Care Home: George Mason Lodge

What the care home does well This is a very well run service, providing high levels of care and support to service users. People who use the service spoken to expressed satisfaction with the home, one commenting that "It`s very good here, the staff are all kind." Service users are able to have control over their daily lives, and care planning within the home was of a very good standard. Health and safety management takes place as appropriate, and the home has taken steps to ensure that all medications are administered correctly. The home was well maintained, and service users have been able to personalise their bedrooms to their own individual tastes. Indeed, there was evidence that the home seeks to meet the needs of service users as individuals, and to meet their needs around equalities and diversity issues. The staff and management demonstrated a good understanding of their roles and responsibilities, and of the needs of service users. What has improved since the last inspection? There have been improvements to the home since the last inspection, and the inspector was pleased to note that three of the four requirements set at the last inspection were found to have been met. In particular, the home was able to evidence that it now carries out all appropriate pre employment checks for staff, including an enhanced Criminals Record Bureau (CRB) check. The Statement of Purpose now contains accurate and up to date information, and clear records are now maintained of all medical appointments. What the care home could do better: Only two requirements have been made in this report. The home must ensure that sluice rooms containing soiled continence pads are kept locked, and that foodstuffs within the home are stored and used appropriately. CARE HOMES FOR OLDER PEOPLE George Mason Lodge Chelmsford Road Leytonstone London E11 1BS Lead Inspector Rob Cole Unannounced Inspection 16th January 2008 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 George Mason Lodge DS0000036539.V356937.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 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. George Mason Lodge DS0000036539.V356937.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service George Mason Lodge Address Chelmsford Road Leytonstone London E11 1BS 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) 020 8539 0218 020 8556 4599 peter.stanley@soc.lbwf.gov.uk London Borough of Waltham Forest Mr Peter Kenneth Stanley Care Home 41 Category(ies) of Dementia (17), Dementia - over 65 years of age registration, with number (17), Mental disorder, excluding learning of places disability or dementia (8), Mental Disorder, excluding learning disability or dementia - over 65 years of age (8), Old age, not falling within any other category (25) George Mason Lodge DS0000036539.V356937.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The 9 bedded intermediate care unit can accommodate OP, DE(E) and DE 60 years. 18th September 2006 Date of last inspection Brief Description of the Service: George Mason Lodge is a registered care home for older persons situated in the Leytonstone area of the London Borough of Waltham Forest. The home is run by the Local Authority. The home also includes the provision of a nine bedded intermediate care facility that was set up in March 2003 to provide a period of short term rehabilitation, using specialist occupational and physiotherapy interventions to a similar group of service users. In addition to the Intermediate Care Unit, the home has two residential units, one dementia unit and one mental health unit. The current range of fees charged by the home is between £566 and £621 per week. George Mason Lodge DS0000036539.V356937.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 3 stars. This means the people who use this service experience excellent quality outcomes. This inspection took place on the 16/01/08 and was unannounced. The inspector had the opportunity of speaking with service users, their relatives, staff from the home and the homes manager was present throughout the day of the inspection. The inspection also included an examination of records and other documents, along with a tour of the premises. The inspector was able to observe staff interaction with service users, which helped to form judgements about the care and support provided. The home completed an Annual Quality Assurance Assessment (AQAA) prior to this inspection at the request of the CSCI, and this was used as part of the overall inspection process. An Expert by Experience was also used during the course of this inspection, with the aim of ensuring the views and experiences of those people who live in the home would be understood and reflected within this report. Parts of this report have been written by the Expert by Experience, along with some of the good practice recommendations. These sections are written in bold type. The home is a well run friendly establishment and the minor short falls can easily rectified with some fine tuning. What the service does well: What has improved since the last inspection? George Mason Lodge DS0000036539.V356937.R01.S.doc Version 5.2 Page 6 There have been improvements to the home since the last inspection, and the inspector was pleased to note that three of the four requirements set at the last inspection were found to have been met. In particular, the home was able to evidence that it now carries out all appropriate pre employment checks for staff, including an enhanced Criminals Record Bureau (CRB) check. The Statement of Purpose now contains accurate and up to date information, and clear records are now maintained of all medical appointments. