Inspection on 05/10/05 for Marlin Lodge

This inspection was carried out on 5th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 25 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Marlin Lodge 04/05/07

Marlin Lodge 20/09/06

Marlin Lodge 04/05/06

Marlin Lodge 21/02/06

Marlin Lodge 30/11/04

Marlin Lodge 10/08/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Marlin Lodge 31 Marlborough Road Luton Beds LU3 1EF Lead Inspector Georgia Chimbani Unannounced Inspection 5th October 2005 09:00 Marlin Lodge DS0000060196.V256117.R01.S.doc Version 5.0 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.V256117.R01.S.doc Version 5.0 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.V256117.R01.S.doc Version 5.0 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 Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Marlin Lodge DS0000060196.V256117.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. Number of places: 9 Age: 18 - 65 years Category: Learning disability The responsible individual must start the Professional Development Certificate in Management (Care) within six months of the date of this registration The responsible inividual must complete the Professional Development Certificate in Management (Care) by 31 December 2005 The registered provider must ensure that the home has a registered manager by 31 August 2004 Mr & Mrs Karuthsami will provide direct support in managing the home by providing up to 20 hours support per week for a period of six months following the registration of Quality Care (Surrey) Ltd. The nature of this support will be in accordance with that described in their letter to the CSCI on 26 April 2004. 30 November 2004 Date of last inspection 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. As most of the bedrooms are on the first floor the home cannot take people who have significant physical disabilities in addition to their learning disabilities. Marlin Lodge DS0000060196.V256117.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection lasted for a duration of 4 hours 45 minutes. Present at the inspection was the deputy manager Ms Bridget Flaherty. At the time of the inspection the home had one vacancy. Of the 9 service users living in the home, 7 were attending a daycentre and 2 were in the home. The inspector attempted to interview the 2 service users present in the home however this was unsuccessful due to their limited verbal communication skills. The inspector observed that they were neatly dressed but they were not engaged in any meaningful activity. This has been addressed under standard 12 in the body of this report. Towards the end of the inspection, the inspector was able to interview a service user who had just arrived from the daycentre. Feedback on the quality of care in the home was very positive. 11 requirements were made following the last inspection. 3 are met and 8 are restated with shorter timescales. A further 17 requirements are issued bringing the total number of requirments following this inspection to 25. It is the inspector’s opinion that the lack of a manager in the home has had an adverse effect on the management of the home and compliance with requirements made by the CSCI. The registered persons are urged to give priority to restated requirements to avoid the possibility of enforcement action by the CSCI. What the service does well: What has improved since the last inspection? The home has reviewed its statement of purpose in accordance with national minimum standards. The medication has been reviewed to reflect the nature of the home and competence of the staff. Staff are subject to criminal records bureau checks before commencing employment. Marlin Lodge DS0000060196.V256117.R01.S.doc Version 5.0 Page 6 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. Marlin Lodge DS0000060196.V256117.R01.S.doc Version 5.0 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.V256117.R01.S.doc Version 5.0 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, 2, 3 and 5 The lack of an appropriate service user guide and contract means service users are unable to understand and therefore make informed choices about the services offered by the home. Pre-admissions assessments ensure that service users needs are identified however this is meaningless if staff do not have the knowledge and skills to meet these needs. EVIDENCE: At the previous inspection a requirement was made for the registered persons to produce a statement of purpose. A copy of the statement of purpose was not available at the home however the inspector was informed that a copy had been sent to the local office of the CSCI. A discussion with an inspector at the local office confirmed that the statement of purpose had been sent and it met the national minimum standards. The service user guide was available but it has not been reviewed since the last inspection. It is still too complex for the service users to understand and the symbols used inappropriate in the sense of many of the words. The registered persons must ensure that the service user guide is reviewed to ensure that it is in a format and language appropriate to the needs of service users. There have been no new service users admitted to the home since the last inspection however the home hopes to fill the remaining vacant room soon. Examination of the file of a service user admitted in January 2004 indicated Marlin Lodge DS0000060196.V256117.R01.S.doc Version 5.0 Page 9 that an assessment was carried out before they were admitted to the home. At the previous inspection a requirement was made for staff to receive any specialist training tailored to service user’s conditions. Training records for three members of staff indicated that they had all received training in managing challenging behaviour but were still waiting to receive training in person centred planning. The inspector noted that a service user at