Inspection on 07/11/05 for Silverdale

This inspection was carried out on 7th 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Silverdale 23/05/06

Silverdale 25/05/05

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 Mrs Nikki Gibson Unannounced Inspection 7th November 2005 09:30 X10015.doc Version 1.40 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 Maple Lodge DS0000018051.V265795.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 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 DS0000018051.V265795.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Maple Lodge Address 116 Lodge Lane Grays Essex RM16 2UL 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) 01375 396789 01385 396789 Mrs Masarath Jahan Khan Mr Mohamad Ali-Khan, Mr Firasat Ali-Khan Manager post vacant Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places Maple Lodge DS0000018051.V265795.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 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 DS0000018051.V265795.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine, unannounced inspection, which took place over seven hours by two inspectors. Lead Inspector Nikki Gibson was accompanied by Regulation Inspector Pauline Marshall as part of her induction. During the inspection there was a tour of the premises and an inspection of records and documentation. Time was spent talking with residents in the lounge and in their own rooms. Seven residents were spoken to about life at Maple Lodge. No visitors were seen during the inspection. One of the proprietors, the acting manager and four members of staff were also spoken with. The proprietor, acting manager, staff, and residents were most helpful and welcoming and this was greatly appreciated. Discussion of the inspection findings took place with the proprietor, acting manager and senior staff throughout the inspection and guidance and advice was given. What the service does well: What has improved since the last inspection? A part from one report to the Commission for Social Care Inspection from the proprietor on the running of the home there was no evidence that the home had made any progress since the last inspection. All the requirements and recommendations detailed in previous reports remain outstanding. Maple Lodge DS0000018051.V265795.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Maple Lodge DS0000018051.V265795.R01.S.doc Version 5.0 Page 7 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 Outcomes Statutory Requirements Identified During the Inspection Maple Lodge DS0000018051.V265795.R01.S.doc Version 5.0 Page 8 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 the following standard(s): 1, 2, 3, 4, 5 & 6 The admission process does not include a full and comprehensive assessment undertaken by trained staff to ensure the suitability of the home. EVIDENCE: The home’s Statement of Purpose did not include room sizes however, the provider said that both the Statement of Purpose and the Service User Guide were in the process of being updated. On completion copies must be sent to the CSCI. Revised copies should also be provided to present and prospective residents and their supporters. Copies of residents written contracts/statement of terms and conditions were requested from the proprietor who was unable to provide them. Records required by legislation must be made available for inspection. Maple Lodge DS0000018051.V265795.R01.S.doc Version 5.0 Page 9 Three residents files were inspected. All three files inspected contained a Social Worker Assessment and a limited assessment carried out by the home. Prospective residents are assessed by the registered provider. The tick box assessment form used did not cover all the areas required and detailed in Standard 3 of the National Minimum Standards. Some assessments were incomplete. To ensure that residents needs can be met by the home prospective residents must receive a full and comprehensive be assessment conducted by someone trained to do so. Maple Lodge is not registered for people with dementia and the facilities do not lend themselves to this category of care. Staff said that one resident was admitted who did have a diagnosis of dementia, and the proprietor is reminded that this is outside her registration category and therefore an offence. Two staff have undertaken two day training in the care of people with dementia. Due to the lack of training in most other areas of care of the elderly staff, although committed and caring, were unaware of current good practice. Two residents said that they felt sorry for the less able residents as staff get them up very early in the mornings from 6.00 to 6.30 am. The times residents wish to get up should be recorded in their care plans. Staff said that prospective residents were invited to visit the home prior to admission, but this could not be evidenced. Maple Lodge does not provide intermediate care. Maple Lodge DS0000018051.V265795.R01.S.doc Version 5.0 Page 10 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 the following standard(s): 7, 8, 9, 10 & 11 Care Plans are not completed fully and there are no clear instructions to staff on how to meet the personal and social care needs of the residents. Staff do not have up to date appropriate training on administering medication and shortfalls in practice were noted. Residents’ wishes on their death