Inspection on 25/05/05 for Silverdale

This inspection was carried out on 25th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Silverdale 23/05/06

Silverdale 07/11/05

Silverdale 09/02/05

Silverdale 19/07/04

Silverdale 14/01/04

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 HOMES FOR OLDER PEOPLE Maple Lodge 116 Lodge Lane Grays Essex RM16 2UL Lead Inspector Ron Reeves Unannounced Wednesday 25th May 2005 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 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 Older People. 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. Maple Lodge I56-I06 S18051 Maple Lodge V228270 250505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Maple Lodge Address 116 Lodge Lane Grays Essex RM16 2UL 01375 396789 01385 396789 Telephone number Fax number Email 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 Massarath Jahan Khan Ms Talath Khan CRH Care Home 14 Category(ies) of OP Old Age (14) registration, with number of places Maple Lodge I56-I06 S18051 Maple Lodge V228270 250505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate 14 persons of either sex who only fall within the category of Old Age. Date of last inspection 9th Feb 2005 Brief Description of the Service: Maple Lodge provides personal care and accommodation for up to14 older people. The home has applied to become registered for dementia and this is currently being processed by the CSCI. The home has eight single bedrooms and three shared rooms. Three of these having private en-suite facilities. Each bedroom has a call bell facility and a TV point. The home also has a passenger shaft lift.The home is furnished, equipped and maintained to a good standard and bedrooms are personalised. There is a large garden area at the rear and planning permission is being sought for an extension to improve facilities on offer and if it goes ahead will increase the number of service users that the home can admit. The home is in a residential area, close to Grays Town and Lakeside Shopping Centre. Maple Lodge was registered in 1992 and is a private home. The proprietors are closely involved with the day-to-day running of the Home. Maple Lodge I56-I06 S18051 Maple Lodge V228270 250505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced Inspection that took place on the 25th May 2005 lasting 6 hours. The inspection process included discussion with the proprietor and senior carer on duty, 6 residents, 3 staff and 2 visiting relatives: a tour of the building and inspection of a sample of policies, procedures and records. What the service does well: What has improved since the last inspection? 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. Maple Lodge I56-I06 S18051 Maple Lodge V228270 250505 Stage 4.doc Version 1.30 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Maple Lodge I56-I06 S18051 Maple Lodge V228270 250505 Stage 4.doc Version 1.30 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1-5 The admission process is well managed and service users are given sufficient information and the opportunity to visit the home in order to make inform choices. EVIDENCE: The home has a well-developed Statement of Purpose, however it did not include room sizes. The home’s statement of terms and conditions contained all the information required. Care plans seen evidenced a full assessment carried out and also contained a Social Worker assessment. Visiting relatives said they had seen the care plans and felt the home was meeting their relative’s needs. The home benefits from a core group of staff that have worked in the home for many years. Visiting relatives said they were always made welcome. Prospective service users are invited to visit the home and encouraged where possible to spend a day in the home before making a decision. Maple Lodge I56-I06 S18051 Maple Lodge V228270 250505 Stage 4.doc Version 1.30 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7-10 Service users personal and health care needs are being met. Service users are treated respectfully, maintaining their privacy and dignity. The home must pursue accredited medication training and obtain current guidelines. EVIDENCE: Care plans need further development to ensure instructions to staff are clear and comprehensive. Good use is made of local health resources. Medication was generally seen to be appropriate. However the home did not have a copy of the Royal Pharmaceutical Society’s guidelines and an up to date version of the British National Formula Training for medication administration is carried out in house. However there was no evidence of staff undertaking recognised accredited training. There were no protocols in place for the administration of medication prescribed as and when required (PRN). Residents spoken with said staff treat them respectfully and personal care is provided in their own bedrooms or in the bathrooms. However in one shared bedroom screening was not appropriately positioned to ensure complete privacy. Maple Lodge I56-I06 S18051 Maple Lodge V228270 250505 Stage 4.doc Version 1.30 Page 9 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13,15 Maple Lodge encourages residents to maintain contact with their family and friends. The home provides a good quantity and quality of food, providing a well balanced diet, which met individual needs. EVIDENCE: Activities are held every morning and residents are encouraged to participate. Visitors are made welcome at any time and visiting relatives commented that they are always made welcome and enjoyed the relaxed homely atmosphere and friendliness of the staff. Services users were unanimous in their praise for the food provided by the home. Although only one choice of main meal the cook said that alternatives can be provided. Maple Lodge I56-I06 S18051 Maple Lodge V228270 250505 Stage 4.doc Version 1.30 Page 10 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16-18 Staff’s lack of knowledge of adult protection issues could place residents at possible risk of harm. EVIDENCE: No complaints have been received since the last inspection. The home has an appropriate complaints procedure. A brief complaints procedure is displayed around the home. All residents are included in the local voters register and those wishing to generally choose to have a postal vote. There was no information regarding advocacy services. The home has appropriate abuse and whistle-blowing procedures. Staff said they were not conversant with the adult protection procedures but were aware of whistleblowing. No member of staff has attended training regarding the protection of vulnerable adults. The lack of understanding regarding allegations or evidence of abuse could potentially jeopardise residents safety and any adult protection investigations. Maple Lodge I56-I06 S18051 Maple Lodge V228270 250505 Stage 4.doc Version 