the home suffers from epilepsy but besides the deputy manager, no other staff have training in epilepsy management. This is required. All three files examined contained a copy of a contract/statement of terms and conditions. Two had been signed by the service user but as noted at the last inspection, the language and terms were very complex for the intended service users. A discussion with the deputy manager confirmed that compliance with this requirement was still outstanding. A restated requirement is made for the registered persons to provide service users with a contract/ statement of terms and conditions in a suitable format to which they can give informed agreement. Marlin Lodge DS0000060196.V256117.R01.S.doc Version 5.0 Page 10 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 Inappropriate recording on service user files places service users at considerable harm of abuse. The poor quality of care planning documentation calls into the question the home’s ability to meet the needs of service users. The views of service users are currently sought regarding food and activities but this must encompass issues relating to their individual care. This will make service users fell valued by the home. EVIDENCE: Three service user files were inspected. Two of the 3 files contained care plans. The third did not have a care plan. There was however evidence of annual multi-agency review meetings but this was considered insufficient. There was no information on what the service user’s needs were and how these were going to be met by the home. A risk assessment for the same service user was seen dated 24/5/04, covering issues relating to hygiene and a skin condition. This risk assessment was inadequate as it covered only one aspect of the service user’s needs and there was no evidence of a recent review. The absence of a care plan meant it was difficult to determine how the identified Marlin Lodge DS0000060196.V256117.R01.S.doc Version 5.0 Page 11 risks were translated into care for the service user. Risk assessments were available on the other 2 files but they had been last reviewed in the previous year. The registered persons must ensure that all risk assessments are comprehensive and are reviewed regularly. Another file contained a care plan dated 19/8/04 with no evidence of a recent review. An inspection of this service user’s room indicated they had continence problems but this was not mentioned of this on their care plan. Of the care plans viewed only one had evidence of consultation with the service user. The registered persons must ensure that comprehensive care plans are available for all service users. These must be reviewed at least once every six months. A restated requirement is also made for service users to be consulted regarding their care. At the previous inspection it was noted that some of the language used by staff when recording on service user files was inappropriate. The inspector was concerned to note that this was still occurring. This was drawn to the attention to the deputy manager who was asked to address this issue without delay. Documentary evidence such as minutes of residents meetings was seen confirming that service users are encouraged to make decisions about their life in the home. Records on a service user’s file indicated that they had access to an advocate. An interview with a service user revealed that they were able to choose the colour of the paint of their bedroom. Marlin Lodge DS0000060196.V256117.R01.S.doc Version 5.0 Page 12 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 and 17 The lack of meaningful, structured activities at the home leaves service users restless and unmotivated. The home is able to meet service user’s dietary needs. EVIDENCE: At the time of the inspection 7 out of 9 service users were attending a day centre. Discussions with the manager revealed that of the two service users at home, one attended day centre 4 times a week and the other was due to start attending a new daycentre soon. There was no clear information or structure of activities over the weekend when service users were at home. The deputy manager explained that service users would eat out or go shopping. There was no documentary evidence confirming this and interviews with service users present in the home were unsuccessful due to their limited verbal communication skills. There was no indication that the 2 service users present in the home at the time of the inspection did not appear to be engaged in any meaningful activity. The registered persons are required to ensure that there is a structured and meaningful programme of activities for service users when Marlin Lodge DS0000060196.V256117.R01.S.doc Version 5.0 Page 13 they are not at the daycentre. This must be based on their individual needs and preferences. This requirement is restated. An inspection of the kitchen revealed that there were sufficient quantities of fresh and frozen food. Several bottles of ketchup belonging to one service user were seen in the fridge. They had all been opened but were not labelled with the date on which they were opened. The registered persons must ensure that all food is labelled and dated. A copy of the current menu was seen although no records were available for the food to be offered to service users for evening meal on the day of the inspection. A list noting a service user’s food preferences was displayed on the kitchen notice board. A service user informed the inspector that they were happy with the food offered at the home. Marlin Lodge DS0000060196.V256117.R01.S.doc Version 5.0 Page 14 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): 19, 20 and 21 Support from a variety of healthcare professionals ensures that service users’ healthcare needs are identified and appropriate levels of intervention provided. Medication practises within the home are generally satisfactory. Improvement