disorder, excluding learning of places disability or dementia (15), Mental Disorder, excluding learning disability or dementia - over 65 years of age (15), Old age, not falling within any other category (24) Maple Lodge Nursing Home DS0000018201.V304174.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users within the category of MD/MD(E) may only be accommodated on the first floor 22nd February 2006 Date of last inspection Brief Description of the Service: Maple Lodge is a two storey care home which was purpose built in 1995 and offers accommodation to a maximum of 54 older people. The home provides both personal and nursing care to those living there, some of whom may have dementia, mental health needs or general nursing care needs. The service users who require general nursing are accommodated on the ground floor and those with dementia and mental health needs are accommodated on the first floor. The property is located in a residential area of Witherwack and is within walking distance of a small range of local amenities, including shops, a post office, and a pub and bus station to the city centre of Sunderland. Local churches are accessible by car or public transport. A mini-bus is available to the home for use by service users but this must be pre-booked. Accommodation is provided on two floors, each with self-contained facilities including lounges, dining areas, WCs and bathrooms. All bedrooms are single rooms, of good size and are provided with en-suite WC facilities. Entry to the home is accessible with lift access to the first floor. Externally, generous car parking space is provided to the front of the building, and extensive grounds surround the home. This area is enclosed with fencing for security but would benefit from landscaping. The scale of charges per week for living in the home is £359 to £373. Maple Lodge Nursing Home DS0000018201.V304174.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was carried out over two days. The first day of the inspection was spent on observing the interaction between the staff and the service users and to speak with service users, staff and relatives. The second day involved further interaction with senior staff and ancillary staff. It also involved discussions with the manager, tour of the home, examination of health and safety records, medication systems, servicing records and service users personal files including care plans. Before the inspection date, pre-inspection questionnaires were sent to the manager to supply some information about the home. Questionnaires were also sent to service users and relatives for their comments on the quality of the service. Five responses were received from relatives. The responses were complimentary of the home. The atmosphere in the home at the time of the inspection visits was calm although there were a lot of festive activities going on which service users enjoyed. Some of the activities were outside of the home thus maintaining contacts with the local schools and the community at large. This report takes account of the observations, discussions and responses from the questionnaires. Service users and relatives who were spoken with were complimentary of the service and the respect and dignity that the staff show to them. What the service does well: The home provides good arrangements for prospective service users and or their relatives to visit the home and assess the facilities for themselves. Service users spoke very highly about the opportunities available to them to engage in social activities. At the time of the inspection visits a number of festive activities had been arranged for the service users both within the home and in the community. The work of the handyman was very noticeable. He had maintained regular maintenance programme and maintained records as evidence, thus maintaining accountability. Maple Lodge Nursing Home DS0000018201.V304174.R02.S.doc Version 5.2 Page 6 Some areas of the home have benefited from a redecoration programme. A number of bedrooms and other communal areas have benefit from this programme. New furniture and matching soft furnishings have been provided in a number of bedrooms. This has enhanced the quality of the environment for the service users. All staff continue to receive regular one-to-one supervision on two monthly basis. Staff confirmed these arrangements and commented that this further enhanced their professional development for the benefit of the service users. Staff also receive annual appraisal from the manager. The home maintains their policy of six monthly reviews for each service user. Letters go to the families, inviting them to be part of the review. This allows the service user and the family to have an input into their future care needs. Two relatives who were interviewed confirmed these arrangements. What has improved since the last inspection? Following requirements and recommendations made in the last inspection report, appropriate arrangements have been made to address all of the issues raised. A new bath and shower facility has been provided on the ground floor to address the previously unsuitable shower. The new shower/bath facility is well used and service users said they find it more comfortable and relaxing. The lighting in the reception has greatly improved and the areas is now well lit and brighter. This benefits service users who may have poor eyesight. Suitable arrangements have been put in place for regular cleaning of bedrooms that have odour problems. The domestic staff commented on the positive arrangements to improve on the control of odour in the home. There have been great improvements to the external surrounding of the home. Fences have been erected to provide the service users with secure and safe garden. Maple Lodge Nursing Home DS0000018201.V304174.R02.