CARE HOME ADULTS 18-65
Marlin Lodge 31 Marlborough Road Luton Beds LU3 1EF Lead Inspector
Pursotamraj Hirekar Unannounced Inspection 20 October 2006 12:45 Marlin Lodge DS0000060196.V311717.R01.S.doc Version 5.2 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 Marlin Lodge DS0000060196.V311717.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 Adults 18-65. 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. Marlin Lodge DS0000060196.V311717.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Marlin Lodge Address 31 Marlborough Road Luton Beds LU3 1EF 01582 723495 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) Quality Care (Surrey) Ltd Vacant Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Marlin Lodge DS0000060196.V311717.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. Number of places: 10 Age: 18 - 65 years Category: Learning disability Date of last inspection 4th May 2006 Brief Description of the Service: Marlin Lodge is a large detached house that has been extensively enlarged to provide residential accommodation for up to 10 adults with learning disabilities. All accommodation is in single bedrooms. There is a lounge and dinning area/conservatory on the ground floor. The property is within easy reach of local amenities and Luton town centre. The home provides care for adults between the ages of 18 to 65 with learning disabilities, most of whom attend day activities outside of the home during weekdays. All of the bedrooms on the first floor the home cannot take people who have significant physical disabilities in addition to their learning disabilities. Marlin Lodge DS0000060196.V311717.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This is the report of the unannounced key inspection carried out on 20/10/06 over 6 hours by pursotamraj hirekar. The method of inspection included review of outstanding requirements, study of care plans, risk assessments, needs assessments; discussion with the service users’, staffs on duty, manager, provider, partial tour of the premises and observations. The manager and the provider had coordinated the entire inspection. What the service does well: What has improved since the last inspection? What they could do better:
The home must ensure that all the service users’ risk assessments and needs assessments were carried out. The must ascertain and take into account the service users wishes and feelings and ensure to enable service users to make decision with respect to the care they are to receive. The home must ensure that unnecessary risks to the health or safety of service users are identified and eliminated. The home must ensure to promote and make proper provision for health and welfare and supervision of services of service users. The home must ensure that staffs are appropriately supervised. The home must ensure compliance of all the out standing requirements and have a registered manager. Marlin Lodge DS0000060196.V311717.R01.S.doc Version 5.2 Page 6 The home must ensure that the records referred to in schedule 3 and 4 are at all times available for inspection. The home must ensure proper provision of health and welfare service based on a robust risk and needs assessments of the service users. The registered provider must review the quality of care at appropriate intervals and improve the care delivery and ensure to meet the outstanding requirements. The registered persons must ensure that all risk assessments are comprehensive and are reviewed regularly. (This was a requirement from the previous inspection) Now, having the risk assessments in place, regular reviews must be carried out and recorded. (This was a requirement set on two previous inspections, but although the hand written assessments were ready for typing, some still did not fully address risks, such as risks associated with night care needs and self medicating risk assessments for service users that were self medicating.) A new time-scale is now set and the potential enforcement action, if not met, will be implemented. (This was a requirement set on the previous inspection with the time scale to 30/06/06 and now the new manager in post asked for an extension of the time scale, after completing several but not all risk assessments) All risk assessment must be updated. (Previous time scale 30/08/06) Care plans must contain a working summary that would allow staff to obtain necessary information on service users’ needs with suggested actions on how to meet these needs. The plan must contain evidence of reviews when new needs are identified, such as night care needs. The plans must be signed to demonstrate that they were discussed with service users or their representatives, if they were unable to comprehend the content. All inapplicable documents and charts must be removed from the files to prevent potential confusion. (This was a requirement set on a previous inspection with the time scale 30/06/06 and was generally met, apart from removing some irrelevant documents from the files and making files consistent) The new manager was given extra time to consolidate and make care plans consistent. (Previous time scale 30/08/06) The manager must ensure that records kept in respect of each individual service user are accurate and up to date. (This was a requirement set on the previous inspection with the time scale to 30/07/06 and with the induction of the new manager, the time scale was extended to 30/08/06.) 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.