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. George Mason Lodge DS0000036539.V356937.R01.S.doc Version 5.2 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 George Mason Lodge DS0000036539.V356937.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 and 6. People who use this service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that the home provides people who use the service with sufficient information to enable them to make an informed choice as to move in to the home or not. This information is provided through written documentation, and by the opportunity of visiting the home. EVIDENCE: The home has a Statement of Purpose in place, this is written in plain English. This has been reviewed since the last inspection, and now all information is accurate and up to date. The Statement includes details of the staff team and their qualifications, the facilities and services provided and of the George Mason Lodge DS0000036539.V356937.R01.S.doc Version 5.2 Page 9 organisational structure. The Statement also includes individual sections on the mental health unit, the dementia unit and the intermediate care unit (ICU). All service users (or their relatives where appropriate) are provided with a welcome pack on moving into the home. This includes a colour brochure briefly outlining the facilities and services provided by the home, a copy of the Service User Guide and a copy of the Local Authorities adult protection procedure. This is provided in an easy to read version, which helps to meet service users equalities and diversity needs around disability and ageing. The Service User Guide includes a description of the physical environment, a summary of the Statement of Purpose, and a copy of the homes complaints procedure, and is in line with National Minimum Standards (NMS). The home has an admissions procedure, this makes clear that prospective service users and their relatives will be given the opportunity of visiting the home before making a decision as to move in or not. Service users spoken to during the course of the inspection confirmed that this was indeed the case. Service users initially move in on a six week trial basis, after which a placement review meeting is held, which is attended by the service user, their next of kin, their social worker and staff from the home. Comprehensive pre admission assessments are carried out for all prospective people who use the service to establish whether the home would be able to meet their needs. In the ICU an assessment is made by a physiotherapist around any therapy needs, and a separate assessment is carried out by a member of the care staff around any other needs. For the rest of the home, an assessment is carried out by a social worker, and again, a member of the homes care/management staff will carry out an assessment. Assessments cover needs around medication, mobility, mental health needs, social and leisure needs and equality and diversity needs. There was evidence that the home is able to meet the collective and individual needs of service users. As stated, comprehensive pre admission assessments are carried out, and care plans are based on these assessments. Staff in the various units demonstrated a good understanding of their roles and responsibilities, and it was clear that care is provided to service users on an individual basis, for example one service user is provided with talking books due to their sight impediment, and they are able to choose which books to order. All service users are provided with a written contract/statement of terms and conditions, which they sign. Contracts include details of fees payable, what they cover and what is not covered by the fees. The home has a dedicated nine bedroom ICU. Service users stay here for a period of approximately six weeks after been discharged from hospital, before moving back to their homes. Occupational therapy and physiotherapy staff George Mason Lodge DS0000036539.V356937.R01.S.doc Version 5.2 Page 10 provide therapeutic support, and care staff also work in the unit. The home has a designated therapy treatment room for the use of the ICU. The ICU was clean, tidy and well decorated. All service users have their own ensuite bedrooms, which are decorated to a good standard. Service users spoken to in the ICU expressed high levels of satisfaction with the care and support received, one commented that “It’s like a home from home.” George Mason Lodge DS0000036539.V356937.