CARE HOME ADULTS 18-65
Mar Lodge 26 Nottingham Road Melton Mowbray Leicestershire LE13 0NP Lead Inspector
Steve Hunnybun Unannounced 26 July 2005 at 9:30am
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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Mar Lodge D C51 C01 S31542 Mar Lodge V241115 260705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Mar Lodge Address 26 Nottingham Road Melton Mowbray Leicestershire LE13 0NP 01664 560302 01664 560302 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) Park Care Home (No.2) Ltd Cheryl Ann Palmer Care Home 7 Category(ies) of LD Learning disability (7) registration, with number of places Mar Lodge D C51 C01 S31542 Mar Lodge V241115 260705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 16th February 2005 Brief Description of the Service: Mar Lodge is a residential home is situated in the town of Melton Mowbray on the main Nottingham Road, approximately 1 mile from the town centre. The home is within easy access to local shops and public transport. Mar Lodge is a detached old building which has been modernised whilst retaining its original features. It is registered to provide care for up to seven people with learning disabilities. The emphasis is on homeliness, and there is no feel of an institutional setting.The home has seven single bedrooms one with ensuite facilities. All rooms are decorated to an acceptable standard after consultation with residents regarding the décor. The home has one lounge and one dining area and a large kitchen. outside the house is a paved seating area and a pleasant conservatory that provides additional space for residents to use when the weather is good. Mar Lodge D C51 C01 S31542 Mar Lodge V241115 260705 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the first statutory unannounced inspection this year and took place over approximately four hours. Four residents cases were tracked; their files were read, they spoke with the inspector and two of them showed the inspector their rooms. The inspector also spoke with a member of staff and the registered manager. Comments from residents were good. They all said they liked living at the home; the food was described as ‘good’ and the staff as ‘nice’. All residents who spoke with the inspector were aware of who their keyworker is and all stated that they know who to speak with if unhappy. What the service does well:
Residents’ needs are assessed using a comprehensive and useful tool. This information is then used to inform the care planning and risk assessment process. Care plans and risk assessments are comprehensive, useful documents. Residents are enabled to make choices about their own lives and can contribute to the running of the home through residents’ meetings. Residents are enabled to enjoy a positive lifestyle through varied activities, contact with the local community, contact with friends and family and through a healthy and varied diet. Residents’ personal and healthcare needs are comprehensively assessed and recorded in their files. They are able to choose who provides personal care within reasonable limits. Medication is stored, administered and recorded appropriately. The home has robust procedures for complaints and protection. Residents feel able to express their views and are protected from abuse. The premises are clean, tidy and safe. Resident rooms are personalised with pictures and possessions. The staff recruitment procedure is designed to protect residents from abuse. Staff are offered a comprehensive package of training that enables them to meet residents’ needs. The home actively promotes residents’ health and safety. Mar Lodge D C51 C01 S31542 Mar Lodge V241115 260705 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? 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. Mar Lodge D C51 C01 S31542 Mar Lodge V241115 260705 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Mar Lodge D C51 C01 S31542 Mar Lodge V241115 260705 Stage 4.doc Version 1.40 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 Residents’ needs are comprehensively assessed so that they can be met within the home. EVIDENCE: All files tracked contained useful assessments of residents’ needs. These covered areas such as personal hygiene, mobility, social care and communication. The assessments are cross-referenced to care plans and risk assessments. Mar Lodge D C51 C01 S31542 Mar Lodge V241115 260705 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8,9 Residents’ assessed needs are reflected in their care plans and risk assessments. They are enabled to make choices and contribute to the running of the home. EVIDENCE: All files tracked contained useful care plans and risk assessments that are cross-referenced to the needs assessments. Residents appeared to be aware of their care plans; one lady offered to show hers to the inspector. Residents who spoke with the inspector stated that they are enabled to make choices and decisions in their lives. The care plans and risk assessments are geared towards enhancing residents’ independence. One resident stated that she is allowed to go shopping on her own. The inspector asked residents about house meetings and they reported that these are held, enabling them to take part in the planning of meals, holidays and outings. Residents were asked about bedtimes and they all reported that they can be flexible with bedtimes and in fact can retire to their rooms and watch TV if they wish. Mar Lodge D C51 C01 S31542 Mar Lodge V241115 260705 Stage 4.doc Version 1.40 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15,17 Residents enjoy a range of activities, are part of the local community, maintain contact with friends and family and are offered a healthy, varied diet. EVIDENCE: Residents are enabled