Care Home: Mermaid Lodge

What the care home does well The service provides care and support for up to ten younger adults with present or past history of mental health disorders within a family type environment. The owners, one of whom is the manager, live on site and provide the majority of the care and support for the people in the home. The home is clean and comfortable and all residents have their own room. Residents spoken with were happy with the care and support provided saying: ` It`s the best thing that could have happened to me, it`s really great here`. ` They do a good job here, they really put themselves out to try to help you, you have always got support when you need it`. ` Its like a five star hotel here, couldn`t be better and they are always here to help you`. A care manager, who has the responsibility for the residents in the home that were spoken with at the inspection, was contacted. She said that ` The home is very client centred, it goes the extra mile and is good at liaising with both social services and the families of residents. The manager spends a lot of time with the residents and I notice an improvement of their life skills of about 60% when they have been in the home. They are allowed and supported to take risks and it is unbelievable the way that the manager works with them.` Care plans examined were good; they contained comprehensive assessments of need and very good risk assessments. The majority had been reviewed on a regular basis. Policies and procedures had been reviewed and included policies that addressed current legislation including the mental capacity act. The standard of medication administration was good. Residents are allowed to choose how they wish to spend their day, all have a key to the front door and are encouraged to become involved in the local community, take college courses and pursue any interests that they have. The home has recently purchased an eight seater vehicle to enable them to take residents out. What has improved since the last inspection? The home has been extended to support ten residents. This has provided a well-decorated and modern interior to the building. The manager has recently obtained training material for care staff and enrolled with a local training consortium. A recent environmental health inspection showed that all requirements made at a previous inspection had been met and a fire office from West Sussex fire services recently visited the home. One requirement was made and this has been complied with. The exterior of the home has undergone some refurbishment but this cannot be completed as further works are to be undertaken. The manager has a development plan for the home. What the care home could do better: There was no information available on any of the staff that work at the home. Staff only work in the home on an intermittent basis and the provider undertakes the majority of the support of the resident. However certain documentation is required for staff that are employed by the home regardless of the amount of time they work. Documentation required included Criminal Records Bureau checks, Protection of Vulnerable Adults first checks, references, proof of identity, application forms and work history. This information is required to ensure that residents are safeguarded and protected from abuse. An immediate requirement was made to commence obtaining this information. Subsequent to the inspection information was received from the manager to confirm that the Immediate requirement had been complied with prior to the compliance date. There was no evidence of any staff training other than fire training. A requirement relating to quality monitoring was made at the last inspection, whilst some work has been done towards meeting this standard; it is insufficient to provide evidence that the home meets the expectations of residents and stakeholders. A further requirement has not been made but discussions were held with the manager regarding the importance of this and she gave assurances that further work would be commenced. The manager does not currently inform prospective residents in writing about whether the home can meet their needs. The manager gave assurances that this would be commenced. Requirements have not been made around some issues that have been identified due to the manager having given assurances that these would be addressed. These will be checked at the next inspection. CARE HOME ADULTS 18-65 Mermaid Lodge 68 Brighton Road Lancing West Sussex BN15 8LW Lead Inspector Elizabeth Dudley Unannounced Inspection 14th August 10:00 Mermaid Lodge DS0000014629.V369423.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 Mermaid Lodge DS0000014629.V369423.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. Mermaid Lodge DS0000014629.V369423.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mermaid Lodge Address 68 Brighton Road Lancing West Sussex BN15 8LW 01903 763945 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) NildaDooraree@aol.com Mrs Nilda Yasuda Dooraree Mr Raj Narsing Dooraree Mrs Nilda Yasuda Dooraree Mrs Yasoda Dooraree Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Mermaid Lodge DS0000014629.V369423.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 double room may only be used for single occupancy or for a couple who have made an application to share a room. 21st June 2006 Date of last inspection Brief Description of the Service: Mermaid Lodge is situated near to the seafront in Lancing, with access to local bus services and shops. The service has been providing a family home type of support for up to ten service users with a present or past history of mental health problems. The home aims to provide short term ‘half way house’ care to service users although some service users are admitted with a view to long-term care. The home provides care within a family type environment, the majority of the care being provided by the manager and her husband, both of whom are the owners of the home. The manager’s family live on the premises in self contained accommodation. Current fees range between £350 and £750 per week and services users are accepted for care via the local authority. Mermaid Lodge DS0000014629.V369423.