is required in recording to ensure the health of service users is not compromised. The absence of a guidance on dealing with aging means the particular needs of older service users can be overlooked. EVIDENCE: Records examined confirmed that service users had access to a variety of health care professionals such as GPs, Community Nurses, Dentists, and Opticians. Weight monitoring records were also seen on the three service user files examined. Medication in the home is stored in a locked medication cabinet. At present no service users are self-administering. Staff with relevant training give out medication. Sample signatures for staff that give out medication were available. The medication policy was examined and the inspector confirmed that it had been appropriately reviewed. The controlled drugs register was inspected and records were up to date and accurate. Controlled drugs are stored in a locked cabinet inside the medication cabinet. No temperatures of the medication cabinet are maintained. This is required. A Marlin Lodge DS0000060196.V256117.R01.S.doc Version 5.0 Page 15 sample of medication administration records sheets [MAR sheets] was seen. The inspector observed that there were gaps where it was not clear whether the service user had received their medication or if not, the reason why. The registered persons must ensure that daily temperatures are maintained of the area where medication is stored. MAR sheets must be completed at the time that medication is dispensed. Where medication is not dispensed a record must be maintained of the reason for non-administration. There was evidence of service user’s wishes in the event of their death on all 3 files examined. The home has a policy on the treatment of dying service users however there is no policy on aging. The inspector considers this essential in light of the fact that several service users in the home are in their mid-fifties. A discussion with the deputy manager confirmed that the home would continue to admit service users up to the age of 65. The registered persons must ensure that a policy on ageing is formulated. Marlin Lodge DS0000060196.V256117.R01.S.doc Version 5.0 Page 16 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): 23 The lack of a clear adult protection procedure casts doubt on the home’s ability to protect vulnerable service users. EVIDENCE: Three staff files were examined. There was evidence that all three staff had been subject to a Protection of Vulnerable Adults [POVA] check before commencing employment. All three staff had received adult protection training. The home’s policy on the protection of service users was seen. It listed some of the possible types of abuse but it did not give step-by-step procedures of how to deal with allegations of abuse. There was also no information on the role of the local authority and the CSCI. No whistle blowing policy was available. The deputy manager advised that staff had been given a copy of the whistle blowing policy however in the absence of documentary evidence a requirement is made relating to this. The registered persons must review the adult protection policy to ensure that there is a clear step-by-step procedure on the action to be taken in the event of an allegation of abuse. A whistle blowing procedure must be available. Marlin Lodge DS0000060196.V256117.R01.S.doc Version 5.0 Page 17 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, 27 and 30 Despite the recent renovations to the home, priority must be given to specific areas to ensure a comfortable, clean and safe environment for all service users. EVIDENCE: Following the last inspection the home has undergone some renovations. The bathroom on the ground floor has been fitted with a walk in bath and a separate shower. The flooring has also been replaced. The home now has a separate lounge and dinning area with a conservatory. The conservatory/ dinning area was brightly painted and furnished with tables and chairs however the carpet required cleaning. The lounge was furnished with sofas and a television. There were no pictures or ornaments to make the room comfortable or homely. The deputy manager advised the inspector that there were plans to replace the flooring in the lounge and dinning room. The registered persons must ensure that the carpet in the dinning room is cleaned or replaced. The lounge must be decorated to ensure a homely and comfortable environment for service users. The inspector was able to tour the rest of the house and inspect most of the service user rooms. Most were comfortably furnished and brightly decorated however two rooms were identified as requiring attention. The mattress in the Marlin Lodge DS0000060196.V256117.R01.S.doc Version 5.0 Page 18 first room was stained and there was an unpleasant odour. The deputy manager advised that the service user was doubly incontinent hence the stained mattress. The inspector was concerned at the state of the mattress and the fact that no windows were open to air the room. An immediate requirement was issued requiring the registered persons to ensure that the mattress was replaced with one suitable for the service user’s needs by 12/10/05. In the second room the inspector observed that there was a drawer missing from the chest of drawers and the paint has peeled off on the drawer of the beside table. The registered persons must ensure that repairs are carried out to the chest of drawers and bedside table in a named service user’s room. At the previous inspection a requirement was made for water temperatures to be regulated. At this inspection the water temperatures were checked in the two upstairs bathrooms. Temperatures were scalding hot and were found to be 57 and 60 degrees Celsius respectively. This is way beyond the recommended water temperatures of 43 degrees Celsius and poses a high level of risk for service users. An immediate requirement