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11. People who use this service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home is able to meet the health and personal care needs of people who use the service. Personal care procedures help to promote and develop service users independence and dignity, while the medication procedures are comprehensive and designed to reduce the risk of any errors occurring. EVIDENCE: Individual care plans are in place for all service users. These are of a very good standard, and have been developed considerably since the last inspection. Care plans are clear, comprehensive and easy to understand. Care plans are based on the initial assessments of service users, and are reviewed on a monthly basis. Daily logs are also maintained, which are based around the care George Mason Lodge DS0000036539.V356937.R01.S.doc Version 5.2 Page 12 plans. Care plans consist of a strengths and needs analysis, a day care plan, a separate night care plan and a life history which helps to provide staff with a fuller picture of the individual and of their past life experiences. Plans cover needs around health, mobility, personal care, social and leisure needs and needs around equalities and diversity issues such as religion and ethnicity. Plans have been drawn up with the involvement of the service users. Comprehensive risk assessments are in place for all people who use the service, which are again subject to regular review. The AQAA supplied by the home makes clear that service users are able to take risks, but that the home seeks to manage and reduce any risks as much as possible. Assessments included risks around falling, mobility and mental health issues. Service users needs around personal care are clearly recorded in their care plans, and these make clear that service users are supported to manage their own personal care as much as possible to help promote and develop independence and dignity. To help promote service users needs around equalities and diversity, the home ensures that only female staff provide support with personal care to female service users. The homes laundry system helps to ensure that service users are only ever given their own clothes to wear, and on the day of inspection all service users were appropriately dressed. Staff were observed to knock and wait before entering any bedrooms. The home has sought the views of service users on their wishes in the event of their death, and this forms part of their care plan. The AQAA supplied by the home states that service users are able to remain in the home with a terminal illness, so long as the home can meet their medical needs, and that the home supports relatives and friends to be as involved as much possible in these circumstances. All service users are registered with a GP, and service users are able to retain the GP they had prior to admission where practical. The home routinely carries out health related checks, for example checking service users weight, and checking sensitive skin areas for evidence of any pressure sores. It was positively noted that no service users had any pressure sores at the time of inspection. The inspector was pleased to note that since the last inspection the home now keeps clear records of medical appointments, including details of any follow up action necessary. Records evidenced that service users have access to health care professionals as appropriate, including dentists, opticians and psychiatrists. The home seeks advice from the Continence Advisory Service, and used continence products are disposed of appropriately. The home has a comprehensive medication policy in place, and only staff that have received training are able to administer medications. Medications are stored in locked secure cabinets on each unit, and in a designated medication fridge which is kept locked, the temperature of which is checked daily. The home has implemented systems to help ensure that medications are George Mason Lodge DS0000036539.V356937.R01.S.doc Version 5.2 Page 13 administered appropriately, and to reduce the risk of errors occurring. All medications are thoroughly checked for any service users either returning from hospital or been first admitted from hospital. Medication is always administered by two staff, who check on each other to make sure it is administered correctly. Records are maintained of any medications entering the home, and of those medications that are returned to the pharmacist. The supplying pharmacist visits the home every six months to carry out an inspection of the medication practices and procedures. Medication Administration Record charts are maintained. Those checked by the inspector were all accurate and up to date. George Mason Lodge DS0000036539.V356937.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspector’s judgement that people who use the service are supported to live valued and fulfilling lives, and that they have a large measure of control over their daily lives. However, the home must ensure that all foodstuffs are stored appropriately. EVIDENCE: The home arranges various social and leisure activities. An activities programme was on display within the home, planned events included bingo and sing-a-longs, on the day of inspection the home had arranged a coffee morning. This was well attended, and service users appeared to be enjoying it. The home is temporarily employing someone in the role of an activities coordinator, and the manager informed the inspector that the home is considering appointing a permanent activities coordinator, and this is recommended. Professional entertainers visit the home once a month, and again this is advertised within the home. Occasional day trips are arranged, for George Mason Lodge DS0000036539.V356937.R01.S.doc Version 5.2 Page 15 example to London Zoo. Service users have access to TV and music, and the home has a large screen TV on which films are sometimes shown. The home seeks to meet service users needs around religion, thus helping to meet their needs around equalities and diversity issues. The AQAA supplied by the home states that representatives form the Church of England, the Pentecostal Church and the Seventh Day Evangelists