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 key unannounced inspection took place on the 14th August 2008 over a period of five and a half hours and was facilitated by the registered manager and provider, Mrs Nilda Dooraree. Methods used to collect information about the home included examination of documentation in the home, observation of interaction between the manger and residents, conversations with four residents, and a tour of the home. Documentation examined included care plans, personnel files, staff training and supervision records, catering records and health and safety files. A care manager from the local authority who has responsibility for many of the residents in the home was contacted by telephone as part of the inspection process. The Annual Quality Assurance Assessment, required by the CSCI, which gives an overview of what has been achieved in the home and issues to be addressed, was received by the CSCI prior to the inspection. This accurately reflected the current status of the home and was used as part of the inspection process. Thanks are extended to the providers and the residents for their courtesy, help and hospitality during this inspection. What the service does well: The service provides care and support for up to ten younger adults with present or past history of mental health disorders within a family type environment. The owners, one of whom is the manager, live on site and provide the majority of the care and support for the people in the home. The home is clean and comfortable and all residents have their own room. Residents spoken with were happy with the care and support provided saying: ‘ It’s the best thing that could have happened to me, it’s really great here’. ‘ They do a good job here, they really put themselves out to try to help you, you Mermaid Lodge DS0000014629.V369423.R01.S.doc Version 5.2 Page 6 have always got support when you need it’. ‘ Its like a five star hotel here, couldn’t be better and they are always here to help you’. A care manager, who has the responsibility for the residents in the home that were spoken with at the inspection, was contacted. She said that ‘ The home is very client centred, it goes the extra mile and is good at liaising with both social services and the families of residents. The manager spends a lot of time with the residents and I notice an improvement of their life skills of about 60 when they have been in the home. They are allowed and supported to take risks and it is unbelievable the way that the manager works with them.’ Care plans examined were good; they contained comprehensive assessments of need and very good risk assessments. The majority had been reviewed on a regular basis. Policies and procedures had been reviewed and included policies that addressed current legislation including the mental capacity act. The standard of medication administration was good. Residents are allowed to choose how they wish to spend their day, all have a key to the front door and are encouraged to become involved in the local community, take college courses and pursue any interests that they have. The home has recently purchased an eight seater vehicle to enable them to take residents out. What has improved since the last inspection? The home has been extended to support ten residents. This has provided a well-decorated and modern interior to the building. The manager has recently obtained training material for care staff and enrolled with a local training consortium. A recent environmental health inspection showed that all requirements made at a previous inspection had been met and a fire office from West Sussex fire services recently visited the home. One requirement was made and this has been complied with. The exterior of the home has undergone some refurbishment but this cannot be completed as further works are to be undertaken. The manager has a development plan for the home. Mermaid Lodge DS0000014629.V369423.R01.S.doc Version 5.2 Page 7 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. Mermaid Lodge DS0000014629.V369423.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mermaid Lodge DS0000014629.V369423.R01.S.doc Version 5.2 Page 9 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): 1,2,3,4,5. People who use the service experience good quality outcomes in this area Prospective residents receive sufficient information to enable them to make an informed choice about the home. Comprehensive assessments of the residents needs take place and residents are invited to spend time in the home prior to admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose is clear and sets out the aims and objectives of the home, but requires review of the front page to identify that the registration of the home has changed insofar that it can now accommodate ten residents as opposed to three. Prospective residents are given a copy of the home’s brochure, which contains the Service User Guide. This gives information to the residents about the aims of the home and the way in which the home will meet their expectations. All residents are assessed by the manager prior to being considered for admission to the home. They are invited to spend a few days in the home in order that their needs can be thoroughly assessed prior to admission. Mermaid Lodge DS0000014629.V369423.R01.S.doc Version 5.2 Page 10 Five preadmission assessments were examined and these were comprehensive, giving a clear picture of the prospective residents needs and goals and how the home will meet these. Prospective residents should be informed in writing about whether the home can accept them for admission currently this is done verbally. The manager gave assurances that this would be put in place. All of the residents receive a contract and terms and conditions on their admission to the home and this document complies with the regulations. Mermaid Lodge DS0000014629.V369423.R01.S.doc Version 5.2 Page 11 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): 6,7,8,9,10 People who use the service experience good quality outcomes in this area. Care plans reflect the current and changing needs of the residents and are person centred, they incorporate comprehensive risk assessments and identify personal goals. Whilst residents spoken with were aware of the content of their care plans, there was no formal evidence that these had been formed in consultation with the individual. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During this inspection five care plans (60 ) were examined. These were person centred and concentrated on the individual’s needs and goals, how these were to be addressed and resident’s individual expectations. Mermaid Lodge DS0000014629.V369423.R01.S.doc Version 5.2 Page 12 These had been reviewed to show the current and changing needs of the residents. Whilst some care plans had been reviewed at more frequent intervals than six monthly as directed by the standards, there was evidence that some care planning had not been reviewed during this period. Good daily records were in place and there was clear evidence of instructions to staff and plans to ensure that residents received maximum benefit from their time in the home. The service concentrates on providing short-term ‘half-way house’ care and therefore resident’s expectations are that some of their issues, which prevent them from living in the community, will be addressed. Residents spoken with were positive about the home, some saying that they felt more positive and that confidence had returned and new skills learned since being at the home. One resident said that they felt they were ‘really working towards normality’ whilst another said that the ‘care is good and the manager is very supportive’. Whilst one resident said that they knew what was in their care plan and ‘ I ask about it or argue if I don’t agree’, there was no written evidence that the care planning process had been shared with the resident. Another resident had his care plan on his computer for easy reference. It was evident through observation, care planning and talking to residents that residents can make decisions about their daily lives and that the manager gives help and encouragement to the residents in their decisions. The home does not manage resident’s finances, some residents do manage their own but generally family or advocates manage these. Residents are expected to help with cleaning their rooms, their laundry and in some cases helping with the shopping and cooking within the home. Residents meetings are held, but not at regular intervals. The service has produced very comprehensive risk assessments for each individual, and these showed that residents are encouraged to take acceptable risks both in and out of the home. Residents spoken with said that they had freedom to go out and about and were only expected to let the home know they were going out and when they would be back. There is a confidentiality policy in place and residents said that they were confident that their confidentiality was respected. Mermaid Lodge DS0000014629.V369423.R01.S.doc Version 5.2 Page 13 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): 11,12,13,14,15,16,17. People who use the service experience good quality outcomes in this area. Residents are encouraged to follow their interests and are enabled to take part in the life of the community and the home. The standard of catering meets the resident’s expectations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents have the opportunity to participate in college courses, clubs and social activities both in and out of the home. One resident has joined a local radio club and another has completed a computer course. Several residents have their own laptop computers and the home is considering installing broadband. The home encourages residents to go out in the local area and the social care manager spoken with said that residents life skills have improved since being at the home, with residents who previously lacked confidence now going out shopping and for walks. Mermaid Lodge DS0000014629.V369423.R01.S.doc Version 5.2 Page 14 Residents are encouraged to follow their own interests and hobbies and appropriate risk assessments are in place. The manager and husband take residents shopping or out for car drives etc, and residents are supported in religious worship if they wish to do so. Visitors are welcomed at the home during times suitable for residents, resident’s families or significant others visit and the manager liaises with families regarding the residents. Residents spoken with said that there were few restrictions placed on them and these had been agreed with them as individuals and agreed boundaries set. This was evidenced in the care plans. All residents have a front door key and a key to their room if they wish; they said that their privacy was respected. All residents said that they enjoyed the food. Choices of meals are discussed with the residents and the three vegetarian residents are well catered for. The manager or her husband cooks the food. For safety reasons residents have restricted access to the kitchen but all have tea making facilities in their rooms. The home provides packed lunches for people that wish to go out and although most residents come into the dining room for meals, some have them in their rooms on occasions. Fresh fruit and vegetables are used and there is a varied menu, with records being kept of resident’s choices of meals and the individual likes, dislikes and dietary restrictions. Mermaid Lodge DS0000014629.V369423.R01.S.doc Version 5.2 Page 15 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): 18,19,20. People who use the service experience good quality outcomes in this area Residents have access to appropriate health care facilities The standard of medication administration, recording and storage safeguards the residents This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussions with residents and examination of care plans showed that residents have access to full health care facilities and the advice from health care professionals. Residents affirmed that they see Community psychiatric nurses, psychiatrists and general practitioners. They also visit the opticians and dentist. The results of appointments and any change in treatment are written in the care plans. Care plans identified current and changing mental and physical health care needs and the manner in which they were to be addressed. A social care manager spoken with stated that residents in mermaid lodge had not needed so much acute psychiatric health care input since admission to the home. Mermaid Lodge DS0000014629.V369423.R01.S.doc