Inspection on 14/05/07 for Mascotte Lodge

This inspection was carried out on 14th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mascotte Lodge 14/03/06

Mascotte Lodge 29/11/05

Mascotte Lodge 23/03/05

Mascotte Lodge 03/03/05

Mascotte Lodge 24/02/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Mascotte Lodge Football Green Hornsea East Yorkshire HU18 1RA Lead Inspector Pam Dimishky Key Unannounced Inspection 14th May 2007 10:00 Mascotte Lodge DS0000019825.V339970.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 Mascotte Lodge DS0000019825.V339970.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. Mascotte Lodge DS0000019825.V339970.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mascotte Lodge Address Football Green Hornsea East Yorkshire HU18 1RA 01964 534765 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) Mrs Judith Ann Major Mrs Judith Ann Major Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Mascotte Lodge DS0000019825.V339970.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th March 2006 Brief Description of the Service: Mascotte Lodge is a privately owned care home that is registered to offer care and accommodation to 3 residents with a learning disability. It is owned by Mrs. Judy Major and was first registered on the 17th July 1980. The home is located in the centre of Hornsea, a small seaside town on the coast of the East Riding of Yorkshire, and it is close to all local amenities. The home comprises of one single bedroom, with en suite toilet and shower, and one shared bedroom and provides the appropriate amount of bathrooms and toilets for the residents’ needs. All communal areas required by residents are provided on the ground floor ie lounge, dining room and conservatory. The registered provider/manager and her husband live at the home and share all facilities with the residents. The ethos of the home is based on maintaining a family type atmosphere for the residents. Mascotte Lodge DS0000019825.V339970.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection visit took place over a period of 3 hours split into two parts of the day to enable the inspector to speak with the residents. The inspector looked around all of the home and a number of records were examined. The registered person/manager was present throughout the visit and the three residents were spoken with when they returned from their respective day centres. No requirements were made at the last inspection and all of the key standards have been assessed at this visit. Surveys were returned from the three residents and two relatives, all responding positively about the service. Due to the specific communication needs of some of the residents, the registered person supported them to be part of the inspection process. What the service does well: What has improved since the last inspection? The registered person is proactive in maintaining the environment and for keeping up to date with training and systems of working which is ongoing. Mascotte Lodge DS0000019825.V339970.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Mascotte Lodge DS0000019825.V339970.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 Mascotte Lodge DS0000019825.V339970.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The admission procedure includes a proper assessment being made of residents moving into the service to ensure the home can meet their needs. EVIDENCE: The case file was examined for a resident who has moved into the home since the last inspection. This resident was already known to the registered person, but spent some time visiting the home and staying overnight to get to know the home and other residents before moving in. An assessment of needs was seen in the file along with a copy contract and care plan. All residents have a contract but these have not been signed either by the registered person or representative of the resident and it would be in both parties interests for this to be done. The latest resident was clearly very “at home”, relaxed and was noted to have a good relationship with the registered person and other residents. Mascotte Lodge DS0000019825.V339970.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is a clear and consistent care planning system in place which adequately provides the information needed to satisfactorily meet residents needs. EVIDENCE: All three care plans were examined and found to be very comprehensive and reflecting the needs and personal goals needed to be met. Records included details of general practitioner, dental, hospital, optical and chiropody appointments along with notes. Weight is a good indicator of a person’s well being and this is monitored and recorded monthly. Risk assessments are in place and, along with the care plans, are reviewed monthly by the registered person. Care management reviews the care plan annually, and there is also a six monthly paper update from the home. The manager explained how residents are supported to make decisions about their lives based on knowledge of the resident and from information from Mascotte Lodge DS0000019825.V339970.R01.S.doc Version 5.2 Page 10 relatives who are equally involved. Residents explained how they choose their own clothes when shopping and daily when deciding what to wear. Mascotte Lodge DS0000019825.V339970.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Daily life and social activities meet the individual expectations and choice of the residents living in the home. EVIDENCE: Residents are able to take part in age, peer and culturally appropriate activities. All the residents attend day centres. Two residents spend five days a week at a local day centre where they have an education programme twice a week and other days spend time swimming, bowling, going out on organized trips out eg picnics. Another resident attends a different day centre three times a week, participates in activities at an older persons’ home once a week and has a work placement in a local café one day a week. Weekends are spent being taken out every Saturday for shopping and lunch and Sundays relaxing in the home “doing their own thing” eg writing, colouring, knitting, making cards watching television (each resident has their own DVD’s to choose from as well as television programmes). One more able resident attended a local Mascotte Lodge DS0000019825.V339970.R01.S.doc Version 5.2 Page 12 polling station to cast a vote at the recent local elections, plays pool every Thursday at a local pub, goes to Rovers matches with the registered person’s husband and is currently learning about first aid at a course run by St John’s Ambulance. All the residents are taken (and paid for) as part of the family for two weeks holiday abroad; the last few years this has been to Spain but this year are going to Cyprus. A holiday has also been arranged through Social Services for later in the year for a week in Filey joining other people with a learning disability. The home operates to a six-week menu but this is varied to meet individual choices. A copy of the menus was enclosed with the pre inspection questionnaire and indicates a healthy diet is being offered which residents, when asked, said they “loved the meals”. The residents were very relaxed at the time of this visit and were happy to chat to the inspector whilst continuing with their activities, ie one writing, one colouring and another watching television; it was very evident they enjoy living in the home, receive the support they need and have a very good relationship with the registered person. Mascotte Lodge DS0000019825.V339970.