all visit the home regularly, and that service users are also able to visit a place of worship if they choose to. Visitors are welcome at any reasonable time, and service users can see visitors in private if they so wish. Service users are able to go out with relatives if they wish. Relatives spoken to during the course of the inspection expressed satisfaction with the level of care and support provided, one commented that “Mum seems very happy here.” Through observation and discussion there was evidence that service users have a large measure of control over their daily lives, for example when to get up, go to bed, what to wear etc. Regular service user meetings are held, which give service users the opportunity to discuss any issues of interest or concern, for example around activities or menus. When bedrooms are decorated, service users are provided with the opportunity of been involved in choosing new décor. Records are kept of menus, these evidenced that people who use the service are offered a varied, balanced and nutritious diet. On the day of inspection there was a choice of a chicken dish or sausages, both looked appetizing, and service users spoken to said that they enjoyed the food. The kitchen was clean and tidy, and all staff involved in food preparation have undertaken training in food hygiene. The home employs designated cooking staff. Records are maintained of fridge and freezer temperatures. However, several items of foodstuffs stored in the kitchen and food store were found to have expired past their best before dates, and several cartons of fresh cream were found to be stored in the food store, although they were clearly marked “keep refrigerated”. To help ensure that all food served is safe, it is required that all foodstuffs are stored appropriately, and that they are used within their marked timescales for use. I had the lunch with some residents in one of the dining rooms. The food was hot and served with a smile by carers. There were no serviettes and I saw several residents wipe their lips with handkerchiefs. Paper serviettes should be available. The Expert by Experience talked to several service users and staff, the following are a selection of quotes from service users. “Everything is fine, I am happy here.” George Mason Lodge DS0000036539.V356937.R01.S.doc Version 5.2 Page 16 “Staff are very friendly and helpful” “Very good. Food is marvellous. Carers are very good. Can’t improve anything.” “Food is not too bad. Comfortable. No problems with the staff.” “Very nice here. I’ve been here a year and everything goes alright.” “You never get the same carer twice.” The following are a selection of quotes from staff interviewed. “I’ve been here for 15 months, I am really happy and studying for my NVQ.” “I have been here for three years, I am happy with the organisation. The manager frequently comes to have a look at us.” George Mason Lodge DS0000036539.V356937.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspector’s judgement that the home has taken reasonable steps to help ensure that people who use the service are protected from the risk of abuse, through appropriate procedures and staff training. EVIDENCE: The home has a complaints log, this indicated that any complaints received have been recorded and investigated appropriately. There is a complaints procedure in place. All service users are given their own copy of this, and a copy was on display within the home. The procedure includes timescales for responding to any complaints received, and contact details of the CSCI. People who use the service spoken to demonstrated a good understanding of whom they could complain to if they so wished. The home is run by the Local Authority, and has a copy of the Local Authorities adult protection procedures. Service users are all given their own easy to read version of this procedure. All staff working at the home are expected to undertake adult protection training, and staff spoken to demonstrated a good understanding of their roles and responsibilities with regard to adult protection. There was evidence that service users legal rights are protected, for example George Mason Lodge DS0000036539.V356937.R01.S.doc Version 5.2 Page 18 the AQAA states that service users are on the electoral register, and service users spoken to during the course of the inspection confirmed that they are able to vote in elections. George Mason Lodge DS0000036539.V356937.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector believes that physically the home is suitable to meet its stated purpose. People who use the service have adequate communal and private space, and the home was generally well maintained and domestic in character. EVIDENCE: The home is situated in the Leytonstone area of the London Borough of Waltham Forest, close to shops, transport networks and other local amenities. The home is built over three floors; service users are accommodated on all three floors. The home was generally well maintained. George Mason Lodge DS0000036539.V356937.R01.S.doc Version 5.2 Page 20 The home provides adequate communal sitting and recreational space for people who use the service, consisting of sitting rooms, dinning areas and a well maintained garden with appropriate garden furniture. The home has a designated smoking area. The home was generally clean and tidy, and furniture was well maintained and domestic in character. Decoration throughout the communal areas was of a good