Care Home: Maefin Lodge

What the care home does well People live in a comfortable, homely environment that is well maintained suitable for their needs. Prospective residents are given opportunities to visit to test out if they like the home and peoples` needs are assessed prior to their move. Each individual has comprehensive care plans and risk assessments which identify what their needs are, actions identified to meet their needs and measures to minimise identified risks. Peoples` personal, health and social care needs are met. People are supported to engage in a range of activities according to their needs and abilities and have opportunities to lead fulfilling lives. Peoples` choices are respected and individuals are valued. Individuals receive personal care in the way that they prefer and are supported to ensure their healthcare needs are met. Medication administration procedures are generally good in practise. Individuals know how to complain and feel safe and secure in the home. The home listens people and protects them from abuse. Suitably qualified staff appropriately staffs the home. Recruitment practises are generally good to ensure the protection of people living in the home. Health and safety procedures are well observed and the home is generally well managed. What has improved since the last inspection? Requirements made at the previous inspection have all been met. Care plans have been reviewed. Two satisfactory references and a new enhanced Criminal Records Bureau are obtained for all new employees. People are consulted about staff recruitment. Storage arrangements for residents` meeting minutes are stored away to maintain confidentiality. People requiring assistance with their finances have this detailed in their individual plan. All "as required (PRN)" medication is fully listed on the Medication Administration Record. Fridge and freezer temperatures are monitored on a daily basis and staff receive regular supervision. CARE HOME ADULTS 18-65 Maefin Lodge Maefin Lodge 194 South Esk Road Forest Gate London E7 8HD Lead Inspector Nurcan Culleton Unannounced Inspection 06th May 2008 10:00 Maefin Lodge DS0000022871.V362607.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Maefin Lodge DS0000022871.V362607.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Maefin Lodge DS0000022871.V362607.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Maefin Lodge Address Maefin Lodge 194 South Esk Road Forest Gate London E7 8HD 020 8586 7812 020 8586 7940 theresa.john1@tiscali.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Theresa John Mrs Theresa John Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) Maefin Lodge DS0000022871.V362607.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th February 2007 Brief Description of the Service: Maefin Lodge is a three bed roomed terraced house situated on a residential road in Forest Gate. It is a registered care home for 3 adults with mental health needs. The accommodation comprises a communal lounge that is well maintained and includes a sofa, armchairs, television and stereo system. There is a kitchen/dining area to the rear of the ground floor with a toilet and shower room. There is a patio area to the side of the kitchen that leads onto a small lawned area. There is a storage shed at the end of the garden. One bedroom is on the ground floor and there are a further two bedrooms, one of which has ensuite facilities, on the first floor. On this level there is a further bathroom comprising of toilet, hand basin and bath. The office is located to the rear of the first floor. There are currently three people residing at the home. The home is situated close by to local bus links on the Romford Road with frequent services to both Stratford and Ilford. Local shops are available within walking distance on Green Street. The registered provider also owns the care home adjacent to Maefin Lodge, which provides residential care to three adults with learning difficulties. The fees currently start from a minimum of £606 per week and vary depending on individual needs. Maefin Lodge DS0000022871.V362607.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 2 star. This means the people who use this service experience good quality outcomes. This unannounced inspection took place on 6th May 2008. We spoke with the manager, a support worker, two people living in the home and a relative visiting the home. The inspection process also involved examining people’s individual files containing documents such as their care plans and risk assessments; staff files, medication records and looking at other records including those relating to health and safety. The inspection takes into account the homes’ most recent Annual Quality Assurance Assessment and we toured the premises. What the service does well: What has improved since the last inspection? Requirements made at the previous inspection have all been met. Care plans have been reviewed. Two satisfactory references and a new enhanced Criminal Records Bureau are obtained for all new employees. People are consulted about staff recruitment. Storage arrangements for residents’ meeting minutes are stored away to maintain confidentiality. People requiring assistance with their finances have this detailed in their individual plan. All “as required (PRN)” medication is fully listed on the Maefin Lodge DS0000022871.V362607.R01.S.doc Version 5.2 Page 6 Medication Administration Record. Fridge and freezer temperatures are monitored on a daily basis and staff receive regular supervision. 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. Maefin Lodge DS0000022871.V362607.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Maefin Lodge DS0000022871.V362607.