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What the care home does well Maple Lodge provides a comfortable, clean environment and has a friendly, homely atmosphere. Residents were complimentary about, their rooms, the food and the kindness of the staff. What has improved since the last inspection? The Home now has an acting manager who provides excellent leadership and is committed to providing a high standard of care. The staff are to be commended on the changes and improvements that have taken place since the new manager has been in post. Most staff are adjusting well to the changes. One member of staff said the manager had introduced a more flexible routine, which enabled staff to provide more individualised care. Each resident now has access to a Service User Guide. Care plans have been reviewed and this development continues. Arrangements have been made to ensure that residents do not go to hospital alone. Improvements are being made to the way that medication is stored and administrated. The quality and choice of the food has improved and there is more flexibility. Staff training is taking place. Residents` safety has been considered and hazardous materials are now stored safely and hot surface radiators have been covered. The recruitment procedure now meets regulatory standards and protects the residents. Supervision of staff has been introduced. A big issue in the past has been a lack of adequate staffing levels. The acting manager has addressed this and has given an assurance that appropriate levels will be maintained. More staff are being recruited and there is little use of agency staff. Staff morale is higher, one member of staff said, "The new manager said we are not a set of shifts but one big team". Another staff member said, "I enjoy coming to work now". What the care home could do better: The positive changes introduced by the acting manager must be maintained and developed. Training must continue and NVQ level 2 progressed. The range and availability of pastimes needs to develop to meet all the residents` individual needs. A system needs to be in place which enables the home to assess how well they are performing. Each resident must have a contract/statement of terms and conditions. Risk assessment for fire and the building and procedures must be developed. The garden must be maintained so that it is safe and suitable for residents to use. CARE HOMES FOR OLDER PEOPLE Maple Lodge 116 Lodge Lane Grays Essex RM16 2UL Lead Inspector Mrs Nikki Gibson Unannounced Inspection 16th January 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Maple Lodge DS0000018051.V326587.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. Maple Lodge DS0000018051.V326587.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Maple Lodge Address 116 Lodge Lane Grays Essex RM16 2UL Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01375 396789 01385 396789 Mrs Masarath Jahan Khan Mr Mohamad Ali-Khan, Mr Firasat Ali-Khan Manager post vacant Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places Maple Lodge DS0000018051.V326587.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd May 2006 Brief Description of the Service: Maple Lodge provides personal care and accommodation for up to 14 older people. It is not registered to care for people with dementia. The home has eight single bedrooms and three shared rooms. Three of these have private en-suite facilities. Bedrooms are situated on the ground and first floor and a passenger shaft lift gives access to the first floor. There is one communal lounge and a separate dining room. The home is furnished, equipped and maintained to a good standard and bedrooms are personalised. There is a large garden area at the rear laid to lawn. The home is in a residential area, close to Grays Town and Lakeside Shopping Centre. Maple Lodge was registered in 1992 and is a private home. The Service User Guide has been reviewed and copies placed in each bedroom. The inspection report was available in the entrance hall. The fees at the time of this report range from £375.69 to £395.43 per week. The homes e-mail address is masarathkhan@btinternet.com Maple Lodge DS0000018051.V326587.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which covered all the key National Minimum Standards. The site visit took place over 8 hours, in the afternoon the inspector was accompanied by a second inspector. During the visit there was a tour of the premises and a selection of records and documents were studied. Time was spent in the lounge and dining room observing practice, and with residents in their own rooms. Two residents were spoken to at length about life at Maple Lodge. The inspection process also included discussions with the acting manager and staff on duty. Meetings with the proprietor and other reports and correspondence provided by the proprietor were also used as evidence to inform this report. For some time Maple Lodge has been failing to meet National Minimum Standards and due to breeches of statutory requirements legal action by the CSCI has been considered. However three months ago the proprietor appointed a new manager. The new manager is working with the CSCI and in a short period of time there are pleasing signs that standards in the home are being raised. The home will be closely monitored to ensure that the improvements are maintained and progressed. What the service does well: What has improved since the last inspection? The Home now has an acting manager who provides excellent leadership and is committed to providing a high standard of care. The staff are to be commended on the changes and improvements that have taken place since the new manager has been in post. Most staff are adjusting well to the changes. One member of staff said the manager had introduced a more flexible routine, which enabled staff to provide more individualised care. Each resident now has access to a Service User Guide. Care plans have been reviewed and this development continues. Arrangements have been made to ensure that residents do not go to hospital alone. Improvements are being made to the way that medication is stored and administrated. The quality and choice of the food has improved and there is more flexibility. Staff training is taking place. Residents’ safety has been considered and hazardous materials are now stored safely and hot surface radiators have been covered. The recruitment procedure now meets regulatory standards and protects the residents. Supervision of staff has been introduced. Maple Lodge DS0000018051.V326587.R01.S.doc Version 5.2 Page 6 A big issue in the past has been a lack of adequate staffing levels. The acting manager has addressed this and has given an assurance that appropriate levels will be maintained. More staff are being recruited and there is little use of agency staff. Staff morale is higher, one member of staff said, “The new manager said we are not a set of shifts but one big team”. Another staff member said, “I enjoy coming to work now”. 