Inspection on 15/07/08 for Mere Lodge

This inspection was carried out on 15th July 2008.

CSCI found this care home to be providing an Adequate service.

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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mere Lodge 16/07/07

Mere Lodge 30/05/06

Mere Lodge 04/11/05

Mere Lodge 18/07/05

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Mere Lodge 93 Mere Road Leicester LE5 5GQ Lead Inspector Ruth Wood Unannounced Inspection 15th July 2008 14:20 Mere Lodge DS0000064385.V368590.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 Mere Lodge DS0000064385.V368590.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. Mere Lodge DS0000064385.V368590.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mere Lodge Address 93 Mere Road Leicester LE5 5GQ 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) 0116 251 7441 Mere Lodge Healthcare Ltd Vacant Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Mere Lodge DS0000064385.V368590.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th July 2007 Brief Description of the Service: Mere Lodge is a converted 2 storey, 4 bedded terraced property in the Highfields area of the city of Leicester. It is situated adjacent to Spinney Hill Park and close to many shops and local amenities. The home consists of 2 lounges, a dining kitchen, and large bathroom with whirlpool bath to the ground floor. The 4 bedrooms, toilet with shower enclosure, and office are on the first floor accessible by the main staircase. To the rear of the home is a small outside paved area. Fees charged range from £950 to £1950 per week. The last inspection report is held in the home and is available upon request. Information about the home is contained in the service users guide. Mere Lodge DS0000064385.V368590.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The inspection visit took place on a weekday between 14:20pm and 18:45pm. Before the inspection visit the last inspection report, together with information received about the service since that inspection was reviewed. During the inspection visit, two people’s support plans were seen and their needs and how they are met was discussed with the acting manager and staff members and the interaction between the people who live and work in the home was observed. The inspector spoke to the people who live in the home about what it was like to live there and looked at their rooms and the rest of the rooms in the house. How people are supported to manage their finances and medication was also looked at. The inspector spoke to staff about their training and the kind of support they receive and looked at their recruitment, training and development records. The home hasn’t had a registered manager for 18 months. A new project manager has recently started work for the people who own the home. He visits the home at least once per week and has produced formal reports of these visits; these were looked at during the inspection. The reports demonstrate that the project manager has identified and started to address many of the requirements and recommendations made for improvement in this report. What the service does well: The people who live at Mere Lodge get on well with the staff that work there and said that they were well supported, one person said, “They look after you here.” Relationships are friendly and open and people appeared comfortable with staff and able to speak with them freely. Regular ‘residents meetings’ are held so that people can express their views. People are supported to maintain their own culture and good arrangements are in place to make sure people can eat culturally appropriate food and have their spiritual needs met. Staff listen to what people say about the kinds of things they would like to do and support people to go out to different places and to go on day trips. People’s health care needs are met and people are referred to specialists (such as psychologists and speech and language therapists) if they need additional support. Mere Lodge DS0000064385.V368590.R01.S.doc Version 5.2 Page 6 People who are thinking of coming to live in the home can visit and stay overnight to try it out first. What has improved since the last inspection? What they could do better: Information in the service users guide needs updating so that people who want to move into the home have accurate information. People’s individual support plans and risk assessments must be updated so that they outline how people’s current needs should be met. This makes sure that staff support people in a consistent way. People who live in the home should be reminded about the home’s complaints procedure so that they know how to raise any concerns they may have. Clear procedures should be in place to make sure that people’s medication is regularly reviewed; a record of the date of the review should also be kept. There have been some changes in the Regulations about how certain drugs (called controlled medication) should be stored in care homes. This means that the people who own Mere Road must make sure that the home has a special metal cabinet, fixed to a solid wall so that they can store these drugs if any of the people living in the home need to take them in the future. Staff must receive regular training, which helps them to meet the needs of the people living in the home. The Annual Quality Assurance Assessment (AQAA) is a self-assessment, that focuses on how well outcomes are being met for people using the service. It also gives us some numerical information about the service. This should have been completed and sent back to the Commission for Social Care Inspection before the inspection visit. The project manager has promised to complete and return it