Version 5.2 Page 16 The standard of medication administration safeguards the residents. The manager and her husband have the responsibility for administering medication and both have medication expertise or training. Intentions are to ensure that other staff receive this training. All medications have been signed for following administration and residents have a full review of medications at a minimum of six monthly periods. The home should ensure that PRN medications identify in which situations they would be required to be used. Hand written prescriptions should be checked and signed by two members of staff. Residents who self medicate have appropriate risk assessments and their medication is checked weekly. No residents in the home are currently prescribed controlled drugs, but the manager is aware of the necessity to have appropriate storage and recording facilities in place should this occur. Mermaid Lodge DS0000014629.V369423.R01.S.doc Version 5.2 Page 17 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. People who use the service experience good quality outcomes in this area Residents are confident that any complaints that they may have will be addressed in an open and fair manner. Staff have not received training in safeguarding of adults but there is a comprehensive policy to address this. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no complaints or adult safeguarding issues in the past twelve months. The homes complaints procedure is included in the Service Users Guide and the home’s brochure, this requires amending to show the correct address of the CSCI. Records are kept of any minor concerns. Resident’s said that they were aware of how to make a formal complaint but would talk with the manager if they were not happy and were confident that any matters raised would be dealt with in an open and fair manner. It is recommended that the senior members of staff update their safeguarding training with the local authority; the manager has arranged for a training consortium to deliver safeguarding training to staff, this has not yet commenced. A requirement around training of staff has been made. There is a full safeguarding policy and policies addressing challenging behaviour, bullying and whistle blowing and these have been reviewed. Mermaid Lodge DS0000014629.V369423.R01.S.doc Version 5.2 Page 18 Mermaid Lodge DS0000014629.V369423.R01.S.doc Version 5.2 Page 19 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): 24,25,26,27,28,29,30. People who use the service experience good quality outcomes in this area The home provides a clean comfortable and pleasant environment for residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has recently been refurbished and extended to provide accommodation for ten residents. The providers are in the process of refurbishing the exterior of the home. There is a small garden and seating area to the front of the home and a lounge and separate dining room. The home is able only to take residents who are fully mobile as the access to the front door is unsuitable for people with mobility problems and there is no lift in the home. Mermaid Lodge DS0000014629.V369423.R01.S.doc Version 5.2 Page 20 Resident’s accommodation is over two floors and consists of single accommodation apart from one double room, which the manager intends to use as a single room. All rooms were comfortable and residents have personalised their rooms with their own possessions. Residents can have keys to their rooms within the auspices of a risk assessment. Most rooms have an ensuite bathroom or a bathroom adjacent to the room, the ensuite bathrooms contain either a bath or a shower, WC and wash hand basin and there is a communal bathroom available. There is an infection control policy, but staff have not received formal training in infection control. The communal bathroom requires a soap dispenser and disposable towels provided, individual rooms should also have these. Disposable aprons and gloves are provided and there are red bags for disposal of soiled linen. Residents are encouraged to do their own personal laundry where able. Mermaid Lodge DS0000014629.V369423.R01.S.doc Version 5.2 Page 21 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): 31,32.33.34.35.36 People who use the service experience adequate quality outcomes in this area. Whilst the provider covers the majority of staff hours, other staff work in the home on an occasional basis. No staff training or employment checks are in place, this could put residents at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is usually staffed solely by the providers who work in the home as manager and carer, they also live on site. Three members of staff are employed occasionally, to be in the home when the providers are not available and in this case the manager said that two members of staff would work on a shift. Residents said that the manager and her husband (the co-provider) were usually available and there were staff in the home when they were not there. The manager has not employed any new staff since 1999, however in view of now accommodating extra residents and therefore in the eventuality of needing more staff, the ‘Skills for care’ programme has been set up (a nationally recognised induction programme). Mermaid Lodge DS0000014629.V369423.R01.S.doc Version 5.2 Page 22 None of the existing staff have received any training other than fire training from the home, and no staff have the National Vocational Qualification level 2 in care. The co-provider has National Vocational Qualification level 3 in care and the manager is a registered mental health nurse (level 1) and has completed National Vocational Qualification level 4 in management and is about to complete the Registered Managers Award. The manager should ensure that staff are encouraged to participate in the National Vocational Qualification level 2 in care. Staff must attend health and safety training such as moving and handling, first aid, and food hygiene in addition to ensuring the fire training is regularly updated, other training should include Protection of Vulnerable Adults training and some training in the work they perform which includes training in mental health issues and challenging behaviour. A requirement has been made around