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. Maple Lodge DS0000018051.V326587.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 Maple Lodge DS0000018051.V326587.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, 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information is available about the home to enable prospective residents to make informed choices and they would be encouraged to visit. It was unknown whether all residents have appropriate contracts. The home has a comprehensive document for assessing prospective residents. Staff knowledge and training in specific needs of the elder is developing. EVIDENCE: The updated Service User Guide had been given to residents and was observed in a number of bedrooms. An addendum had been included regarding the lack of a registered manager this will again need to be updated shortly. The inspection report was available in the entrance hall. The acting manager said that she was unaware whether all residents had a contract/statement of terms and conditions but she would be addressing this once the proprietor was back in the country. Maple Lodge DS0000018051.V326587.R01.S.doc Version 5.2 Page 9 A comprehensive pre-admission assessment form had been drawn up which the acting manager had used to reassess the present residents. No new residents had been admitted since the last inspection. The acting manager said that from recent training she was very aware of the number of people and agencies she would want to involve when assessing a new resident. The home is not registered to admit residents with a diagnosis of dementia, however a number of residents who have lived at Maple Lodge for some time were displaying dementia behaviours. Staff understanding of their specific needs was developing and training was in progress. One member of staff said she had found the training on Parkinson’s disease very helpful. She said in the past she had thought a resident ‘awkward’ but now realises it was a symptom of Parkinson’s disease. The acting manager said that prospective residents and there supporters would always be encouraged to visit the home before making a decision and they would move in on a trial basis. Maple Lodge does not provide Intermediate Care. Maple Lodge DS0000018051.V326587.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Vast improvements are being made to the care plans. Resident’s medical needs are being met. Changes and improvements are being made to the way medication procedures are being managed. Residents are treated with dignity and respect. EVIDENCE: New Care Plans have been introduced by the acting manager which will benefit the residents and be easier for staff to use. One senior member of staff said they were much clearer. The acting manager said that initially they had been written by her but with training and guidance all staff will be expected to take an active role in ensuring they contain appropriate and up to date information regarding each residents’ needs and wishes. Key workers will be responsible for involving the resident and where appropriate the family. Each care plan studied contained appropriate and clear information, risk assessments and the daily notes. There was a separate sheet for GP and District Nurse visits to enable easy access to information. Discussion took place round the need to Maple Lodge DS0000018051.V326587.R01.S.doc Version 5.2 Page 11 provide slightly more detailed instructions for staff in the care plans to ensure that they are individualised to meet the needs of each resident. There are plans to introduce a more effective nutrition assessment. A member of staff said that the home was working much closer with GPs and District Nurses since the acting manager had been in post. A GP visiting the home said that he was happy with the standard of care offered and staff always followed any instructions he left. There are monthly meetings with a link social worker and district nurse and the acting manager said she felt well supported in the area of the residents’ medical needs. The acting manager said that an on-call system has been put in place to ensure residents do not go to hospital un-escorted. The acting manager was dissatisfied with the service provided by the old Pharmacy and a new Pharmacy will be supplying the home shortly. The old filing cabinet presently used for medication has been moved to a cooler more convenient place. Patient Information Leaflets were not available for all drugs held in the home but this will be addressed by the acting manager and the new pharmacy. The home had identified that teatime and evening medication rounds were being undertaken too closely together. This is being rectified by training night staff to administer medication. Training involves working along side an experienced carer as well as formal accredited training and assessment. It was pleasing to have confirmed that the practice of treating or examining residents in other people’s rooms has now ceased. The visiting chiropodist said that she now uses an extension cable in the bathroom. Care staff were heard asking a GP to wait a moment while a resident was taken to her bedroom so she could be examined in private. New protection for residents to wear at mealtimes have been purchased so that residents dignity is preserved. Maple Lodge DS0000018051.V326587.