Marlin Lodge DS0000060196.V311717.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Marlin Lodge DS0000060196.V311717.R01.S.doc Version 5.2 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 the following standard(s): 1 and 2 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The statement of purpose and service user guide enabled potential service users to make informed decisions. The aspirations and needs were not assessed by relevant personnel and were not comprehensive to help develop care plans of service users. EVIDENCE: The home had developed a comprehensive statement of purpose and service users’ guide which would enable the potential service users’ and their families for an informed decision. These documents were produced in a simplified pictured format easy to understand. On this inspection 3 service users’ were case tracked randomly. Service user – 1 needs assessment document was blank with no information at all. Service user-2, hand written needs assessment document was made available on this inspection, the needs assessed were not comprehensive detailing the various needs of the service user. There was no evidence on the needs assessment document who had conducted the needs assessment and when. Service user – 3, hand written 2 page needs assessment document was provided on this inspection which had only basic information such as name and address, learning disabilities, washing hair call a member of staff to wash hair, oral health every 6 months, dressing can do herself that’s all. The manager had agreed to complete the needs assessment before 07/11/06 and person centred planning by end of January 2007.
Marlin Lodge DS0000060196.V311717.R01.S.doc Version 5.2 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 the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. In the absence of comprehensive needs and risk assessments the home did not develop detailed care plans, which is a major cause of concern for service users’. EVIDENCE: Service user – 1, personal assistance at night was assessed on 25/8/6 and incorporated into the care plan on 25/08/06 by the manager. Kitchen wash-up sink hot water risk assessment was carried out and signed by the manager on 21/08/06. However, there was no evidence of whether the care plan was agreed by the service user and seen by support staff that work with the service user. Care plan was prepared on the 21/08/06 which covered areas including bathing and showering, morning wash and brushing teeth, nail care, GP appointment, dental appointments, eye tests, shaving, privacy independence and dignity, coping with dementia. This care plan was hand written and signed by the home manager. However, there was no evidence of whether the care plan was agreed by the service user and seen by support staff that work with the service user.
Marlin Lodge DS0000060196.V311717.R01.S.doc Version 5.2 Page 10 Clinical risk assessment and management plan was drawn up by the Bedfordshire and Luton NHS trust on the 29/09/06 which recommended action ASAP that included to ensure staff are aware of the risk assessment and is incorporated into service users’ care plan about falling down the stairs. To refer to OT and sensory impairments to carry out joining assessment and provide guidelines, to assess and identify risk associated with the service user’s level of confusion/deterioration and apply for funding a 1:1 waking night staff, to complete dementia assessment and inform doctor of any deterioration and refer to physio if necessary and the doctor to review service user as an patient at the dementia clinic. There was no evidence provided on this inspection with regard to the above actions that needed to be taken by the home. The monthly evaluation of the care plans was not available from February 2006 onwards. Service user – 2, fire risk assessment was carried out by one of the support staff on the 29/08/06 and identified risk level as high. The care plan was prepared on the 24/08/06 which covered aspects such as GP appointments, dental checks, chiropodist appointment, optical appointment, social contacts, day services, hair wash, fingernails, clothing, hair dressing, relationships, religion and independence. The fire risk assessment carried out on 29/08/06 that rated high risk was not reflected in the care plan. The manager had agreed to complete Person centred planning by the end of January 2006. Service user –3, Kitchen washing up sink risk assessment was carried out on the 25/08/06, which said the service user would ask the support of the staff if needed. Service users had fire risk assessment on 29/08/06, which was not reflected in the care plan. Monthly evaluation of the care plans was not carried out after 16/12/05. Care plan review was not made available on this inspection. The home had prepared a care plan dated 21/08/06 that included information regarding GP appointments, dentist, chiropodist, eye test, events, college day service and washing hair. The needs assessments and risk assessments were not carried out by relevant professionals and do not form the basis for preparation of the care plans. The care plans do not reflect the changing aspirations and needs of the service users’. Marlin Lodge DS0000060196.V311717.R01.S.doc Version 5.2 Page 11 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 the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had consultations with