before the end of July. There must be a system put in place to review and improve the quality of care in the home. The review must include consultation with the people who live at the home and their representatives, such as relatives and social workers. Mere Lodge DS0000064385.V368590.R01.S.doc Version 5.2 Page 7 Several improvements are needed to the home’s environment: • • • • There must be sufficient bathing facilities suitable for all the people who live in the home. Communal areas must be repaired and re-decorated to make sure that people live in a pleasant environment. Furniture suitable for the needs of the people living in the home must be provided in the living/dining room. The washing machine and tumble dryer are in the kitchen but there are plans to move them. Until this happens, the people who own the home should talk to the environmental health department to make sure there is no risk of infection and ask them the best ways to prevent this from happening. 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. Mere Lodge DS0000064385.V368590.R01.S.doc Version 5.2 Page 8 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 Mere Lodge DS0000064385.V368590.R01.S.doc Version 5.2 Page 9 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): 1,2,4 Quality in this outcome area is adequate Good assessment procedures ensure people’s needs are met. The information in the service user guide needs updating so that accurate information is available to enable people to make an informed choice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Arrangements made for the person who came to live in the home most recently were discussed with the acting manager. The company’s area manager and the home’s acting manager visited the person at their previous placement and completed an assessment through discussion with the person themselves and their current support worker. A social worker’s comprehensive assessment was also obtained and both these documents were on file. The person visited the home to have a meal and made another visit to stay overnight before moving in. A copy of the service users guide is located in the kitchen. This doesn’t reflect the current management and staffing arrangements in the home and needs updating so that anyone considering moving into the home has accurate information. Mere Lodge DS0000064385.V368590.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is adequate Support plans and risk assessments do not accurately reflect people’s current and changing needs. People are supported to make decisions about their lives This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector focused on how two people’s needs are met. Discussion was held with the acting manager and with two staff members and all displayed a good understanding of people’s needs and how they were changing and developing. However this is not reflected in written care plans or risk assessments. For one person these have not been updated since January 2007. Although support staff have signed to say that the plan is still current, it is clear from discussion and observation that many changes in the person’s needs are not reflected in the support plan or in the risk assessments in place. This is particularly so for the person’s physical needs and the risk assessments associated with activities such as bathing. To ensure consistency in the delivery of care, support plans and risk assessments must accurately reflect people’s current needs and the way they should be met. Mere Lodge DS0000064385.V368590.R01.S.doc Version 5.2 Page 11 Full daily records about each person’s activities, mood and behaviour are kept. Discussion with all four people who live in the home indicated that they are supported to make decisions about the kind of food they eat, the activities they take part in and the places that they visit. Mere Lodge DS0000064385.V368590.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17 Quality in this outcome area is good People have opportunities to engage in vocational, leisure and community activities and are supported to maintain links with their families and friends. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One person attends college on a regular basis and has done courses in cookery and office skills, which they said they had enjoyed. None of the other people who live in the home attend regular, vocational activities although each person said that they went out, supported by staff and this was confirmed by reading daily records. One person said that they had gone on a trip to Nottingham with their key worker and had asked at the ‘residents meeting’ to go to Skegness for the day. All the people who live in the home were going on a day trip to Twycross Zoo the following day and said that they were looking forward to it. The previous day people had gone strawberry picking. Some people make drinks, snacks or help with cooking, with staff support – other people choose not to be involved in these activities. Mere Lodge DS0000064385.V368590.R01.S.doc Version 5.2 Page 13 Efforts are made to meet the dietary needs of people, whether these arise from cultural or health reasons. Clear guidance is available to meet the dietary needs of a person who is having difficulty swallowing. Menu records are kept and show that a balanced diet is served in the home despite people expressing strong preferences about food such as “I don’t like vegetables”. The acting manager and other staff members explained how the dietary needs of a person of the Muslim faith were met. An additional staff member, of the same faith, from one of the group’s other homes visits this person to assist them to maintain their faith and cultural traditions. When discussing with this person what they did in the home, they mentioned celebrating Eid and going to the Mosque and it is clear that their religious and cultural needs are being addressed. People are supported to maintain contact with their families and staff spoke about the supportive relationship they had with the relatives of people who live in the home. People are free to visit at any time. Mere Lodge DS0000064385.V368590.