are not recorded. EVIDENCE: A comprehensive document entitled ‘Assessment for Good Care Planning’ was held on each resident’s file. Those inspected varied in quality but none contained clear instructions for staff on the actions to be taken to meet the resident’s health, personal and social care needs. Staff had taken time to fill in various sections and were interested to discuss the shortfalls, however it was clear that staff had not received adequate training on using the booklet. Lack of adequate care planning compromises the homes ability to provide residents with appropriate care in a consistent manner. Residents and/or their supporters had not been involved in drawing up the care plans and had not signed to show agreement. One resident said that she expected that staff had notes about her, but she had never been given opportunity to read or agree them. Maple Lodge DS0000018051.V265795.R01.S.doc Version 5.0 Page 11 Residents’ daily notes showed evidence of health care needs being met, however no record could be provided of GP visits. It was unclear if residents receive adequate access to dentists and opticians. The processes for administering medication were inspected. The staff giving out medication did not have a copy of the Royal Pharmaceutical Society of Great Britain guidelines for ‘The Administration and Control of Medicines in Care Homes and Children’s Services’. A copy can be obtained by contacting 0207 572 2409 or e-mailing: ifearon@rpsgb.org.uk. Senior staff administer medication, however staff records identified that they had not received adequate training. This has been raised at previous inspections and must be addressed to ensure that safe procedures are followed. The home does not have an adequate record of all medication coming into or leaving the home. This prevents them from being able to follow a medication audit. The home’s medication policy stored with the Medication Administration Records (MAR) sheets states that medication not taken is to be discarded, but it did not state how. Staff said that all discarded medication is thrown down the sluice. Staff were also unaware of the correct timescale for keeping medication after the death of a resident. All medication that had been transcribed by hand on to the MAR sheets did not show the quantity or have a signature of the person transcribing. Staff had made changes to some entries without sufficient proof that they had been instructed by the GP. There were protocols in place for medication prescribed ‘as and when required’ (PRN), for clarity the home was advised to identify these as PRN protocols. It was also recommended for safety that photographs of the residents are attached to their medication files. Patient information leaflets for each drug prescribed should be available in the home and the home will need to discuss this with the pharmacist. Medication was kept in a locked filing cupboard from which it was administered. More appropriate storage needs to be considered. A tablet was noted in an open pot in the office, the acting manager said that it had been found on a bedroom floor at the weekend. During the inspection another resident was observed with a pot of pills left in her room. This is further indication of the need for training. Residents spoken with said that staff treat them respectfully and that personal care is given in either their room or in a bathroom. This was observed throughout the day of the inspection. A pay phone for residents was situated in the hallway and staff said that private calls could be taken in the office. Of the three care files inspected, one had information with regard to the wishes of the resident on death and dying. The ‘Assessment of Good Care Planning‘ document has provision for this information but was not completed on any of the three files inspected. Maple Lodge DS0000018051.V265795.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 12, 13 & 15 Activities take place regularly both inside and outside the home. Residents have contact with family and friends and are encouraged to exercise choice and control over their lives. The menu does not offer an alternative choice to the main meal. EVIDENCE: A good variety of activities were listed on the wall of the lounge and an entertainment book showed when these activities occurred, however it did not state who participated and there were no entries since 25/10/05. There was no record of participation in activities in the daily notes. Staff spent some time in the lounge during the morning while residents were singing to old time music. At one time both the television and the radio were on at the same time in the small lounge area which was confusing for all. Residents confirmed that the hairdresser visits the home fortnightly; some residents said their family take them out to the hairdresser. Arrangements are made for residents to receive communion in the home or friends and family take them to local churches. Residents said that visitors were made welcome and that they could use the facilities available. One resident said that she regularly has visits from her friend who brings her dog and they sit in the garden and have refreshments. Maple Lodge DS0000018051.V265795.R01.S.doc Version 5.0 Page 13 The small dining room was clean and comfortable and displayed the menu for the current week; there were no choices of either meal or