standard. The home has suitable bathing and toilet facilities to meet service users needs. These are situated throughout the home with locks fitted, which include an emergency override device. Many of the baths are adapted to make them accessible to service users with mobility issues, thus helping to meet their needs around equalities and diversity. On the day of inspection bathrooms and toilets were clean, tidy and free from offensive odour. All bedrooms in the ICU are ensuite. The inspector checked several service users bedrooms, all of which were clean, tidy and free from offensive odours. Bedrooms were decorated to service users personal tastes, with family photographs much in evidence. Rooms had adequate furniture, including wardrobes and chest of draws. Bedding, carpets and curtains were well maintained and domestic in character. Bedrooms meet National Minimum Standards on size requirements. All bedrooms have central heating, and radiators all have appropriate protective covering. Lighting in rooms is domestic in character, and there is emergency lighting situated throughout the home. Bedrooms have adequate natural light and ventilation. The home has a policy in place on infection control. There are sluice rooms on all floors, and used continence products are disposed of in a macerator. However, on the day of inspection the sluice room on the second floor unit was found to be unlocked, and containing used continence products. At the last inspection a sluice room was found unlocked, and a requirement was made against this, this requirement is repeated in this report. Protective clothing such as gloves and aprons are available for staff. The home employs designated laundry staff, and the laundry room was well maintained, with an impermeable floor covering. Hand washing facilities are situated within the laundry room, and throughout the home. George Mason Lodge DS0000036539.V356937.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspector’s view that the home is staffed in sufficient numbers to meet the needs of people who use the service, and that staff have a good understanding of their roles and responsibilities, and that they are suitably qualified and experienced. EVIDENCE: The home provides 24-hour support, including waking night staff and an emergency on-call procedure. There was a staffing rota, this accurately reflected the staffing situation on the day of inspection, and clearly identified who was in charge of the home at any given time. As well as care staff, the home employs designated cooking, domestic, therapeutic, administrative and management staff. Through observation and discussion there was evidence that staff have a good understanding of their roles and responsibilities, and of the individual and collective needs of the people who use the service. For example, staff are provided with training relevant to the unit they work on, so that staff on the George Mason Lodge DS0000036539.V356937.R01.S.doc Version 5.2 Page 22 dementia unit have had training around dementia, while staff on the mental health unit have had training around understanding mental health needs. Staff were observed to interact with service users in a friendly and respectful manner, and were seen to have good ability to communicate with service users, some of whom have complex communication needs. The inspector observed frequent examples of positive staff interactions with service users, including dancing, and helping service users solve some anagram puzzles, an activity that the service users were seen to be enjoying. One service user said of the staff “They are very good here.” All staff have been provided with a copy of their job description and of the General Social Care Council codes of conduct. The home has various employment related policies in place, for instance on equal opportunities, disciplinary and grievance and recruitment and selection. At the previous inspection it was found that the home did not have CRB checks in place for all staff, and a requirement was made around this. The inspector was pleased to note that this has now been addressed, and enhanced CRB checks have now been carried out for all staff working in the home. The home was also able to evidence that it has completed all other necessary employment checks on staff, including obtaining proof of ID and references. All new staff undertake comprehensive induction training within the first six weeks of their employment. This covers the principles of care, understanding the organisation and the role of the worker, understanding the needs of the service user and health and safety. Training is on going for staff, and records are maintained of staff training. Recent training has included manual handling, first aid, dementia, fire safety, food hygiene and understanding diabetes. 94 of care staff working in the home have successfully achieved an NVQ Level 2 in care or equivalent qualification, well above the 50 required by the NMS. The AQAA also indicated that three more staff are currently working towards such a qualification. I used one of the toilets and was impressed. There was no obnoxious smells and the toilet and wash basin were spotlessly clean. The water was hot, and the soap and towel dispensers were full. George Mason Lodge DS0000036539.V356937.