Inspection on 10/11/05 for Mermaid Lodge

This inspection was carried out on 10th November 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mermaid Lodge 21/06/06

Mermaid Lodge 17/01/05

Mermaid Lodge 15/06/04

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

CARE HOME ADULTS 18-65 Mermaid Lodge 68 Brighton Road Lancing West Sussex BN15 8LW Lead Inspector Mr E McLeod Unannounced Inspection 10th November 2005 10:00 Mermaid Lodge DS0000014629.V252750.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 Mermaid Lodge DS0000014629.V252750.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. Mermaid Lodge DS0000014629.V252750.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Mermaid Lodge Address 68 Brighton Road Lancing West Sussex BN15 8LW 01903 763945 01903 763945 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 Nilda Yasuda Dooraree Mr Raj Narsing Dooraree Mrs Nilda Yasuda Dooraree Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Mermaid Lodge DS0000014629.V252750.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st June 2005 Brief Description of the Service: Mermaid Lodge is situated near to the seafront in Lancing, with access to local bus services and shops. The service has been providing a family home type of support for up to three service users with a present or past history of mental health problems. The registered providers Mr and Mrs Dooraree advised at the inspection that, further to rebuilding work which is taking place at the property and the adjacent property, that an application will be made to seek a change in registered numbers. Mermaid Lodge DS0000014629.V252750.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was arranged to follow up recommendations made at the previous inspection, and lasted 2.5 hours. Two of the three residents were interviewed, as were the registered providers and main carers Mr and Mrs Dooraree. A tour of the premises was made, and some policies and procedures, including those on adult protection, were sampled. The inspector would like to thank everyone who contributed to the inspection. What the service does well: What has improved since the last inspection? What they could do better: Adult protection procedures need to be updated to better ensure the care and safety of residents. It is recommended that the registered manager undertake appropriate adult protection training. Mermaid Lodge DS0000014629.V252750.R01.S.doc Version 5.0 Page 6 The providers need to ensure that the environment is safe for residents, and that the home is in compliance with standard 24. The health and safety policies in the home are in need of updating, and the health and safety of residents need to be ensured by compliance with standards 42.2 and 42.3 and the provision of risk assessments. A self-monitoring system based on seeking the views of service users must be provided to measure success in achieving the aims, objectives and statement of purpose of the home. 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. Mermaid Lodge DS0000014629.V252750.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 Mermaid Lodge DS0000014629.V252750.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 Arrangements are in place for the assessment of prospective service users. EVIDENCE: The inspector advised registered manager Mrs Dooraree that there would be a need to update the Statement of Purpose and Service User’s Guide to reflect any changes planned in the service, and that this would form part of any application to vary the registration of the service. As there have been no new admissions to the home in a while, there were no new pre-admission assessments to provide evidence of standard 2 being met or not. The inspector discussed with Mrs Dooraree some of the good practice recommendations contained within standard 2 and their implementation in the service. Mermaid Lodge DS0000014629.V252750.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 Clear care plans are being provided for each resident, and care plans are being regularly reviewed. EVIDENCE: Two sets of care plans were sampled. The care plans set out clearly the resident’s needs and how they will be met. Regular reviews of the care plans are taking place, including medication reviews and reviews under the Care Programme Approach (CPA). Interviews with residents provided examples of how they are being assisted to take decisions and responsibilities, and there was also evidence of this in care plans seen. Mermaid Lodge DS0000014629.V252750.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 16, 17 Residents are being supported with their lifestyles, and supported to exercise choice and independence. EVIDENCE: Residents are being supported to go shopping, remain in contact with family and friends, access health and support services, and further their interests and hobbies. Residents are taking up opportunities to do things in the local community, and being supported to take an interest in the local community. Residents indicated that they have individual choice and freedom of movement, and are receiving support in the way they would prefer. It was observed during the inspection that staff respect the privacy and dignity of residents. Residents said they had a choice in the meals provided, and enjoyed the food. From what residents were saying it was gathered that meals are balanced, nutritious and varied. Mermaid Lodge DS0000014629.V252750.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 The physical and emotional needs of residents are being met. EVIDENCE: Care records and discussions with residents indicated that support is being provided in a caring manner which is assisting the residents to maintain good mental health. It was also evidenced that residents are accessing the health care support they require. Mermaid Lodge DS0000014629.V252750.