dessert. Staff said that an alternative was available should anybody want it, however there was no evidence of this in practice. The meal provided at lunchtime was not the meal stated on the menu and no explanation could be given for the change. Sandwiches and cake is provided every teatime which have been prepared before 1.00pm. There is no cook on duty in the evenings and a cooked tea is not offered. One resident said that her family supplemented her choice with tins of salmon. Cereal and toast is offered at breakfast. The proprietor said that fruit or fruit juice is not offered. Residents spoken to on the subject said they would like more choice at meal times. Nutrition records were in separate books for lunch and tea and showed the meal that was offered and the amount residents had eaten. Diabetics were offered fresh fruit as an alternative to a sweet dessert or cakes and biscuits and this was confirmed by the residents and staff. The provision of fruit for all the residents was discussed and the registered provider stated that fruit was expensive and she would expect families to provide it. If this continues to be the case it must be clearly detailed in the residents contract. Staff said that two residents’ food required liquidising and they acknowledged that their policy of mixing it all together made it not very appetising. They said one resident had refused to eat the liquidised meal believing it to be the same meal as the previous day. In line with good practice each item of the meal should be liquidised or mashed separately and presented to the resident in separate piles so that they can enjoy the colour, taste and smell of each item of the meal. Maple Lodge DS0000018051.V265795.R01.S.doc Version 5.0 Page 14 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 the following standard(s): 16 & 18 The home has a detailed complaints procedure, but in practice this is not followed. The staff’s lack of understanding and training in adult protection issues could place residents at risk of possible harm. EVIDENCE: A comprehensive complaints policy is contained in the Statement of Purpose. The homes complaints log was studied. A recent complaint was recorded, however it was unclear how it had been investigated or what the outcome was. To evidence that complaints are treated seriously the homes complaints policy should be followed. A lack of evidence of how complaints have been investigated has been raised with the home previously. A shortened version of the home’s complaints policy is displayed throughout the home. The home has appropriate abuse and whistle blowing policies. However, staff said that apart from referring allegations to the proprietor they were unclear of the correct procedures. None of the staff has attended training regarding the protection of vulnerable adults. This lack of training and understanding regarding allegations or evidence of abuse could potentially jeopardise residents safety and any adult protection investigation. Maple Lodge DS0000018051.V265795.R01.S.doc Version 5.0 Page 15 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 the following standard(s): 21, 22, 23, 24, 25 & 26 Maple Lodge provides the residents with a comfortable and homely environment, however health and safety issues put residents at serious risk of harm. EVIDENCE: The home is situated in a pleasant residential area. It is generally in an adequate decorative state. A broken light fitting exposing electrical contact points was noted in one bedroom and the risk to the resident was pointed out to the acting manager. One bedroom had a children’s nursery border which was not the choice of the resident occupying the room and is not appropriate. It was noted that at the time of the inspection all fire doors were wedged open and this included the laundry and kitchen door. The front door which should be a means of escape in an emergency was locked with a key which was not readily available. These and other poor fire safety arrangements put residents at risk and the home is require to take immediate advice and action to protect the residents. The fire service visited the home recently and a letter dated 6th Maple Lodge DS0000018051.V265795.R01.S.doc Version 5.0 Page 16 September 2005 highlighted sixteen areas of fire safety which has to be addressed. One resident said that the noise of the laundry equipment and staff talking at night disturbed their sleep. However, they did not feel confident to raise this with the staff and reluctant to make a ‘fuss’. There is one lounge and a small dining room for the residents that have domestic lighting and furniture. The dining room provides limited space for all the residents to eat and a notice on the wall reminds staff to move the table away from the fire door between meals. Bathrooms and toilets are clearly marked with pictorial signs. There are two bathrooms with bath hoists. Water temperatures were checked and some hot taps did not provide any warm water and staff said that they carry jugs of hot water to rooms where there is an inadequate supply. In some hand bowls and baths the water temperature was in excess of 50° C. This put residents at risk of scalding and immediate action must be taken. Temperature regulating valves appear to have been fitted, however staff said they did not know how to adjust them. To protect residents the water temperatures need to be