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is adequate People’s health and personal care needs are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussion with the acting manager and staff and examination of records demonstrated that people’s health care needs are addressed within the home. Referrals to appropriate professionals such as physiotherapists and speech and language therapists have been made for one person whose physical health needs have recently increased. Guidance on food and diet for this person were clearly displayed in the kitchen and staff demonstrated an awareness of their needs. How people’s personal care needs should be met is not recorded accurately in each person’s plan, staff however were able to explain the personal care needs of individuals and how these were met. The current bathing and shower facilities are not appropriate to meet the needs of all the people living in the home; one person is unable to get in and out of the bath currently fitted in the bathroom. Senior support staff that administer medication have undertaken appropriate training. Medication records are accurate and contain information about the side effects of the medicines people take. Each person in the home has a Mere Lodge DS0000064385.V368590.R01.S.doc Version 5.2 Page 15 medication profile, which states that the person has given consent for staff to administer their medication and explains how they like to receive their medication. There is also a list of ‘homely remedies’ for each person; these have been checked with the person’s GP to ensure that there are no contra indications with prescribed medication. It is unclear from records when people’s medication was last reviewed or when it will be reviewed again – this is particularly significant for one person who no longer seems to need the ‘as required’ medication they are currently prescribed. Clearer procedures are recommended to ensure that people’s medication is reviewed regularly and that there is a clear record made when this has taken place. Amendments to Regulations relating to the Misuse of Drugs mean that the home must have separate storage for controlled medication. This should be a metal cupboard of specified gauge with a specified double locking mechanism. It should be fixed to a solid wall or a wall that has a steel plate mounted behind it with Rawl or Rag bolts. No controlled medication is currently stored or administered in the home. Easily transferable information is available about all the people that live in the home should they need to be admitted to hospital in an emergency and the acting manager said that they were looking to instigate health action plans within the home. Information within care files showed that referrals had been made for people to have general health checks and to receive chiropody, dental and optical checks. Mere Lodge DS0000064385.V368590.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is adequate People’s concerns are listened but some improvements in risk assessment are required to ensure that people are consistently protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who live in the home have an open relationship with staff members, ‘Residents Meetings’ are held in the home and people appear confident in expressing their opinions when speaking to staff. Two people said that they would tell a member of staff if they were not happy about anything, one person said that they didn’t know what they would do if they were unhappy. People who live in the home should be reminded about the home’s complaints procedure so that they all know how to raise any concerns they may have. There is some difficulty in displaying procedures, as one person who lives in the home likes to remove things from the walls. Consideration should be giving to ensuring that people who live in the home have a personal copy of the complaints procedure. Three staff spoken with displayed an understanding of whistleblowing procedures and knew how to report any concerns. The acting manager was aware of the protocols with regards to referring safeguarding incidents to social services and had obtained a copy of Leicester City Council’s Adult Abuse Awareness Pack. Staff have undertaken in-house training about how to recognise abuse and basic awareness in adult protection. Arrangements have been made for this training to be updated. Mere Lodge DS0000064385.V368590.R01.S.doc Version 5.2 Page 17 Staff have Criminal Records Bureau checks and their names have been checked against the vulnerable adults register. This helps to make sure that only suitable people work at Mere Lodge. Risk assessments in support plans identify how staff should respond to behaviour that challenges but not all of these are up-to-date or are an accurate reflection of the potential challenges that some people living in the home present. These assessments must be regularly updated and reviewed to ensure that staff are clear how to correctly and consistently manage such incidents. Updates to staff training in responding to incidences of challenging behaviour have been planned. Clear records are kept for all transactions relating to people’s monies. Two people’s records were checked – there was a clear audit trail, which showed where money had come from. Receipts or petty cash vouchers were in place for each transaction and two