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Personal support in this home is offered in such a way as to promote and meet residents physical and emotional health needs. EVIDENCE: All the residents receive personal care and support, some with prompts, needed to meet their individual needs and aspirations. Arrangements are in place to access healthcare support as needed and general practitioner, dental, optical, chiropody and hospital appointments were seen to be documented in each case file. Daily notes for each resident reflect their involvement with life in the home. The manager has received a Boots certificate in care of medicines, dated May 2006, and administers all medications to the residents. Records were checked and reconciled with the medications, although night time medication had already been potted up and recorded as being given; the registered person was advised regarding this practice. Advice was also given with regard to keeping a record of any drugs returned to the pharmacist and having evidence of being signed as received. A policy and procedure is in placed for self-medication should this become possible. Mascotte Lodge DS0000019825.V339970.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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People using the service are able to express their concerns and have access to an effective complaints procedure and are protected from abuse and have their rights protected. EVIDENCE: Residents are supported in sharing any concerns in connection with their protection and safety with the registered person. This was confirmed in conversation with one of the residents, “I would speak to Judy” and the home has no records of any complaints as concerns are resolved informally before becoming more serious. The registered person is clear when an incident needs to be referred to the local authority as part of the local safeguarding procedures and is open and transparent when discussing incidents with external investigating bodies. The registered person has recently attended a managers training course in awareness of adult protection. Mascotte Lodge DS0000019825.V339970.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables residents to live as part of the family in a domestic, safe, well-maintained and comfortable environment which encourages independence. EVIDENCE: Residents live in a very homely, comfortable and safe environment as part of the family; the home was seen to be clean and hygienic at the time of this visit. A decorator was busy decorating the dining area and will be returning to decorate residents’ bedrooms whilst they are away on holiday later in the year. The registered person, and residents, confirmed they are able to choose their own colour schemes although for communal areas this is decided by the home. Visitors to the home are able to spend time in private with the residents if they wish. Communal areas used by residents and the family include the lounge, a dining room and conservatory all of adequate proportions. Two residents confirmed they enjoy sharing a room and one resident has a first floor room Mascotte Lodge DS0000019825.V339970.R01.S.doc Version 5.2 Page 16 with en suite shower and toilet; both rooms are highly personalised and reflect individual personalities. A large domestic kitchen was seen to be clean and hygienic with easily washable floors and walls; the environmental health officer does not intend to visit again due to his satisfaction with the arrangements but will keep the registered person up to date with information. The registered person has a basic food hygiene certificate dated 02.04.04. Mascotte Lodge DS0000019825.V339970.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The registered provider is the sole carer and is trained and experienced to support the people who use the service. EVIDENCE: The home is run and managed by the registered person who is the sole carer, and who has cared for people with a learning disability since 1980. No staff are employed, but she is supported by her husband and daughter. Certificates seen indicate the registered person accesses training to ensure individual needs are met, eg epilepsy awareness, enteral feeding study day and administration of rectal Diazepam. Mascotte Lodge DS0000019825.V339970.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The registered person manages the home based on openness and respect and has effective quality assurance systems in place. EVIDENCE: The registered person has managed this home since initial registration in 1980, is experienced and highly competent in providing continuous improvement, customer satisfaction and quality assurance. Certificates awarded to the registered person include health and safety, basic food hygiene, fire safety, moving and lifting people, emergency first aid and arrangements have been made with a nearby care home to attend their fire safety training. Quality assurance systems are in place and include a new annual resident feedback questionnaire. Monthly resident meetings are held where residents are able to express their views and agree decisions about life in the home. Minutes for the Mascotte Lodge DS0000019825.V339970.R01.S.doc Version 5.2 Page 19 last meeting held 10th May 2007, record the discussion around shared birthday celebrations when it was agreed to go out for a meal. Questionnaires returned by relatives indicate their total satisfaction with the services and care provided. The health, safety and welfare of residents is promoted and protected by the homes policies and procedures. The pre-inspection questionnaire listed maintenance records which are kept by the home and up-to-date. The inspector was shown the annual gas homecare customer work report dated 2.10.06 and the registered person stated her husband checks portable electrical equipment and electric sockets. Mascotte Lodge DS0000019825.V339970.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 X 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 N/A 32 N/A 33 N/A 34 N/A 35 N/A 36 N/A CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 x LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 X 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 2 x 4 x 4 X X 4 x Mascotte Lodge DS0000019825.V339970.R01.S.doc Version 5.2 Page 21 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 YA5 Regulation 5 Requirement The registered person should ensure contracts are signed by both the registered person and the resident and/or their representative Timescale for action 14/05/07 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 YA20 Good Practice Recommendations The registered person should ensure medications are only written up at the time they are administered and it is good practice to ensure the home has evidence of the date, type, strength and quantity of any medicines returned to the pharmacist and signature obtained Mascotte Lodge DS0000019825.V339970.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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