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37 and 38. People who use this service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspector’s judgement that this is a very well managed home. The manager has many years experience, and is well supported by the rest of the senior staff team. EVIDENCE: The manager has many years experience of working in social care, including several years in a managerial capacity. They have achieved appropriate George Mason Lodge DS0000036539.V356937.R01.S.doc Version 5.2 Page 24 qualifications in both care and management. They are supported in the running of the home by a deputy manager and an acting senior support worker. People who use the service, staff and relatives all informed the inspector that the found the manager to be accessible and approachable, and staff were observed to interact with the management staff in a relaxed manner during the course of the inspection. The manager presents as having a dedicated and flexible approach to their duties. For example, a recent relatives survey has suggested that the manger should hold occasional surgeries in the evenings, when it is easier for relatives to visit the home, and the manager informed the inspector that they plan to introduce this. There was evidence that the manager and the home have built up good relations with social and health care professionals. Through the way the home seeks to meet the needs of service users as individuals, for example through food, religion and activities etc, it was evident that the manager is committed to equal opportunities within the home. Care plan reviews, staff appraisals and staff meetings all contribute to the quality assurance within the home, as do the medication inspections by the home’s supplying pharmacist. Copies of previous inspection reports are available to view in the home, and there was evidence of monthly unannounced Regulation 26 visits taking place. It was positively noted that the home makes use of advocacy services to support people who use the service feeding back on the quality of care and support that they receive, and questionnaires are also sent to relatives. Feedback from relatives surveys was generally very positive, one relative commented that “I always find the staff helpful and polite, the premises clan and bright.” Record keeping in the home is of a god standard. Confidential records are stored securely, staff and service users can access their records as appropriate. The home has all relevant policies and procedures in place in line with NMS. Those checked by the inspector, including the Statement of Purpose, the admissions procedure and the complaints procedure were seen to be satisfactory. To help ensure that services users are not at risk from financial abuse, any monies held on behalf of service users are kept in a locked safe, and only a very limited number of staff have access to this. Records and receipts are maintained of any financial transactions involving service users monies. The AQAA supplied by the home states that all staff receive regular formal one to one supervision. Staff spoken to by the inspector confirmed that this was indeed the case, and that supervision included discussions on health and safety, training needs and service user issues. In addition to formal supervision, all staff also have an annual appraisal of their performance and development needs. George Mason Lodge DS0000036539.V356937.R01.S.doc Version 5.2 Page 25 The home has various health and safety related polices in place, including on infection control, fire safety and first aid. Staff undertake health and safety training as appropriate, for example on food hygiene and manual handling. Fire extinguishers were situated around the home, these were last serviced in June 2007. Fire exits were clearly marked, and free from obstruction. Fire alarms are tested weekly, and the home holds regular fire drills. The fire alarms were last serviced on the 19/9/07. The home has a comprehensive fire risk assessment in place. Emergency lighting, hydraulic lifting equipment and the service lift are all serviced as appropriate. The home has in date safety certificates for gas safety, PAT testing and electrical installation. Hot water and fridge/freezer temperatures are checked regularly. The home has in date employer’s liability insurance cover in place. George Mason Lodge DS0000036539.V356937.R01.S.doc Version 5.2 Page 26 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 3 3 3 4 3 4 HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 4 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 X 3 3 3 4 George Mason Lodge DS0000036539.V356937.R01.S.doc Version 5.2 Page 27 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 OP26 Regulation 13 and 23 Requirement The registered person must ensue that all sluice rooms containing clinical waste are kept locked. (Timescale 30/09/06 not met) The registered person must ensure that all foodstuffs are stored appropriately, and that they are not used once their use by date has expired. Timescale for action 31/01/08 2. OP15 13 31/01/08 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 OP12 OP15 Good Practice Recommendations It is recommended that the home gives consideration to the appointment of a permanent activities coordinator. It is recommended that serviettes are provided at mealtimes. George Mason Lodge DS0000036539.V356937.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 George Mason Lodge DS0000036539.V356937.R01.S.doc Version 5.2 Page 29 - 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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