staff sign after each transaction. Balances of monies held are checked weekly and the two balances and records checked during the inspection were accurate. Mere Lodge DS0000064385.V368590.R01.S.doc Version 5.2 Page 18 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): 24,26,27,30 Quality in this outcome area is adequate Communal areas of the home need considerable improvement to ensure that the environment meets the needs of people living in the home and is a pleasant place to live and work in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Much of the home requires refurbishment and the recently appointed project manager informed the inspector that this is due to take place. Reports of his weekly visits to the home indicate that areas for improvement have been identified and quotes are being obtained. Although considerable improvement is required the home was clean, tidy and fresh smelling. The washing machine and tumble dryer are still located in the kitchen, which has the potential to spread infection. At the previous inspection the responsible individual was asked to consult with environmental health as to the suitability of laundry facilities being sited in the kitchen where food is prepared and cooked. There is no available evidence to say that this consultation has taken place. The project manager said that laundry facilities are to be re-located to the first floor. Until this is achieved then the Mere Lodge DS0000064385.V368590.R01.S.doc Version 5.2 Page 19 environmental health department must be consulted and a suitable risk assessment put in place to minimise the potential for any cross-infection. The upstairs shower room is currently not operational and the downstairs bath and shower room is in need of refurbishment. Again plans are in place to undertake this work to ensure that these facilities more appropriately meet people’s needs in terms of accessibility. At the moment one person is unable to access the bath because of their deteriorating physical mobility. Several windows do not have blinds or curtains because these are pulled down by one of the people living in the home. The project manager explained plans to fit special curtains which can be easily re-fitted when pulled down. These should be instigated as soon as possible to ensure the privacy and dignity of people living in the home. The sitting and dining areas both require refurbishment, including new furniture and re-decoration. The door to the sitting room needs repairing. The hall, stairs and landing need re-decorating, inappropriate light fittings in this area need replacing, as does the carpet. The home’s office is currently sited on the first floor in a very small room. This space is not really sufficient for confidential meetings or supervisions and alternatives for office provision should be considered. The acting manager said that an electrician was visiting the home the day after the inspection to check the wiring and change the fuse boxes. Most people’s bedrooms are pleasantly decorated and contain personal items and personal furniture. Fire extinguishers are located in special safety boxes so that they cannot be removed, until needed in the case of a fire. The kitchen is kept security locked but the people who live in the home are encouraged to use the facilities with staff support – one person was observed to make a drink with staff supervision and people were later observed helping staff to prepare the evening meal. Mere Lodge DS0000064385.V368590.R01.S.doc Version 5.2 Page 20 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 Quality in this outcome area is adequate Improvements to staffing levels and training should help staff to support and protect the people who live in the home more effectively. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels and staff training and development have not been maintained at the standard observed at the last CSCI inspection. This has been recognised by the new Project Manager who is seeking to address this. Rotas show that there are always two staff on duty for each shift during the day and one waking night staff. The new project manager is looking to increase this to 3 or 4 staff on duty during the day to enable people to have more opportunities to go out and engage in activities. During the inspection there were 3 staff members on duty during the afternoon shift. Interaction between staff and the people who live in the home was friendly and appropriate. Three staff members’ recruitment records were examined, including the person most recently appointed to work in the home. All contained a completed application form, evidence of a formal interview, two written references and in two cases a full criminal records bureau check and evidence that their name had been checked against the vulnerable adults register. The most recently Mere Lodge DS0000064385.V368590.R01.S.doc Version 5.2 Page 21 appointed staff member’s name had been checked against the protection of vulnerable adults register and a full criminal records bureau check applied for. Arrangements were in place for this staff member to work with support at all times until the full criminal records bureau check was received. Staff have received information, including reading material, from a clinical psychologist about the needs of people with Autistic Spectrum disorders; they have not received any formal training in this area however and said that this would be useful, to enable them to meet people’s needs more effectively. Arrangements have been made for all staff members’ training, in such areas as health and safety, moving and handling, first aid and food hygiene to be updated. Training is also to be updated in such areas as dealing with behaviour that challenges. Two