all service users’ individually and developed activites that meet the individual service users’ lifestyle needs. EVIDENCE: On the day of this inspection Service users’ were met in person, all the service users’ had a buffet dinner followed by recreation activity music and dance, which they all had enjoyed. When asked they have said that they had enjoyed their stay at the home and like the food. Service user –1 was in regular contact with the family and visited day care centre. Service user –2, daily activity schedule was up for a review that was scheduled to take place on 27/10/06. Currently the service user visited day care centre and college. The service user was in regular touch with the family. Service user – 3 visited day care centre and the college and a review of the daily activity was carried out on the 08/06/06 and the weekly plan needed update. Marlin Lodge DS0000060196.V311717.R01.S.doc Version 5.2 Page 12 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 the following standard(s): 18,19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was no information recorded about the health care plans and the efforts made by the home to meet personal and health care needs of the service users’ was adhoc. EVIDENCE: The 3 service users’ case tracked their personal and health care details are as follows: Service user –1, Personal hygiene records which included bath, shower, trip wash, hair wash, teeth clean, ears, finger nails, toe nails, help dress, toilet, bowels open, urine, change bed, clean room, haircut and shave were not made available after 05/06. Medical report dated 20/10/06, sensory test dated 3/10/06 change in medication dated 27/09/06 mars sheet as of 20/10/06 were maintained satisfactorily. Service user –2, Personal hygiene records which included bath, shower, trip wash, hair wash, teeth clean, ears, finger nails, toe nails, help dress, toilet, bowels open, urine, change bed, clean room, haircut and shave were not made available after April 2006. Weight chart was regularly updated till October 2006. Service user –3, Personal Marlin Lodge DS0000060196.V311717.R01.S.doc Version 5.2 Page 13 hygiene records which included bath, shower, trip wash, hair wash, teeth clean, ears, finger nails, toe nails, help dress, toilet, bowels open, urine, change bed, clean room, haircut and shave for the month of 09/06 was seen that was empty except for bath and hair wash on 1 day. The latest medical appointment was dated 01/06/06 and dental appointment was dated 16/01/06. However, the manager had agreed to complete the health action plan for all the service users’ before the end of January 2007. Marlin Lodge DS0000060196.V311717.R01.S.doc Version 5.2 Page 14 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 the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had made appropriate arrangements with regard the complaints policy and procedures. EVIDENCE: The home had not received any complaints since the last inspection. Marlin Lodge DS0000060196.V311717.R01.S.doc Version 5.2 Page 15 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 the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had made appropriate arrangements for service users’ to live in a homely, comfortable and safe environment and was maintained without any offensive odours. EVIDENCE: The home was suitable for service users, their abilities and needs. Blinds were installed since the last inspection in a conservatory, making it a very comfortable, pleasant and nice communal area that service users appreciated. However, one user’s bedroom did not have a chair, table or bedside lamp. There were no comments in his care plan or risk assessment related to any of these essential items not being appropriate for him, although the owner, the manager and staff verbally explained a very high associated risk and could justify why these items were not in the bedroom. The home had installed self-closing devices that were connected to a fire warning system. Marlin Lodge DS0000060196.V311717.R01.S.doc Version 5.2 Page 16 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had a good skill mix of staff. The staffs’ were not supported and supervised appropriatly and did not benefit the service users’. EVIDENCE: Staff deployment rota dated from 15/10/06 indicated that the home had 1 locum manager – the rota had no information with regard to contract hours the row was blank. 1 full time home manager, 4 full time support workers and 2 part time support workers. The manager and the staff have signed in a supervision contract. The home had provided evidence of carrying out new staff had induction. Staff member –1 contract was dated 09/09/06 date of employment started on 15/02/06. There was no application form for the employment and had no references undertaken. Staff supervision record sheet indicated that the staff supervision was carried out on 26/06/06, 05/08/06 and 19/10/06. The manager had provided supervision records only for 26/6/6 and for the 05/08/06 and 19/06/06 supervision records were not provided on this inspection. The manager had put up an argument saying that the home need not provide evidence of staffs’ supervision and further said that before 23/10/06 she will prove to the commission that the commission cannot have access to the staffs’ supervision records, despite the inspector during the inspection had read out the regulations from the CSA.