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1-5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information about the home is available to people thinking about moving into the home. Prospective residents are given opportunities to visit to test out if they like the home and peoples’ needs are assessed prior to their move. EVIDENCE: The home has a suitable Statement of Purpose and Service Users Guide. The Service Users Guide has recently been updated. The Service Users Guide contains pictures though needs to ensure the numbers of staff included in the Service Users Guide is correct and has the correct contact details for CSCI. Assessments are completed by the referring authority and are also undertaken by the home prior to admission. These were seen in individual files. Evidence available throughout the inspection, particularly through direct observation, records available and in interviews demonstrates that the home does have the capacity to meet people’s individual needs. Individuals are invited to visit and spend time in the home prior to admission, for example, the latest person to be admitted had made several visits to meet staff and other individual, including an overnight stay and eating meals in the home. Her relative was also engaged and involved in the process. The relative positively stated that, “I think they’re very friendly. I feel really at home here. If I was to come into a Maefin Lodge DS0000022871.V362607.R01.S.doc Version 5.2 Page 9 home, I’d want to come here because what you see is what you get.” People moving into the home receive individual contracts. Maefin Lodge DS0000022871.V362607.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6-10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People each have comprehensive care plans and risk assessments which identify what their needs are, actions identified to meet their needs and measures to minimise identified risks. Peoples’ personal, health and social care needs are met. EVIDENCE: Previous requirements from the last inspection were reviewed as follows: 1) Service users individual plans must be reviewed at least six monthly, or as their needs change. 2) Service users who require support in managing their finances should have the details of this support outlined in their individual plan. Maefin Lodge DS0000022871.V362607.R01.S.doc Version 5.2 Page 11 Care plans seen by us had been reviewed and details about peoples’ income, benefits and who holds financial responsibility were seen recorded in individual care plans. Care plans comprehensively outline people’s individual needs, covering “Areas for development; how we can do it; action by whom and evaluation. These are detailed and show that the home has good insight into what people’s needs are, providing a range of strategies as to how to meet them and good evaluation as to the outcome to the person, for example, the reduction in the frequency of urinary tract infections for one person as a result of the implementation of the care plan. Each plan addresses peoples’ personal, health and social care needs and evidence a person-centred approach to meeting peoples’ needs. Care plans seen were signed by the manager and support worker and the individual, however one person’s care plan which had not been signed by the individual due to their difficulty in doing so had not been signed by their family or other representative. It is recommended that all care plans are signed by the individual, or where not possible, their family, advocate or other representative. Detailed risk assessments are in place, focusing on areas identified in the care plan which present increased risks to the person. A description of risk is provided, risk factor (high, possible, likely), remedy to reduce risk, action by and time line. Risk assessments seen had been recently updated. Residents’ meetings are now held separately in a cabinet and so are stored in a more confidential way. Maefin Lodge DS0000022871.V362607.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11-17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People are supported to engage in a range of activities according to their needs and abilities and have opportunities to lead fulfilling lives. Peoples’ choices are respected and individuals are valued. EVIDENCE: Peoples’ care plans state areas for individual development in maintaining personal and domestic care skills, such as keeping bedroom tidy, laundry and encouragement to maintain personal hygiene. People spoken to confirmed that they assist with washing up and keeping their bedrooms tidy. Staff assist in areas where more support is needed, such as with meal preparation. People are encouraged to help with meal planning and are consulted about what meals they wish to eat. Individuals spoken to were very positive about the Maefin Lodge DS0000022871.V362607.R01.S.doc Version 5.2 Page 13 food. Records seen showed healthy meals being prepared reflecting peoples’ dietary needs and cultural preferences. Residents’ meetings are held as and when new events need may affect people which they may wish to discuss. The last meeting was held in March. Minutes showed that the manager had consulted individuals for their view about having temporary staff in the home and their positive feedback was recorded. Peoples’ daily social and community activities depend on their needs, choices and abilities, however opportunities are made available to them and people are supported to carry out the activities they choose to engage in. One person has has a full weekday activity programme, attending a community care centre run by the local rehabilitation team for people with mental health needs, in addition to a range of other groups, including a community luncheon club with peers who do not have mental health needs and swimming. Another person does not engage with structured activities, but is supported to visit local shops and the park. Individuals also have access to services to meet their diverse cultural needs, including a Caribbean club for elders attended by one person. People are supported to attend church or their chosen places of worship. People keep in touch with their personal friends or family. The relative we spoke to was taking her sister to visit her mother on the day of inspection. The relative confirmed that she is always made to feel welcome and is consulted about her relatives’ needs. We observed that staff interact positively with people in the home and that individuals choose when to be alone and when to join in an activity. Staff currently give someone who is relatively new to the home time to adjust and get used to staff in the home. Special occasions are celebrated and individuals are valued, for example, a birthday party was recently held for one individual, their family members invited and the home had arranged a birthday cake with the individuals’ name on the cake. Maefin Lodge DS0000022871.V362607.