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. Maple Lodge Nursing Home DS0000018201.V304174.R02.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 Nursing Home DS0000018201.V304174.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 5, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are fully assessed before admission, which ensured that the staff, service users and their relatives know the needs of the person can be met. Prospective service users or their relatives are invited to visit the home before making their decisions about coming to live in the home. This gives them the opportunity to assess the home for themselves, thus giving them the means to make informed choice about the home. Maple Lodge Nursing Home DS0000018201.V304174.R02.S.doc Version 5.2 Page 10 EVIDENCE: It is a general policy of the home and the company that prospective service users have their needs assessed by their social worker/Nurse Assessor. The home also carries out their assessment to assure themselves that they have the necessary skills and facilities to meet the needs of the service user. All these are done before admission is agreed. Examination of files show that the home adheres to its admission policies. Files contain copies of pre-admission assessments by social workers/nurse assessors and also assessments that had been carried by the nursing staff of the home. This assures the prospective service users and their families that proper steps are being taken which ensured that the needs of the person have been properly identified and plans put in place to meet them. The nursing staff described the arrangements for inviting service users and or their relatives to visit the home before admission is arranged. Two visiting relatives confirmed the arrangements made by the home for them to visit and meet with staff and other service users before making their decisions about coming to live at the home. They confirmed that they found these visits very helpful in allaying their anxieties about moving into a nursing home. Maple Lodge Nursing Home DS0000018201.V304174.R02.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 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 good. This judgement has been made using available evidence including a visit to this service. Care plans set out how the health, social and personal care needs of each service user and how these are to be met. This has ensured that the care needs of the individuals are met. However, some of the plans are vague and do not provide adequate instructions to staff on how those specific needs are to be addressed. The home has clear medication policies that are followed by the staff that are responsible for the day-to-day administration of medicines in the home. Service users are treated with respect and dignity but a few practices observed indicate that this is not always the case. Maple Lodge Nursing Home DS0000018201.V304174.R02.S.doc Version 5.2 Page 12 EVIDENCE: The service users care plans set out their healthcare needs and action plans for meeting them. The plans are regularly reviewed and updated to reflect changing healthcare needs. However, it was noticed that some of the care plans lack detailed instructions to staff on how certain aspects of care should be managed. On the EMI unit, there were statements in the care plans which were unhelpful to staff. These include statements like, “can be obsessed with certain actions” but this statement failed to tell staff what those actions are so staff can look out for them. Another said “staff should ensure that he is properly dressed”. There was no indication as what is proper dress for this gentleman taking into account his preferences and past lifestyle. Care plans need to provide more details to ensure that specific care needs are met. Records show that the healthcare needs of the service users are fully met. The home continues to maintain a record of contacts with healthcare professionals, including GPs, psychiatrist, chiropody service, dentist, optician, speech therapist and other healthcare services. This ensured that the service users rights to proper healthcare are being safeguarded by the home. The service users confirmed that their healthcare needs are met through these arrangements. Service user records contained evidence of regular checks on their weights and nutritional assessments being carried out which ensured that all the service users receive adequate and nutritious diet. Risk assessments have also been carried out for those service users for whom it is thought necessary. These include falls, nutrition, moving and handling and pressure area risk assessments. These are documented and provide evidence of the care that individuals receive. There are suitable arrangements in place for the storage and administration of medicines in the home. The nurses are responsible for the administration of medicines. The drugs administration system was examined and there were no discrepancies. The nurses carry out weekly drugs checks and the records indicated a regular audit of medicines. This promotes the health and welfare of the service users through the good drug administration system operated by the home. Maple Lodge Nursing Home DS0000018201.V304174.R02.S.doc Version 5.2 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 the following standard(s): 12, 13, 14, 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information from family members help to identify individual’s interest and preferences, and social and recreational