checked, recorded and if necessary adjusted on a weekly basis. To prevent the risk of Legionella water should be stored at 60°C, distributed at 50°C and provided 43°C. The home has a hoist which was being charged in the linen store. Consideration needs to given and advice taken as to whether this could be a fire risk. Staff said that they felt they had the equipment they needed for assisting the residents to mobilise. Bedrooms had been personalised. Some carpets were badly stained and the proprietor said that there were plans to replace some of the carpets. It was noted that one bed had a torn sheet and in a ground floor bedroom the curtains were not properly hooked to the curtain pole. Water damage was noted to some wallpaper and there were cobwebs in some rooms. Large suitcases were observed on the top of many wardrobes and some wardrobes felt unsteady. These issues detracted from the homely feel of the premises. Screening in some shared bedrooms did not provide adequate privacy. Lockable metal cabinets with sharp corners were observed in bedrooms. There was no indication that these were used by residents and they posed a hazard to the shins of the staff and residents. More appropriate lockable facilities are recommended. Some windows had appropriate restrictors, however others were locked and provided residents with a lack of choice and limited ventilation. If there is an adequate reason why a particular window has to be locked it should be recorded on the residents care file. In one room the flex to a bedside lamp Maple Lodge DS0000018051.V265795.R01.S.doc Version 5.0 Page 17 was looped across the pillow and headboard posing a risk to the resident. Loose cables should be secured to prevent accidents. A manual sluice is situated in the laundry, which compromises the hygiene of clean laundry. There is a butler sink for washing commode pots and soiled linen but no hand washing facilities in the laundry. The proprietor said this would be addressed when the new extension is built, however no date for commencement of the work has been provided. Protocols and procedures to minimise the risk of spread of infection in the laundry must be drawn up and followed by all staff. Some bathrooms and toilets had no liquid soap or hand drying facilities and others had a communal towel. The proprietor has been informed at previous inspections and recently by Essex Health Protection Agency that this is unacceptable. Staff have become allergic to the powdered latex gloves which has led to skin conditions and alternatives must be provided. All clinical waste was seen to be disposed of in the domestic waste bin. The proprietor must take advice from the local council as to whether this is appropriate. Due to the concerns raised at the inspection an Immediate Requirement form was issued the following day requiring immediate action in relation to fire procedures, infection control procedures, water temperatures and staff recruitment. Maple Lodge DS0000018051.V265795.R01.S.doc Version 5.0 Page 18 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Staff are caring and well meaning however inappropriate staffing levels, poor staff recruitment procedures and lack of staff training put residents at risk. EVIDENCE: There is a stable team of core staff who work well together and want to provide good care. Some have many years experience and are committed to care work with the elderly which they enjoy. However, staffing levels, staff deployment and lack of training comprise their ability to fully meet the needs of the residents. The staffing level agreed with the previous Registration Authority was one senior and two care staff during the day and two awake staff at night with additional staff to cover domestic and catering duties. The proprietor has reduced this level in the afternoon and care staff are also responsible for the evening meal, and cleaning five days a week. These additional duties are inappropriate as they take them away from the care of the residents. The proprietor is required to review the staffing level and the deployment of staff duties and send details to the CSCI for agreement. Staff training was very poor and staff do not have adequate training and qualifications. A staff training record was requested but was not available in the home for inspection. Four staff files were inspected. Two staff had no evidence of any training. Two staff had limited training and some was out of date. For example the moving and handling training certificate stated that it expired in June 2004. The proprietor is asked to provide a staff training matrix Maple Lodge DS0000018051.V265795.R01.S.doc Version 5.0 Page 19 which clarifies which training has been undertaken and when. Plans for future training must also be supplied. None of the staff in the home have the basic NVQ level 2 in care and at present none are actually undertaking the training. It was reported that training that staff have undertaken in the past has been done in their own time. Staff recruitment procedures were very poor and no checks or references were available for the two most recent members of staff to be employed. The proprietor said some records may be available and misfiled however they were not found during the inspection. The proprietor acknowledged that Criminal Records Bureau checks were not in place and she was unaware of the POVA first procedure available