Marlin Lodge DS0000060196.V311717.R01.S.doc Version 5.2 Page 17 Staff member-2, there was no application, employment start date was 19/06/06, had CRB, references were received 1 from friend volunteer and the 2nd from family relative – the provider and the manager had said that the staff member worked in ASDA 12 years ago and therefore no professional reference was on the file. However, CV was available on the file. The manager signed staff supervision contract and the employee dated 07/07/06. However, there was no supervision record made available on this inspection. Marlin Lodge DS0000060196.V311717.R01.S.doc Version 5.2 Page 18 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 and 43 Quality in this outcome area is poor. The judgement has been made using available evidence including a visit to this service. The home was not managed appropriately and there were concerns of non-compliance of requirements. EVIDENCE: The provider and the manager had coordinated the entire inspection. The home does not have a registered manager. The home had appointed a full time manager on 12/06/06. The contract of employment was signed. Statutory checks were carried out that included CRB, POVA, and references. Induction checklist was dated 15/06/06. Supervision contract was signed. However, 1 supervision record was made available on this inspection, which said that meet again on 08/08/06, and there was no other evidence made available on this inspection. A quality assurance review process started and questionnaires were sent to external health professionals. A review of the homes policies had started. The reviewing and updating of records had started. The home had installed selfclosing devices that were connected to a fire warning system. Marlin Lodge DS0000060196.V311717.R01.S.doc Version 5.2 Page 19 Service user –1 had an accident in the home on 31/07/06 and had an injury resulting in stitches and a 7 day course of medication. The commission was not informed of the accident and the preventive measures in place. Towards the end of this inspection feedback was given to the provider and the manager. The manager had agreed to write to the commission before the 23/10/06 with timescales to achieve the shortfalls that were identified during the inspection under various outcome groups, please refer for details under various outcome groups of this report. The provider had said that he was travelling abroad and on his return on he will write to the commission regarding the proposed management changes at the home. Marlin Lodge DS0000060196.V311717.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 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 Standard No Score 1 3 2 1 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 1 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 1 3 X 1 X 3 X 1 1 1 Marlin Lodge DS0000060196.V311717.R01.S.doc Version 5.2 Page 21 Yes 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 YA2 Regulation 14(1) (2) Requirement The home must ensure that all the service users’ risk assessments and needs assessments were carried out. The home must ensure that all the service users’ care plans were comprehensive and under review. The must ascertain and take into account the service users wishes and feelings and ensure to enable service users to make decision with respect to the care they are to receive. The home must ensure that unnecessary risks to the health or safety of service users are identified and eliminated. The home must ensure to promote and make proper provision for health and welfare and supervision of services of service users. The home must ensure that staffs are appropriately supervised. The home must ensure compliance of all the out standing requirements and have a registered manager.
DS0000060196.V311717.R01.S.doc Timescale for action 15/12/06 2 YA6 15 (1) (2) 15/12/06 3 YA7 12 (2) (3) 15/12/06 4 YA9 13(4) (c) 15/12/06 5 YA19 12 (1) 15/12/06 6 7 YA36 YA37 18 (2) 9 15/12/06 15/12/06 Marlin Lodge Version 5.2 Page 22 8 YA41 17 (3) 9 YA42 12 10 YA43 24 11 YA9 13(4)(c), 14 12 YA6 14,15 The home must ensure that the records referred to in schedule 3 and 4 are at all times available for inspection. The home must ensure proper provision of health and welfare service based on a robust risk and needs assessments of the service users. The registered provider must review the quality of care at appropriate intervals and improve the care delivery and ensure to meet the outstanding requirements. The registered persons must ensure that all risk assessments are comprehensive and are reviewed regularly. (This was a requirement from the previous inspection) Now, having the risk assessments in place, regular reviews must be carried out and recorded. (This was a requirement set on two previous inspections, but although the hand written assessments were ready for typing, some still did not fully address risks, such as risks associated with night care needs and self medicating risk assessments for service users that were self medicating.) A new time-scale is now set and the potential enforcement action, if not met, will be implemented. (This was a requirement set on the previous inspection with the time scale to 30/06/06 and now the new manager in post asked for an extension of the time scale, after completing several but not all risk assessments) All risk assessment must be updated. (Previous time scale 30/08/06) Care plans must contain a
DS0000060196.V311717.R01.S.doc 15/12/06 15/12/06 15/12/06 15/12/06 15/12/06
Page 23 Marlin Lodge Version 5.2 working summary that would allow staff to obtain necessary information on service users’ needs with suggested actions on how to meet these needs. The plan must contain evidence of reviews when new needs are identified, such as night care needs. The plans must be signed to demonstrate that they were discussed with service users or their representatives, if they were unable to comprehend the content. All inapplicable documents and charts must be removed from the files to prevent potential confusion. (This was a requirement set on a previous inspection with the time scale 30/06/06 and was generally met, apart from removing some irrelevant documents from the files and making files consistent) The new manager was given extra time to consolidate and make care plans consistent. (Previous time scale 30/08/06) 13 YA41 17 The manager must ensure that records kept in respect of each individual service user are accurate and up to date. (This was a requirement set on the previous inspection with the time scale to 30/07/06 and with the induction of the new manager, the time scale was extended to 30/08/06.) 15/12/06 Marlin Lodge DS0000060196.V311717.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Marlin Lodge DS0000060196.V311717.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Marlin Lodge DS0000060196.V311717.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!