care plans are formulated to meet those needs. This promotes the service users social and recreational wellbeing. Families and friends are supported and encouraged to visit their relatives thus maintaining family and community contacts. The service users are assisted and supported by staff to exercise as much choice as they are able to, thus allowing them to maintain some level of independence in decision making. Service users receive nutritious and balanced meal, which promotes their nutrition and health. Maple Lodge Nursing Home DS0000018201.V304174.R02.S.doc Version 5.2 Page 14 EVIDENCE: The care needs of the service users are clearly identified in the care plans including some aspects of their social and religious care needs. Staff explained how family members have provided useful information about the service users past lifestyle and how they incorporated the information into the care plans. However, in some of the care plans, these useful information have not been incorporated into the care plans. For example, one gentleman was described as having great liking for a particular music but no indication that attempts have been made to provide him with his favourite music. In some of the files, the sections on social care contained limited information on the recreational and religious needs. Service users confirmed that they enjoy the activities organised for them. They also confirmed that they are free to join in social activities if they wish and that they are not made to join in activities if they did not want to. This is evidenced by the activities organised over the Christmas festive period in which service users were offered a variety of social activities as part of the Christmas celebrations. Two visiting relatives stated that the flexible visiting times allow them to continue to visit at times that are convenient for them. Service users confirmed that their relatives and friends are able to visit at anytime convenient to them and were very appreciative of this level of flexibility. They also confirmed that the daily routines are organised flexibly to take account of individual likes and dislikes. This allows individuals to make choices about some aspects of their routines. A four-week rotational menu remains is operation in the home. The service users commented positively on the quality and quantity of the meals provided. Examination of past menus indicate that the home provides wholesome and nutritious meals for the service users thus promoting good health. However, observations at breakfast indicate that the arrangement for organising meals require urgent review as these arrangements compromise food safety and hygiene standards. The food trolley on the EMI unit had all the various compartments for porridge, scrambled eggs, tomatoes and so on. These were not used and the food items were instead contained in plastic bowls. They were transported via the lift shaft uncovered. The food was cold by the time it was served. Such lapses pose serious health risk to service users and the practice must cease. Maple Lodge Nursing Home DS0000018201.V304174.R02.S.doc Version 5.2 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 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. The complaints procedure is accessible to service users and relatives. The procedure provides the opportunity for service users or relatives to raise concerns and in so doing exercise their rights. Suitable arrangements are in place, which ensured that service users are protected from all forms of abuse and to protect their rights. EVIDENCE: The home continues to have in place a satisfactory policy and procedural guidance on abuse. The staff confirmed that they are aware of the home’s complaints procedure and also how to instigate the ‘Whistle Blowing’ policy should this become necessary. The staff showed understanding of the protection of vulnerable adults (POVA) procedures and also showed an awareness of the need to protect service users from all forms of abuse, thus promoting their safety and welfare. Staff described their role as “advocates” for the service users, especially those service users have suffer from dementia. Such views provide reassurance to service users and their families that the welfare of the service users is assured. Maple Lodge Nursing Home DS0000018201.V304174.R02.S.doc Version 5.2 Page 16 The service user guide and statement of purpose have summaries of the complaints procedure. Copies of these are available to service users and their relatives and therefore provide the opportunity for them to complain if they wish. It also reassures service users and their relatives that any concerns or complaints would be treated seriously with the view to safeguarding the welfare of the service users. Since the last inspection, one major complaint had been received from a relative about the care that her mother received. This is currently being investigated and so far it has been appropriately dealt with in accordance with the company’s complaints procedures. This provides reassurance to service users, relatives and staff that complaints are taken serious and dealt with appropriately. Maple Lodge Nursing Home DS0000018201.V304174.R02.S.doc Version 5.2 Page 17 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, 20, 22, 25, 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 safe, clean and well maintained. This promotes the safety and welfare of the service users. However, there is lack of attention to detailed cleanliness, which compromise the dignity of the service users. Maple Lodge Nursing Home DS0000018201.V304174.R02.S.doc Version 5.2 Page 18 EVIDENCE: The positive observations