staff members spoken with said that they had completed National Vocational Qualifications in supporting people and staff records confirmed this. Mere Lodge DS0000064385.V368590.R01.S.doc Version 5.2 Page 22 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, 40 Quality in this outcome area is adequate Improvements are needed in the management of the home, especially in the area of reviewing the quality of the service to ensure that it is consistently run in the best interests of the people who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager left in October 2006 and a senior support worker has been in the position of acting manager since this time. The senior support worker has made it clear that they do not wish to be the acting or registered manager and a new acting manager is due to start work at the home on 17th August 2008. A new project manager has been appointed and has made weekly visits to the home and produced formal reports of these visits; these were viewed as part of the inspection. These reports demonstrate that the project manager has identified and started to address many of the requirements and recommendations made for improvement in this report. Mere Lodge DS0000064385.V368590.R01.S.doc Version 5.2 Page 23 The Annual Quality Assurance Assessment Document has not been completed or returned to the Commission. The Project Manager made assurances that this would be returned before the end of July. There is no formal process of quality assurance to ensure that the home is run in the best interests of the people who live there. The people who live and work in the home, their relatives and the people who commission the service (such as social workers) are not formally asked for their opinions of the quality of the care given. Discussion with the people who live in the home did indicate however that they do have regular meetings with staff and their views and requests for activities are listened to and where possible are met. Staff meetings are also regularly held in the home; one was held on the day of the inspection. A more formal system of quality assurance must be established. Good provision to ensure people’s health and safety is in place. A health and safety employee handbook is given to all staff members and arrangements have been put in place for all staff to receive updates in their training related to health and safety, fire safety, food hygiene, first aid and moving and handling. Records show that fire systems are regularly tested and labels on plugs indicate that portable electrical appliances were tested in March 2008. The home’s wiring and fuse boxes were due to be checked on the day following the inspection. There is a carbon monoxide meter in the kitchen, which emits an alarm if this gas is detected. Mere Lodge DS0000064385.V368590.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 3 27 1 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 3 12 2 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 2 X 1 X X 3 X Mere Lodge DS0000064385.V368590.R01.S.doc Version 5.2 Page 25 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 YA6 Regulation 15 (2) (b) Requirement Individual plans and risk assessments must accurately reflect people’s current needs to help ensure consistency in the delivery of care and support. Secure storage must be put in place for controlled drugs to meet the requirements of the Misuse of Drugs and Misuse of Drugs (Safe Custody) (Amendment) Regulations 2007 Furniture suitable for the needs of the people living in the home must be provided in the living/dining room. Redecoration and repair of communal areas must take place to ensure that people live in a pleasant environment. Sufficient bathing facilities, which meet the needs of all the people living in the home, must be provided. The washing machine and tumble dryer are based in the kitchen and there is the potential for the spread of infection as people prepare and cook meals here. Timescale for action 30/09/08 2 YA20 13(2) 31/10/08 3 YA24 16 (2) (c) 30/09/08 4 YA24 23 (2) (b)(d) 23 (2) (j) 31/10/08 5 YA27 31/10/08 6 YA30 13 (3) 15/08/08 Mere Lodge DS0000064385.V368590.R01.S.doc Version 5.2 Page 26 Managers must seek guidance from environmental health to ensure safe outcomes for people who live in the home. (Original timescale of 31/08/07 not met) Staff must receive regular 30/09/08 training appropriate to the work that they perform and to enable them to successfully meet the needs of the people living in the home. A system must be established for 31/10/08 reviewing at appropriate intervals and improving the quality of care at the home. The review must include consultation with service users and their representatives. 9 YA39 24 The Annual Quality Assurance Assessment must be completed and returned to the Commission for Social Care Inspection. 31/07/08 7 YA35 18 (c) (i) 8 YA39 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. 1. 2. 3. Refer to Standard YA1 YA20 YA22 Good Practice Recommendations The information in the service users’ guide must be updated so that it accurately reflects the current management and staffing arrangements in the home. Clear procedures should be in place to make sure that people’s medication is regularly reviewed; a record of the date of the review should also be kept. People who live in the home should be reminded about the home’s complaints procedure so that they know how to raise any concerns they may have. Mere Lodge DS0000064385.V368590.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. Extracts may not be used or reproduced without the express permission of CSCI Mere Lodge DS0000064385.V368590.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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