staff training. It is appreciated that all residents are mobile and therefore staff do not use moving and handling, but there may be an occasion when this is required i.e. in the instance of a resident becoming ill and needing help. There were no personnel files and no details of staff employed, the manager has documentation in place to be commenced but this has not been done. No member of staff apart from the providers (the manager and husband) has Criminal Records Bureau checks or Protection of Vulnerable Adults checks relevant to this home. These must be put in place. An immediate requirement has been made for the providers to commence application for Criminal Records Bureau check and Protection of Vulnerable Adults checks for staff and to put other information about staff in place. Subsequent to the inspection confirmation was received that the immediate requirement had been complied with prior to the due date. Staff must not work unsupervised without a Criminal Records Bureau check and must not come work at all without a Protection of Vulnerable Adults check. When the providers are absent the person taking charge must be suitably qualified. Supervision for staff has only recently been commenced with one member of staff having received one supervision session. This must be taken forward. Mermaid Lodge DS0000014629.V369423.R01.S.doc Version 5.2 Page 23 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): 37,38,39,40,41,42,43 People who use the service experience good quality outcomes in this area Management has put systems in place which identify and minimise the risks for residents. There is no full quality monitoring process in place to gain the views of residents and ensure that the services offered by the home meet residents expectations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is a registered mental health nurse (level 1) and has recently completed the National Vocational Qualification level 4 in care and in the process of completing the Registered Managers Award. She is registered with Mermaid Lodge DS0000014629.V369423.R01.S.doc Version 5.2 Page 24 the CSCI and co-owns the home with her husband who has the National Vocational Qualification level 3 in care. The ethos in the home is good; residents spoken with spoke very highly of the home ‘ I am really happy here’. ‘ We are free to do what we want to do’, ‘ I’ve been here 8 years and I love it’, ‘ Everything here is very good, it’s like living in a 5 star hotel’. ‘ They really put themselves out for you’. Resident s said that the environment was ‘ homely’ and that the manager has one to one sessions with them on a daily basis, and involved them in the day-to-day life in the home. Some actions have been taken towards a quality monitoring system by commencing residents meetings and obtaining the views of stakeholders such as health and social care professionals, this must be enhanced and collated and records kept. This was a requirement at the last inspection but has not been fully complied with. The Annual Quality Assurance Assessment required by regulation was received in a timely manner and accurately reflected the situation in the home. The manager was aware of what was required in the home and aware that some of the documentation was not fully in order and has given assurances that this would be put in place. There was a good awareness of the risks that could affect residents, both generally around the home and in their individual circumstances and risk assessments were in place. Policies and procedures have been updated and reflect the current practices in the home and include relevant policies. There was evidence of servicing for utilities and equipment. Residents take part in fire drills and main doors have automatic closures, which respond to a fire alarm. Doors to resident’s accommodation are kept closed and the home had a fire officer’s inspection recently, which was satisfactory. Records relating to fire safety are in place. Mermaid Lodge DS0000014629.V369423.R01.S.doc Version 5.2 Page 25 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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 X 29 X 30 2 STAFFING Standard No Score 31 2 32 2 33 2 34 1 35 1 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 4 3 LIFESTYLES Standard No Score 11 4 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 3 X 3 3 2 3 2 3 X Mermaid Lodge DS0000014629.V369423.R01.S.doc Version 5.2 Page 26 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 YA34 Regulation Reg 18 Reg 19 Schedule 2 Requirement Timescale for action 21/08/08 2 YA33 Reg 18 3 YA35 Reg 18(2)(d) That the provider commences procedures for obtaining a Criminal Records Bureau check and Protection of Vulnerable Adults first check for all employees. That no member of staff works at the home until a Protection of Vulnerable Adults first check is obtained and then works under supervision until the Criminal Records Bureau check is obtained. The provider must ensure that all documentation is included in personnel files, including references, as required by Schedule 2 of the amended regulations. This is an Immediate requirement. The registered person shall 30/09/08 ensure that only staff who are suitably qualified are left in charge of the home. That a staff training programme 30/09/08 which includes all mandatory training including Protection of Vulnerable Adults training is commenced. Mermaid Lodge DS0000014629.V369423.R01.S.doc Version 5.2 Page 27 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 Refer to Standard YA20 Good Practice Recommendations That the reasons for when an individual requires ‘as required medication are documented in the care plan or medicines administration chart. That two members of staff check and sign hand written prescriptions. That senior staff undertake adult safeguarding training through the local authority. That staff are encouraged to undertake National Vocational Qualification level 2 in care That staff supervision takes place at intervals as directed by the National Minimum Standards. 2 3 4 YA23 YA32 YA36 Mermaid Lodge DS0000014629.V369423.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Mermaid Lodge DS0000014629.V369423.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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