made in the last report have been maintained. The home was designed to accommodate older people, some of whom may have mobility problems. There is good access into and around all areas of the home. There are also specialist bathing facilities, hoists, toilets and shower rooms. These have provided the opportunity for service users to continue to exercise independence and choice in the way they are supported to lead their lives in the home. The home is clean and maintained to good standard. However, the carpet in one of the lounges on the first floor was dirty and require cleaning. An armchair in that same lounge had dried food particles on the side of the chair. This compromised the dignity of the service users who sit in that lounge. Bedside tables in two bedrooms were noted to be dirty and encrusted with dried food. This is unhygienic and compromised the health and dignity of the service uses that live in those rooms. There is now a secluded garden area for the service users. This provides a safe and pleasant area for service users to use when weather permits. All rooms are single occupancy and rooms have en-suit facilities. Service users have personal belongings in their rooms thus providing them with familiar environment. Heating and lighting in individual bedrooms remain adequate and individuals are able to control the room temperature to suit personal preferences. This ensured that service users are able to maintain room temperatures that meet their individual preferences. Individual rooms have good ventilation and natural lighting. These ensured comfortable surroundings for the service users. Window restrictors have been fixed to all windows and all radiators have suitable covering, thus ensuring their safety. The handyman continues to carry out random checks of hot water to ensure they are within the safe limits. The home has written policies and procedures relating to safe handling of hazardous materials for staff to follow. The manager indicated that staff have had training in health and safety, infection control and food hygiene. At the time of the inspection the home was noted to be generally clean and free from offensive odour. Maple Lodge Nursing Home DS0000018201.V304174.R02.S.doc Version 5.2 Page 19 The laundry machines have facilities for sluicing and washing soiled linen at very high temperature to avoid the spread of infection. The above safety measures, practices and policies ensured that service users live in safe and comfortable environment. The kitchen was again found to be clean and all cookers and cooking utensils were clean and well maintained, thus promoting the welfare of the service user. Maple Lodge Nursing Home DS0000018201.V304174.R02.S.doc Version 5.2 Page 20 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 in this outcome area is good. This judgement has been made using available evidence including a visit to this service The home provides sufficient staffing which meet the needs of the service users. However, the registered manager must review the staffing levels to take account of the dependency levels and not just rely on occupancy numbers in determining the staffing levels. Suitable arrangements for staff training and supervision are in place, which ensured that staff are equipped to provide good quality service that benefits the service users. The registered manager follows the company’s staff recruitment and training procedures, which promote the welfare of the service users. EVIDENCE: Recent past staff rotas indicate that the home consistently maintains adequate staffing levels but in discussions with staff and relatives, it was evident that the current staff levels are not adequate to fully meet the needs of the service users. This must to reviewed to ensure that future allocations take account of the dependency levels of the service users in the home and not merely on the number service users living in the home. Maple Lodge Nursing Home DS0000018201.V304174.R02.S.doc Version 5.2 Page 21 The home continues to maintain a staff training programme. The staff training records included moving and handling, first aid, protection of vulnerable adults, health and safety, fire safety and dementia care training. The staff who were interviewed confirmed the training they had received and felt that this had equipped them to do their jobs better. The manager confirmed that the company is committed to training all care staff to NVQ Level 2 or above. A number of staff said they have attained the NVQ qualification. They also indicated that the training had boosted their confidence and are therefore confident in their care practices for the benefit of the service users. There are arrangements in place for all staff to achieve the NVQ qualification. The manager confirmed that currently there are seven care staff doing their training and when they complete it this would increase the percentage of staff with NVQ II to just over the 50 . Staff receive regular supervision and appraisal and evidence of these are kept on individual files. All care staff receive regular supervision from the trained nurses. The nurses also regular receive their personal supervision from the manager. In discussions with the manager, it was evident that also he receives good management support from his line-manager, however, he does not receive formal supervision from him. Arrangements for formal supervision would be helpful in enhancing the support he receives and promote his personal development for the benefit of the service and the people who use the service. The home’s recruitment procedures ensured protection of service users from possible abuse by applicants who would be deemed