was issued as this requirement was still outstanding from the previous inspection. The registered persons must ensure compliance with this requirement to avoid the possibility of enforcement action. As part of the tour of the home the laundry room was inspected. Control of substances hazardous to health [COSHH] chemicals such as washing powder and fabric softener were stored in the unlocked laundry room. Training records of 3 staff indicated that 2 had received infection control training. The registered persons must ensure that all staff receive infection control training. The area where COSHH chemicals are stored must be kept locked. Marlin Lodge DS0000060196.V256117.R01.S.doc Version 5.0 Page 19 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): 34, 35 and 36 Recruitment practices at the home must be improved to ensure staff undergo the required level of checks before commencing employment. This ensures that service users are protected from harm. The home must support staff through induction training and regular supervision to ensure service users benefit from a consistent level of care. EVIDENCE: A sample of three staff files was examined. All files contained 2 references however in cases where staff had worked in a previous position involving work with vulnerable children or adults no reason was given for leaving this employment. Proof of identification was available for all three staff however there were no recent photographs available. 2 of the 3 members of staff had evidence of eligibility to work, this was missing from the third file. There was a statement relating to one member of staff’s physical and mental fitness. This information was not available on the files of the other 2 members of staff. The registered persons must ensure that staff files contain a recent photograph, eligibility to work and a statement as to their physical and mental fitness. Where staff have previously worked in a position involving vulnerable children and adults, written confirmation must be available for their reason for leaving. Records examined indicated that 2 of the 3 members of staff had received induction training. Staff supervision records were also viewed and these Marlin Lodge DS0000060196.V256117.R01.S.doc Version 5.0 Page 20 revealed that while some staff had recently received supervision this was not carried out on a regular basis. The registered persons must ensure that staff receive induction training. Staff must receive supervision on a regular basis at least 6 times a year. Discussions with the deputy manager revealed that at present 2 staff are enrolled on an NVQ course and 1 has recently completed the course. 3 staff applied for NVQ training but the course was over subscribed and they have now been guaranteed places for January 2006. Marlin Lodge DS0000060196.V256117.R01.S.doc Version 5.0 Page 21 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, 40, 41 and 42 The lack of a manager in the home does not give service users confidence in the way the home is managed. The home must actively seek the views of service users and make policies accessible to them to ensure that service users views are heard and acted upon. The home must demonstrate its commitment to promoting the health and safety of service users by undertaking regular checks. EVIDENCE: Discussions with the manager revealed that following the last inspection a manager had been recruited in January 2005. In June the manager resigned and since then the home has been without a manager. The deputy manager informed the inspector that a consultant had been recruited to assist with the management of the home. The deputy manager was unaware what progress if any had bee made to recruit a new manager. A restated requirement is made for registered persons to appoint a manager. Following the last inspection, Marlin Lodge DS0000060196.V256117.R01.S.doc Version 5.0 Page 22 there has been no progress to implement a quality assurance system to seek the views of service users and other professionals. This is required. The home has a policy on recordkeeping that states that service users can have access to their records. Most of the policies and procedures detailed under appendix 2 of the Care Homes Regulations are available and showed the name of the home. Key policies are still not in a format accessible to service users. This requirement is restated. A requirement made at the last inspection for service users to be provided with information in appropriate and accessible formats is still outstanding. The deputy manager advised that the home plans to introduce a pictorial menu for service users. This requirement is restated for the third time. At the last inspection an immediate requirement was issued for the bedroom door of this room to be repaired. At this inspection the bedroom door was still not closing firmly and posed a considerable fire risk. The deputy manager advised that the door had been repaired but it still did not close firmly shut. The inspector expressed great concern that a service user was being placed at great risk through a faulty fire door. The registered persons must ensure compliance with this requirement to avoid the possibility of enforcement action. Documentation was seen confirming satisfactory and up to date completion of the following health and safety checks; fire alarm and emergency lighting, gas, fire risk assessment and weekly fire alarm tests. A requirement is made for the following health and safety checks to be made; portable appliance testing, fire equipment, electrical installations, water storage tanks and legionella. Up to date records must be available to confirm recent completion of fire drills. Marlin Lodge DS0000060196.V256117.R01.S.doc Version 5.0 Page 23 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 2 3 2 X 1 Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 3 3 1 x Standard No 24 25 26 27 28 29 30 STAFFING Score 1 X X 1 X X 1 LIFESTYLES Standard No Score 11 X 12 2 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Marlin Lodge Score X 3 2 2 Standard No 37 38 39 40 41 42 43 Score 1 x 1 2 3 1 x DS0000060196.V256117.