to access a range of day care facilities. All files contained timetables that indicated a varied programme. The inspector spoke with a number of residents who described their activities. One has a job at a local charity shop, one had been at college and one had been swimming. Residents stated that they are able to use local facilities such as pubs and shops, either alone or accompanied as per their risk assessments. Residents also stated that they enjoy varied leisure activities. All files tracked contained contact information about residents’ friends and families. Residents who spoke with the inspector stated that they are enabled to maintain contact. The inspector examined the menu book, which indicated a healthy, varied diet. Residents described the food as good, they all had their favourites and are able to have them regularly. Mar Lodge D C51 C01 S31542 Mar Lodge V241115 260705 Stage 4.doc Version 1.40 Page 11 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20 Residents’ personal and healthcare needs are assessed and met. Residents are protected by the home’s mediation policy. EVIDENCE: Residents reported that they are well looked after. Personal and healthcare needs are recorded comprehensively in residents’ care plans. All files contain a sheet detailing morning routines. These are flexible and enable residents’ needs to be met as sensitively as possible. The staff team are currently all female. This was discussed with a member of staff who stated that residents would choose who they want to support them and this is respected where possible. Residents’ healthcare needs are recorded in their files. The inspector examined the homes system for storing, administering and recording medication and found them to be appropriate. Mar Lodge D C51 C01 S31542 Mar Lodge V241115 260705 Stage 4.doc Version 1.40 Page 12 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 Residents feel their views are listened to and are protected from abuse. EVIDENCE: The home has a robust complaints procedure. All complaints are recorded in a book. Residents who spoke with as stated that they feel able to express their concerns to staff. The home has an up-to-date copy of the Multi-Agency Vulnerable Adult Protection document No Secrets. Staff receive training regarding adult protection. The registered manager stated that she is ensuring staff are familiar with adult protection issues. Mar Lodge D C51 C01 S31542 Mar Lodge V241115 260705 Stage 4.doc Version 1.40 Page 13 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,28,30 Residents live in a homely environment that is safe, clean and individualised. EVIDENCE: The inspector was shown round the property by two of the residents. The house was clean and tidy on the day of the inspection and is pleasantly decorated. The inspector was aware of a homely feel. The residents showed the inspector their rooms, both of which were personalised with belongings, pictures and décor. Residents appeared proud of their home and commented on how nice they think it is. Outside the property is a paved seating area and a conservatory that provides additional space for residents to use when the weather is warm. The unsafe area outside the kitchen as mentioned in the last report has been repaired. Mar Lodge D C51 C01 S31542 Mar Lodge V241115 260705 Stage 4.doc Version 1.40 Page 14 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34,35 Residents are protected by a robust recruitment procedure and are cared for by suitably trained and experienced staff. EVIDENCE: Residents who spoke with the inspector stated that the staff are ‘very nice’. The home has a robust recruitment procedure that is designed to protect residents from abuse. The registered manager stated that staff undertake a comprehensive induction when appointed at the last inspection it was noted that a member of staff was left at the home on her own having only been in post for two weeks. The manager stated that this would only happen if no residents were present and if the person had the back up of an on call person. The home offers staff a comprehensive package of core training backed up with the availability of specific training to meet residents’ needs such as diabetes or epilepsy. Mar Lodge D C51 C01 S31542 Mar Lodge V241115 260705 Stage 4.doc Version 1.40 Page 15 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 Residents’ health and safety are promoted. EVIDENCE: The home now has up to date and accurate recording regarding fire drills and tests. The inspector examined documents relating to the Control of Substances Hazardous to Health and they were found to be accurate. Water temperatures are tested and recorded regularly. Mar Lodge D C51 C01 S31542 Mar Lodge V241115 260705 Stage 4.doc Version 1.40 Page 16 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23
ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 3 3 3 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 x x x 3 x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 x 3 Standard No 31 32 33 34 35 36 Score x x x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Mar Lodge Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 x D C51 C01 S31542 Mar Lodge V241115 260705 Stage 4.doc Version 1.40 Page 17 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 Regulation none Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard none Good Practice Recommendations Mar Lodge D C51 C01 S31542 Mar Lodge V241115 260705 Stage 4.doc Version 1.40 Page 18 Commission for Social Care Inspection The Pavilions 5 Smith Way Grove Park, Enderby Leicester, LE19 1SX 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 Mar Lodge D C51 C01 S31542 Mar Lodge V241115 260705 Stage 4.doc Version 1.40 Page 19 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