1.30 Page 11 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19-21,23-26 The home generally provides a comfortable standard of accommodation for the residents, although there are some issues regarding the laundry which require improving. EVIDENCE: The home is generally in a good decorative state and accessible to the residents. There is a pleasant garden accessible to the residents to the rear. The proprietor has received planning permission for an extension to the premises to provide additional bedrooms and communal space. There is sufficient communal space for the present size of the home and provision of bathrooms and toilets meet current standards although floor covering in one bathroom requires replacing. A sample of bedrooms revealed they were well furnished and contained personal items brought into the home by the residents. Privacy curtains in one bedroom were not appropriately positioned. Laundry facilities are combined with sluice room and did not contain a wash hand basin. This will be addressed when the new extension is built. Maple Lodge I56-I06 S18051 Maple Lodge V228270 250505 Stage 4.doc Version 1.30 Page 12 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27-30 Staff at the home are conscientious and provide a good standard of care for the residents. Staff recruitment and staff training processes require further development. EVIDENCE: The staff rota indication staffing levels are being maintained to meet residents needs. The home benefits from a core group of experienced staff who are fully aware of the service users needs. No care staff has achieved NVQ2 and none are undergoing NVQ training although staff spoken with said they were keen to undertake NVQ training. Of the two staff files examined during the inspection, one did not contain photographic evidence and the other did not contain any references. Service users spoken with were complimentary regarding the staff and the way they were cared for. One said “the staff are really lovely, kind and helpful. A visiting relative said “its like a hotel, anything you ask they always do”. Maple Lodge I56-I06 S18051 Maple Lodge V228270 250505 Stage 4.doc Version 1.30 Page 13 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36,37, 38 It was not possible to fully assess the managers performance. However, it was evident that staff were able to ensure that residents received a consistent quality of care. There are issues involving staff supervision and training that will require the manager’s attention on return from annual leave. EVIDENCE: The manager returned to the home on 1st March 2005 but was on holiday at the time of the inspection. Staff spoken with were complimentary regarding the manager and the support they received. A number of records were studied during the inspection and were found to be generally well maintained and any shortfalls referred throughout this report. Staff supervision was not inspected in detail. However, staff said they do receive supervision but not regularly. Regular health and safety checks are being maintained and safety certificates obtained for services and equipment. Maple Lodge I56-I06 S18051 Maple Lodge V228270 250505 Stage 4.doc Version 1.30 Page 14 The home has not implemented a quality assurance system at the home, monthly visits are not being recorded and submitted by the proprietor, although she stated she is in daily contact with the home. Maple Lodge I56-I06 S18051 Maple Lodge V228270 250505 Stage 4.doc Version 1.30 Page 15 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 2 3 3 2 x 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 2 x x 2 x x 2 3 3 Maple Lodge I56-I06 S18051 Maple Lodge V228270 250505 Stage 4.doc Version 1.30 Page 16 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 7 Regulation 13) Requirement Timescale for action 5.8.05 2. 9 13 and18 3. 19 13 The Registered Person must ensure that care plans must contain clear action plans for staff to follow. 5.8.05 The registered person must make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the home. They must therefore ensure that the persons employed at the home receive suitable training appropriate to the work they are to perform, ensure there are adequate medication policies and procedures in place and that there are clear guidelines for staff to follow. This is a repeat requirement. The registered person shall make On-going arrangements that the sluice and laundry must be positioned in separate areas with adequate hand washing facilities in each. This is a repeat requirement The manager must manage the care home with sufficient care, competence and skill and must be allocated appropriate hours 5.8.05 4. 31 9 and 10 Maple Lodge I56-I06 S18051 Maple Lodge V228270 250505 Stage 4.doc Version 1.30 Page 17 5. 33 24 and undertake relevant training. This is a repeat requirement that was not fully investigated at this inspection due to the abscence of the manager.and will addressed at the next inspection. . The Registered Person must 5.8.05 ensure that there is a quality assurance system, which involves feedback from service users, their relatives and/or representatives and other professionals. This is a repeat requirement. The registered provider must visit the home at least once a month in line with this regulation and must supply a copy of the report to the Commission for Social Care Inspection’s office. This is a repeat requirement. Staff must receive training appropriate to the work they are to perform. This includes training in Protection of Vulnerable Adults and medication administration. The registered person must ensure that residents privacy and dignity is respected at all times. This includes provision of suitable privacy curtains in shared rooms. The home must be kept in a good state of repair. This includes replacing floor covering in one bathroom. 5.8.05 6. 33 26 7. 18(1) 18 Action plan required by 31/7/05 8. 12(4) 24 31/7/05 9. 23(2) (b) 21 31/7/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Maple Lodge I56-I06 S18051 Maple Lodge V228270 250505 Stage 4.doc Version 1.30 Page 18 No. 1. Refer to Standard 9 Good Practice Recommendations The manager should obtain a copy of The Royal Pharmaceutical Society’s guidelines on administration and control of medication in a care home and a current copy of the BNF. A minimum of 50 staff obtain NVQ level 2. The Manager should obtain NVQ Level 4 in Management and Care. Regular staff meetings are held and are recorded. Staff should be supervised at least six times per year including the manager. 2. 3. 4. 5. 28 31 32 36 Maple Lodge I56-I06 S18051 Maple Lodge V228270 250505 Stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection Kingwoods House Baxter Avenue Southend-On-Sea Essex, SS2 6BG 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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