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18-21 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Individuals receive personal care in the way that they prefer and are supported to ensure their healthcare needs are met. Medication administration procedures are generally good in practise, however the expiry date of liquid medicines must be checked and the medication policy and procedure must be revised. EVIDENCE: Discussion with individuals’ in the home evidenced that the home respects and recognises individual preferences in the way assistance with personal care is provided and implements these in practise. Evidence was seen in minutes of individual review meetings, appointments and correspondence of involvement from health professionals from multiMaefin Lodge DS0000022871.V362607.R01.S.doc Version 5.2 Page 15 disciplinary health backgrounds, including consultant psychiatrists. Individuals have check ups with the GP, practise nurse, dentist, optician and chiropodist. The Inspector sampled the homes medication policy. The copy provided in the policies and procedures folder is inadequate and needs to be updated as if does not cover essential areas of information required about medication practises in care homes, including the need for self-medication to occur within a risk assessment framework or address the disposal of controlled drugs. The manager was advised to follow guidance issued by the Royal Pharmacutical Society and CSCI professional website regarding the administration of medicines in care homes. The Inspector sampled the medication kept in the home. manager advised that a pharmacist loads dossett boxes for each service user for a four-week period. Comparison of the Medication Administration Record (MAR) with the medication available showed that MAR sheets are being properly completed with no omissions. However one liquid medicine (lactulose) opened on 22/03/07 recorded as a PRN medicine in the MAR chart was still open and likely to have past its expiry date once opened. It is a requirement that all liquid medicines are appropriately stored in accordance with their expiry date. Individuals’ expressed death and dying wishes are stated in their preadmission assessments. One persons’ assessment, it was stated that their Next of kin should be contacted. This had not been subsequently completed, however a document about funeral service entitlement was seen in their individual file as arranged by their Next of Kin. Maefin Lodge DS0000022871.V362607.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22-23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Individuals know how to complain and feel safe and secure in the home. The home listens people and protects them from abuse. EVIDENCE: The homes complaints policy and procedure clearly outlines the ways in which individuals can make a complaint, the timescales in which the home aims to deal with complaints, and gives contact details for the Commission for Social Care Inspection, though these contact details need to be updated. The home maintains a record of complaints made that includes the date and nature of the complaint and the action taken. There has been one recorded complaint from an ex staff member which resulted in a strategy meeting referred to below. Individuals spoken to were very positive about the home, stating they knew how to complain and had no complaints. The relative also knew how to complain and stated the home provides a good service for the individuals living in the home and are well supported. The home has an adult protection policy that includes definitions of abuse and possible indicators that a service user is being abused. The policy also outlines individual staff responsibilities and makes appropriate reference to local multi agency adult protection procedures, though it is recommended that the role of Maefin Lodge DS0000022871.V362607.R01.S.doc Version 5.2 Page 17 other organisations is included in the policy as well as the contact numbers. Discussion with the member of care staff on duty evidenced a basic understanding of adult protection issues and that they may need more supervision from the manager to be satisfied that they are fully aware of the homes’ policy and procedure. A strategy meeting held recently in the London Borough of Newham examined complaints made by a former member of staff, including issues around staffing, the needs of one person and the ability of the home to meet this persons’ needs. Records related to this individual were examined and found to be comprehensive, including for example, a behaviour chart recording details of any physical or mental discomfort and anxiety. There was no evidence in any records or documents seen, or interviews with people in the home, the relative, manager or staff that the home is unable to meet this individuals’ needs. To the contrary, records indicated a heightened awareness of the individuals’ needs and ability to meet them. This was further confirmed by observations made on the day of inspection in terms of the understanding of and response to this individual’s needs demonstrated by the staff and manager. This inspection showed no evidence to substantiate concerns raised in the complaint. Maefin Lodge DS0000022871.V362607.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24-30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living in the home benefit from a comfortable, homely environment that is well maintained suitable for their needs. EVIDENCE: The premises were observed to be clean, tidy, homely in appearance and well maintained. Each person has their own private bedroom. One of these has en-suite facilities. There is a shared bathroom on the first floor and shared shower room on the ground floor. There is also a communal lounge and kitchen/dining area. Potentially hazardous cleaning materials are appropriately stored in a locked cabinet. The garden at the back has access via a gate to the other home next door which is also owned and managed by the manager. Maefin Lodge DS0000022871.V362607.