as unsuitable to work with vulnerable people. Examination of staff records showed that the manager had consistently adhered to the company’s policy on recruitment, including appropriate references, CRB checks and job interviews, thus protecting the service users from possible abuse. Maple Lodge Nursing Home DS0000018201.V304174.R02.S.doc Version 5.2 Page 22 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, 32, 33, 35, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service The manager provides good leadership to the staff. This ensured that the service is run for the benefit of the service users. However, communication between the manager and the staff should be reviewed to promote good working relations. This would raise staff moral for the benefit of the service users. The system for managing the service users monies is good and protects them from financial abuse. The detailed organisational policies and procedures on health and safety are adhered to by the staff, which protects the welfare of the service users. Maple Lodge Nursing Home DS0000018201.V304174.R02.S.doc Version 5.2 Page 23 EVIDENCE: The manager is a registered mental nurse (RMN) and has long experience of working with older people in nursing home settings. Staff feel that in general the manager runs the service for the benefit of the service user. However, some staff commented on what they perceive as lack of communication between the manager and the staff. Some staff feel that the manager only communicates with them when they have done something wrong and therefore feel unrecognised and unsupported. Staff on the EMI unit commented that they feel the manager is less interested in the activities of the unit compared with the general nursing unit. Staff commented that they seldom see the manager on the EMI unit. These issues were raised with the manager who stated that this is not the case and that he feels he has good communication with staff and that he makes regular visits to the EMI unit and is involved in the review of all care plans on the unit. The records relating to service users personal allowances were examined. These were appropriately maintained and showed evidence of regular auditing by the administrative staff and receipts available for purchases made on behalf of service users. The manager has continued to maintain evidence of proper maintenance of the home. Maintenance certificates for the servicing of electricity, electrical equipment, gas, fire safety, heating, lift servicing and hoists were available and up to date. The company’s Health and Safety policies remain in place and these were made available for inspection. These cover policy areas such as fire prevention and Care of Substances Hazardous to Health (COSHH). The training provided for the staff ensured that the staff maintained safe working practices, which safeguard the safety and wellbeing of the service users. The handyman continues to carry out regular internal and external maintenance, which ensured safe and secure environment for the service users. Records relating to these are maintained and were made available for inspection. This was further reinforced by the provision of health and safety training including first aid, fire training, moving and handling to staff, which promote the safety and welfare of the service users. Maple Lodge Nursing Home DS0000018201.V304174.R02.S.doc Version 5.2 Page 24 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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 3 X X 3 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 X X 3 X X 2 Maple Lodge Nursing Home DS0000018201.V304174.R02.S.doc Version 5.2 Page 25 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. 1 Standard OP15 Regulation 12(3) Requirement Food must served and assistance offered in a way that give due regard to service users dignity and respect. The cleanliness in one of the first floor lounges and in some bedroom must be addressed as the compromise the health and dignity of the service users. The staffing level must be reviewed to take account of the dependency levels in the home. Staff numbers must not be based on number of service users alone. The relationship the staff and the staff must be reviewed to ensure a positive and open relationship. Proper food hygiene and safety measures must be put in place to promote the health and welfare of the service users. Timescale for action 19/12/06 2 OP26 16(2)(j) 01/02/07 3 OP27 18(1)(a) 01/03/07 4 5 OP32 OP38 12(5)(a) 12(1)(a) 01/02/07 19/12/06 Maple Lodge Nursing Home DS0000018201.V304174.R02.S.doc Version 5.2 Page 26 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. Refer to Standard OP8 OP15 Good Practice Recommendations Care plans should contain sufficient details to guide care staff on meeting specific care needs. The practices relating to assistance with meals should be reviewed to ensure that when service users are being assisted this is done in a sensitive manner. Arrangements for settling service users for breakfast should be reviewed to ensure that service users are not waiting at their tables for long periods waiting for the foods. The manager should receive personal supervision from his line manager. This would provide him with further support to enable him to address some of the staffing issues raised during the inspection. 3 OP15 4 OP32 Maple Lodge Nursing Home DS0000018201.V304174.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South of Tyne Area Office St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Nursing Home DS0000018201.V304174.R02.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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