when residents would be at risk if staff are not employed quickly. The lack of a robust recruitment procedure put residents at unacceptable risk. The proprietor was unclear as to the induction procedure followed by the home. Adequate records were not available. A tick box induction check list was on one file but had not been completed. A induction booklet was seen on another staff file but had not been used. An experienced member of staff said that she works long side new staff and guides them with their duties. Maple Lodge DS0000018051.V265795.R01.S.doc Version 5.0 Page 20 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37 & 38 The home is without suitable management and the statutory requirements over several years have not been addressed. This has resulted in some practices which do not safeguard the health and safety of the residents. EVIDENCE: The proprietor said that personal and financial problems had adversely affected the running of the home. The proprietor and senior staff showed a lack of knowledge and understanding of the National Minimum Standards and Care Home Regulations. The acting manager who was covering in the sudden absence of the manager was not provided with supernumerary hours. She undertook the management role in addition to her care duties. She had not been delegated authority to make management decisions and was in a difficult position. Maple Lodge DS0000018051.V265795.R01.S.doc Version 5.0 Page 21 The staff are to be commended on their resolve to work together and to continue to work well without appropriate leadership. They were loyal in there comments regarding the home but also showed an interest in the inspection process and accepted guidance and advice. However in most areas they were not in a position to make the changes that were necessary. This lack of management cannot continue and the proprietor must provide the CSCI with her plans for the future of the home. There was no evidence of any quality assurance system in the home and this has been raised at previous inspections. Residents spoken with were generally happy with the care and were complimentary about the staff. However where things were not to their liking or they lacked choice they did not feel empowered to complain. The proprietor acknowledged that the home was having financial problems and she referred to costs on several occasions i.e. in relation to staffing and purchase of fruit. The CSCI has agreed to the conversion of one first floor lounge to a bedroom to provide additional income. If the home has financial problems they need to discuss these with the CSCI. There are plans to extend the home, however there is no date for the work to start and this will need to be very carefully managed to reduce the inconvenience to the residents. The home holds money in safekeeping for some residents and cash and records were inspected. Balances tallied with the cashbooks and the records were clearly recorded. Advice was given to number receipts and have receipts or a signature for deposits. A record of one supervision session was seen on some files. The proprietor said she was unaware that staff should receive regular formal supervision and the recommendation is a minimum of six times a year. Where records were available they were well organised and stored in the office. However, a number of records were not available for inspection some have already been made reference to. The proprietor said some records were at her home, however they were not retrieved and provided for inspection. Health and safety checks on equipment and services were not checked on this occasion. However the lack of moving and handling training, lack of evidence of staff fire practices, poor infection control procedures, very hot water and poor fire safety procedures evidenced that residents health and safety were put at risk. Advice on preventing Legionella can be obtained from the following sources. Booklets Essential information for providers of residential accommodation and A guide for employers are available free for single copies from 01787 881165 or HSE Books, PO Box 1999, Sudbury, Suffolk. CO10 2WA, fax 01787 313995 Website www.hsebooks.co.uk. Maple Lodge DS0000018051.V265795.R01.S.doc Version 5.0 Page 22 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 1 2 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 1 3 1 3 3 1 2 1 STAFFING Standard No Score 27 2 28 1 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 2 1 2 3 2 2 1 Maple Lodge DS0000018051.V265795.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4, 5, 6 Requirement The registered person must keep the Statement of Purpose and Revised copies must be provided to the residents and the CSCI within 28 days. The registered person must not provide accommodation unless the needs of the resident has been fully assessed by a suitably qualified or trained person. The registered person must promote and make proper provision for the health and welfare of residents. This refers to providing staff with appropriate training to meet the specialist needs of the elderly. The registered person must prepare a written plan (“service user’s plan”) with consultation with the resident as to how their needs will be met. It must include clear instructions for staff as to how the care is to be provided. (Previous tome scale of 5.4.05 not met) The registered person must make arrangements for the DS0000018051.V265795.R01.S.doc Timescale for action 14/12/05 2 OP3 14(1) 14/12/05 3 OP4 18(1) 14/12/05 4 OP7 13 14/12/05 5 OP9 13 14/12/05 Maple Lodge Version 5.0 Page 24 6 OP11 12(30 7 OP15 16(2)(1) 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 and ensure that there are adequate medication policies and procedures on place. (Previous timescale of 19.07/04 not met) The registered person must as 14/12/05 far as practicable enable residents to make decisions with respect to the care they receive and their health and welfare, this includes recording their wishes regarding death and dying. 