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 5, 6 Requirement Timescale for action 05/12/05 2 YA3 12(1), 18(1)(c)(i) 3 YA5 5(1)(b) 4 YA6 14, 15 The registered persons must ensure that the service user guide is reviewed to ensure that it is in a format and language appropriate to the needs of service users. The registered persons must 05/12/05 ensure that staff working at the home receive training in epilepsy and other areas relevant to service user’s needs. [previous timescale of 30/4/05 not met.] The registered persons must 05/12/05 ensure that service users have an individual contract, containing all the required elements, which are provided in a suitable format to which they can give informed agreement. The key terms must be included in the Service Users Guide. [previous timescale of 28/2/05 not met.] The registered persons must 05/12/05 ensure that comprehensive care plans are available for all service users. These must be DS0000060196.V256117.R01.S.doc Version 5.0 Marlin Lodge Page 25 5 YA6 6 YA9 7 YA12 8 9 YA17 YA20 10 11 YA21 YA23 reviewed at least once every six months and show consultation with service users. [previous timescale of 28/2/05 not met.] 12(4)(a) The registered persons must ensure that staff maintain records in a way that upholds the dignity of service users. 13(4)(c), 14 The registered persons must ensure that all risk assessments are comprehensive and are reviewed regularly. 16(2)(m)(n) The registered persons are required to ensure that there is a structured and meaningful programme of activities for service users when they are not at the daycentre. This must be based on their individual needs and preferences. [previous timescale of 31/1/05 not met.] 13(4)(c) The registered persons must ensure that all food is labelled and dated. 13(2) The registered persons must ensure that daily temperatures are maintained of the area where medication is stored. MAR sheets must be completed at the time that medication is dispensed. Where medication is not dispensed a record must be maintained of the reason for non-administration. 12(1)(a)(b) The registered persons must (4)(b) ensure that a policy on ageing is formulated. 13(6) The registered persons must review the adult protection policy to ensure that there is a clear step-by-step procedure on the action to be taken in the event of an allegation of abuse. A whistle blowing procedure must be available. DS0000060196.V256117.R01.S.doc 05/01/06 05/01/06 05/12/05 05/11/05 05/11/05 05/01/06 05/01/06 Marlin Lodge Version 5.0 Page 26 12 YA24 23(2)(d) 13 YA24 23(2)(b) 14 YA24 16(2)(c)(k), 23(2)(d) 15 YA27 13(4)(c), 23(2)(j) 16 17 YA30 YA30 13(6) 13(4)(a) 18 YA34 19 Schedule 2 19 YA35 18(1)(c)(i) The registered persons must ensure that the carpet in the dinning room is cleaned or replaced. The lounge must be decorated to ensure a homely and comfortable environment for service users. The registered persons must ensure that repairs are carried out to the chest of drawers and bedside table in a named service user’s room. The registered persons must ensure that the mattress in a named service user’s room is replaced with one suitable for their needs. Immediate requirement The registered persons must ensure that hot water in bathrooms is maintained around 43 degrees Celsius. [previous timescale of 31/1/05 not met.] Immediate requirement The registered persons must ensure that all staff receive infection control training. The registered persons must ensure that the area where COSHH chemicals are stored must be kept locked. The registered persons must ensure that staff files contain a recent photograph, eligibility to work and a statement as to their physical and mental fitness. Where staff have previously worked in a position involving vulnerable children and adults, written confirmation must be available for their reason for leaving. The registered persons must ensure that staff receive induction training. DS0000060196.V256117.R01.S.doc 05/01/06 05/12/05 12/10/05 12/10/05 05/01/06 05/11/06 05/01/06 05/01/06 Marlin Lodge Version 5.0 Page 27 20 YA36 18(2) 21 YA37 8 22 YA39 24 23 YA40 12 24 YA42 23(4) 25 YA42 23(2)(c)(4) The registered persons must ensure that staff receive supervision on a regular basis at least 6 times a year. The registered persons must appoint a suitably qualified and competent manager for the home. [previous timescale of 28/2/05 not met.] The registered persons must ensure that a quality assurance system is implemented. This must seek the views of service users, their relatives and other professionals. A report of the findings and any recommendations must be compiled. The registered person must provide service users with comprehensive, accessible, understandable and up to date information in suitable formats about its policies, procedures, activities and services. [previous timescales of 30/9/04 and 28/2/05 not met] The registered persons must ensure that fire doors in the home are self-closing. [Previous timescale of 6/12/04 not met.] The registered persons must ensure that there is documentation confirming the satisfactory and up to date completion of the following areas; portable appliance testing, fire equipment, electrical installations, water storage tanks and legionella. Up to date records must be available to confirm recent completion of fire drills. 05/01/06 05/12/05 05/01/06 05/11/06 12/10/05 05/12/06 Marlin Lodge DS0000060196.V256117.R01.S.doc Version 5.0 Page 28 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.V256117.R01.S.doc Version 5.0 Page 29 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.V256117.R01.S.doc Version 5.0 Page 30 - 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!