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31-36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Suitably qualified staff appropriately staffs the home. Recruitment practises are generally good to ensure the protection of people living in the home. EVIDENCE: There are four permanent female staff members employed. According to information given by the people spoken to in the home, including two residents, a staff member and the manager, there is always one person on duty during the day and one person at night. The manager informed that the staff team is stable and there are no sickness or absence problems. Staff have been at the home between 18 months to a year. Agency staff are occasionally used to cover absences, though attempts are made to find the same staff to maintain consistency, as seen in recorded minutes of staff and residents’ meetings. The manager and staff spoken to clarified that people living in the home only visit the home next door if they choose to socialise with the other people in the Maefin Lodge DS0000022871.V362607.R01.S.doc Version 5.2 Page 20 home, for example, to have a cup of tea, have a meal or watch TV together and never join people in the other home due to a lack of staff in the home. It was recommended that clear records are kept of when people in the home mix with the residents next door and what they do in the home. Staff personnel files were examined and found to contain all required documents, including CRB checks and suitable references. However the application forms for some staff had unexplained gaps in employment. Whilst the manager was able to explain the gaps in some instances, having clarified this at the time of the prospective staff members’ interview, it is recommended that an explanation of any gaps in periods of employment are recorded in staff files when known. Some staff training records were available in their files, however the manager informed that due to IT difficulties, she was unable to access the full staff training information. Staff spoken to informed that she had received induction and training, including POVA. One staff member who has an NVQ Level 2 is currently undertaking NVQ Level 3. Another staff member is doing NVQ Level 2 and another is starting a social work course. Training received includes health and safety, risk assessments, food hygiene, COSHH and RIDDOR. The staff member interviewed stated that she had received first aid training as part of her one day training in COSHH. It is recommended that a more thorough first aid training is undertaken by all staff, particularly for staff who may be lone working. Staff receive regular supervision. The manager stated that she assesses peoples’ development needs in an induction she arranges herself but does not follow the Skills for Care induction standards. It is recommended that all staff receive induction in line with the Skills for Care national standards of induction for care staff. Maefin Lodge DS0000022871.V362607.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37-43 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People in the home benefit from a home that is well managed. Health and safety procedures are well observed. An improved system of information and record keeping is needed to ensure more efficient organisation and ease of access to information. EVIDENCE: The homes Registered Manager has successfully completed an NVQ level 4 and has the Registered Managers Award. The staff member spoken gave positive Maefin Lodge DS0000022871.V362607.R01.S.doc Version 5.2 Page 22 feedback about the manager, finding them responsive and ready to take action to address any issues raised. The home has a quality assurance process in place that includes obtaining the views of people in the home; their relatives and professionals through questionnaires on an annual basis. The Inspector viewed a sample of the homes health and safety records and certificates. These evidenced that weekly fire alarm tests are carried out and regular evacuation drills are practised and the safety of gas, electrical wiring and appliances. A weekly record of water temperatures is also maintained. Staff also record daily fridge and freezer temperatures. The insurance certificate is in date. A range of policies and procedures are available in the home and the homes’ records are generally well maintained, however it is recommended that due to the difficulty of the manager of accessing various information when needed, that there is an improved system of information and record keeping to ensure more efficient organisation and ease of access to information. Maefin Lodge DS0000022871.V362607.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 N/A 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 3 3 3 3 3 3 Maefin Lodge DS0000022871.V362607.R01.S.doc Version 5.2 Page 24 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 YA20 Regulation 13(2) Requirement The home must ensure that it records the expiry date of liquid medicines once opened and that liquid medicines are appropriately stored and administered. Timescale for action 10/06/08 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 YA2 YA6 Good Practice Recommendations The Service Users Guide should include accurate information on the staff numbers. All care plans should be signed by the individual, or where not possible, their family, advocate or other representative. Ensure record are clearly kept of when people living in the home when they visit and socialise with people living next door. The medication policy needs to be updated in line with advice from the Royal Pharmaceutical Society for the administration of medicines in care homes. DS0000022871.V362607.R01.S.doc Version 5.2 Page 25 3. 4. YA16 YA19 Maefin Lodge 5. 6. 7. YA22 YA23 YA29 8. YA34 Ensure all staff are familiar with the homes’ policies and procedures, including the Safeguarding Adults policy and procedure. Ensure the Safeguarding Adults (POVA) policy includes the role of other organisations and contact details for referrals. All relevant documents to be updated with the new contact details of the Commission, including the Statement of Purpose, Service Users Guide, complaints and Safeguarding Adults policy and procedure and other relevant policies and procedures. Ensure reasons are recorded in staff files to explain any gaps in periods of employment in the job applications of prospective staff. Ensure all staff have suitable first aid training. Ensure that all staff receive induction in line with the Skills for Care national standards of induction for care staff. An improved system of information and record keeping is needed to ensure more efficient organisation and ease of access to information. 9. 10. 11. YA35 YA35 YA41 Maefin Lodge DS0000022871.V362607.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. 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