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Adult protection procedures need to be updated to better ensure the care and safety of residents. EVIDENCE: Procedures seen included action to be taken following a violent incident, and a chart of procedures in the event of an adult protection incident. Procedures seen do not refer to the provider’s responsibility to make appropriate referrals to the protection of vulnerable adults register, or to ensuring there is no contamination of evidence where an investigation will be carried out by police or social services. Procedures should also indicate the need for notification to CSCI under regulation 37 of the Care Homes Regulations 2001, and to advising relevant care managers (for example social workers) and the local duty social work team for adults (social services being the lead agency for adult protection processes). Mermaid Lodge DS0000014629.V252750.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 The providers need to ensure that the environment is safe for residents, and that the home is in compliance with standard 24. EVIDENCE: The premises were undergoing significant interior rebuilding and extension at the time of the inspection, and Mr and Mrs Dooraree said they anticipated that work would be continuing for a further two or three weeks. Mr and Mrs Dooraree advised the inspector of measures being taken to ensure the safety of residents during this interior rebuilding period. On a tour of the premises, Mrs Dooraree advised that there would be changes in the communal areas provided for residents. The providers need to ensure that changes to communal areas continue to comply with standards 24.1, 24.2, 24.3, and 24.6. The providers also need to ensure that the premises continue to meet the requirements advised under standard 24.11. Areas of the home visited which are not part of the interior rebuilding were found to be clean and hygienic, and the toilet, bathing and laundry facilities are continuing to operate as normal. Mermaid Lodge DS0000014629.V252750.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 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): 35 Effective staff support for residents is being provided. EVIDENCE: The main care in the home is being provided by Mr and Mrs Dooraree, and residents interviewed indicated that they have benefited from living in a supportive family environment. Residents indicated that Mr and Mrs Dooraree have a professional attitude, and are accessible, supportive, and knowledgeable. Mrs Dooraree advised that is presently undertaking the registered manager’s award, and that Mr Dooraree has attained NVQ level 3 in care. Mermaid Lodge DS0000014629.V252750.R01.S.doc Version 5.0 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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, 42 It is recommended that the registered manager undertake appropriate adult protection training. The health and safety policies in the home are in need of updating, and the health and safety of residents need to be ensured by compliance with standards 42.2 and 42.3 and the provision of risk assessments. A self-monitoring system based on seeking the views of service users must be provided to measure success in achieving the aims, objectives and statement of purpose of the home. EVIDENCE: The registered manager Mrs Dooraree has trained and worked as a psychiatric nurse, and is now an experienced manager in the residential care of service Mermaid Lodge DS0000014629.V252750.R01.S.doc Version 5.0 Page 16 users with mental health difficulties. Mrs Dooraree said she was presently undertaking the Registered Manager’s Award in care. Mrs Dooraree advised that she has not undertaken recent training in the protection of vulnerable adults, and the inspector recommended that as manager of the service she do so, and ensure the staff team are appropriately trained in adult protection. Mrs Dooraree advised that no progress had been made with putting into place a self-monitoring system which also seeks the views of residents, their family, friends and advocates, and of stakeholders in the community (refer to standard 39.7) on how the service is performing. The health and safety policies in the home are in need of updating, and the health and safety of residents need to be ensured by compliance with standards 42.2 and 42.3, and the provision of the risk assessments advised under standard 42.6. Mermaid Lodge DS0000014629.V252750.R01.S.doc Version 5.0 Page 17 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 3 3 X X X Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X X 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Mermaid Lodge Score X 3 X X Standard No 37 38 39 40 41 42 43 Score 2 X 1 X X 2 X DS0000014629.V252750.R01.S.doc Version 5.0 Page 18 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 YA39 Regulation 24 Requirement The registered person shall establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided in the care home The registered person shall ensure that all parts of the home to which service users have access are so far as reasonably practical free from hazards to their safety. Timescale for action 10/02/06 2 YA42 13.4 07/01/06 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 Refer to Standard YA23 YA24 Good Practice Recommendations Adult protection procedures need to be updated to ensure better protection of residents. The providers need to ensure that the environment is safe for residents, and that the home is in compliance with standard 24. Mermaid Lodge DS0000014629.V252750.R01.S.doc Version 5.0 Page 19 3 YA37 It is recommended that the registered manager undertake appropriate adult protection training. Mermaid Lodge DS0000014629.V252750.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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. 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