14/12/05 The registered person must provide in adequate quantities, suitable, wholesome and nutritious food, which is varied and properly prepared, and available as may be reasonably required by the resident. This refers to proving a clear choice, adequate fresh fruit and not mixing together liquidised food. The registered person must maintain a record of all complaints about the operation of the home and the action taken. This refers to the need for the home to follow their own complaints policy. The registered person must make arrangements to prevent residents from being abused. This refers to policies and procedures being in place and known to staff and training being provided. (Previous timescale of 31.7.05 not met) The registered person must consult with the fire service and DS0000018051.V265795.R01.S.doc 8 OP16 22(3) 14/12/05 9 OP18 13(6) 14/12/05 10 OP19 23(4) 14/12/05 Page 25 Maple Lodge Version 5.0 11 OP21 23(2)(j) 12 OP24 16 13 OP25 13(4)(a) 14 OP26 13 15 OP27 18(1)(a) take adequate precautions against the risk and spread of fire. The registered person must provide washbasins with a hot and cold supply. This refers to the lack of warn water in some bedrooms. The registered person must provide rooms with appropriate furniture including lockable storage, carpeting without stains, curtaining, unlockable windows, screening and appropriately decorated. (Previous timescale of 31.7.05 for screening not met) The registered person must ensure that all parts of the home are as far as reasonably practicable free from hazards and that unnecessary risks to residents are identified and as far as possible eliminated. Hazards and risks identified at this inspection are: Very hot water Broken light fitting Loose cables Suitcases on unsteady wardrobes Charging hoist battery in linen store The registered person shall make arrangements that the sluice and laundry must be positioned on separate areas with adequate hand washing facilities in each. (Previous timescale of 19.07.05 not met) The registered person must ensure that at all times there are suitably qualified, competent, and experienced persons working at the home in such numbers as are appropriate for the health and welfare of the DS0000018051.V265795.R01.S.doc 14/12/05 14/12/05 14/12/05 14/12/05 14/12/05 Maple Lodge Version 5.0 Page 26 residents. Staffing levels must be reviewed and details sent to the CSCI for agreement. The registered person must 14/12/05 ensure that robust recruitment procedures are in place and applied consistently. Records required by regulation in respect of staff recruitment must be obtained prior to a staff starting work. The registered person must 14/12/05 ensure that staff receive training appropriate to the work that they perform. A copy of staff training records to be sent to the CSCI The registered provider must ensure that a home is managed by someone sufficient training and skill. They must be allocated appropriate hours and undertake relevant training. (Previous timescale of 19.7.04 not met) The registered person must ensure that there is a quality assurance system, which involves feedback from service users, their relatives and/or representatives and other professionals. (Previous timescale of 19.7.04 not met) The registered provider must carry on the home in such a manner as to ensure it will be financially viable for the purpose of meeting its aims and objectives. The registered person must ensure that the records requires by legislation are maintained and are available for inspection. The registered person must DS0000018051.V265795.R01.S.doc 16 OP29 Schedule 2 17 OP30 18(1)(c) 18 OP31 9 & 10 14/12/05 19 OP33 24 14/12/05 20 OP34 25(1) 14/12/05 21 OP37 Schedule 4 13 (4) 14/12/05 22 OP38 14/12/05 Page 27 Maple Lodge Version 5.0 ensure that risks are identified and so far as possible eliminated. This refers to risks related to risks related to moving and handling, fire, infection and hot water. 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 4 5 6 7 Refer to Standard OP2 OP5 OP9 OP28 OP31 OP32 OP36 Good Practice Recommendations Each resident should have a contract and this should be readily available for inspection. The home should be able to demonstrate that prospective residents have to opportunity to visit the home. The manager should obtain a copy of The Royal Pharmaceutical Society’s guidelines on administration and control of medication in a care home. A minimum of 50 of care staff to obtain NVQ level 2 or equivalent. 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. Maple Lodge DS0000018051.V265795.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection South Essex Local Office Kingswood 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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