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Choice and range of activities is an area of care which requires further development. Other aspects of daily life are progressing in a very positive manner. EVIDENCE: The acting manager has plans for the home which when in place will improve the quality of life for the residents. Staff need to look at more ways of providing suitable activities and pastimes for all the residents. The home may wish to obtain further advice on training and appropriate activities for the elderly from the National Association for Providers of Activities for Older People on 02070789375 Fax 02077359633 Email: info@napa-activities.co.uk NAPA Bondway Commercial Centre 5th Floor unit5.12 71 Bondway London SW1 8SQ The acting manager said she was seeking advice from other care homes and had delegated some responsibility for activities to a member of staff. Maple Lodge DS0000018051.V326587.R01.S.doc Version 5.2 Page 13 No relatives or friends visited at the time of the inspection, however the home has an open policy on visiting. There are plans to arrange for the group ‘Pets as Therapy’ to visit the home. In the past there has been complaints that some residents are got up very early in the morning or forced to go to bed at night. At this inspection a senior member of staff said that residents can choose when they get up and the earliest is about 7.00 am. One resident said she liked to sit and chat with another resident until 11.30 at night and there were no restrictions on the time she went to bed. Residents were very complimentary about the new menu and choices at meal times. Fresh fruit was observed in the dining room and the cook confirmed that fresh vegetables are offered daily. The cook is pleased with the new system for purchasing food and residents’ wishes are regularly asked before shopping is ordered. One resident who has regular hospital appointments and is not in the home at lunchtime now has her dinner freshly cooked in the evening. There is a choice of hot dish at teatime and residents were very pleased with this new arrangement. One resident said the food was lovely and she was looking forward to scrambled eggs for tea. Another resident said, “We get better food now and there is a choice. Before if you did not like it you had to lump it”. The acting manager reported that new table clothes had been purchased and she was hoping to introduce tureens so that residents could serve themselves or be served at the table. There are also plans to make sandwiches later in the day so that the cook would have time to make homemade desserts. Meal times are a focus of the day and good nutrition is essential for the elderly and the home is to be commended on the progress they are making and planning in this area. Maple Lodge DS0000018051.V326587.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has an appropriate complaints policy and the acting manager has the knowledge and skills to appropriately responded to suspicions of abuse. EVIDENCE: A copy of the homes complaints policy was seen displayed throughout the home. Residents spoken to on the matter said that they felt able to discuss any concerns with senior staff. A complaints book is now available for recording concerns and the action taken by the home. The acting manager said most complaints were about the laundry and she has addressed this with staff. The new acting manager inherited some areas of concern where allegations of abuse had been made. She dealt with each situation appropriately and pursued them to a full conclusion in a manner which would protect residents. Maple Lodge DS0000018051.V326587.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care is provided in a clean and safe environment. Facilities within the home are improving, except for the garden, which is not suitable for residents in its present state. EVIDENCE: The standard of the environment at Maple Lodge has been improving over the past year. It provides care in a small comfortable, family setting. The manager said that now all hot surface radiators have been covered and no longer pose a hazard. A maintenance person is in the process of being employed. One resident said she had met him and he was very nice and she was looking forward to him securing her TV aerial lead. Unfortunately the garden is over grown and does not provide suitable facilities for the residents. Last year residents and a GP said it was a shame that the garden was not used Maple Lodge DS0000018051.V326587.R01.S.doc Version 5.2 Page 16 more. The Fire Risk assessment has yet to be completed and not all staff have undertaken Fire drills. Residents have one lounge and one dining room for communal use. The furniture and lighting is domestic and of a good standard. The small residents lounge upstairs is at present being used as an office. Bathrooms and toilets are appropriately labelled and provided liquid soap, paper towels and lidded bins. Some wear and damage was noted in one bathroom and redecoration is due to maintain an adequate standard. There is little space for residents to wander or take exercise in the home and corridors are narrow. The present facilities are not suitable for people with dementia who are mobile. To meet the needs of a particular resident a hoist is now in regular use. Staff appeared confident in its use and the resident was moved with the minimum of fuss. Bathrooms and toilets are clearly labelled. The standard of maintenance of residents’ bedrooms has improved and soiled carpets have been replaced and unsafe electrics have been repaired or removed. Work was taking place in one room where damp had been detected. Each room has a new call bell system and two beds have sensors to alert staff if the resident moves. The call alarms can be moved to where the resident is sitting to enable them to call for assistance at any time. The laundry was clean and tidy. Most cleaning fluids were in their original containers and those that had been diluted were clearly labelled. Substances which are hazardous to health had been locked away. There is no wash hand bowl in the laundry and staff have been instructed to use the staff toilet facilities for hand washing after visiting the laundry. Maple Lodge DS0000018051.V326587.R01.S.doc Version 5.2 Page 17 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, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The acting manager gave a commitment to ensure adequate staffing levels are maintained. Staff training is taking place but additional training is required for most staff. There are plans to improve the induction programme in line with good practice. EVIDENCE: Staffing levels agreed with the previous Registration Authority and still considered appropriate are: • one senior and two care staff during the day • two awake staff at night • additional staff to cover domestic and catering duties. • the manager is expected to be supernumerary to these numbers for most of her shifts. Maple Lodge has a history of not maintaining adequate staffing levels and this has been a recurring problem which brought the home close to prosecution. At this inspection the acting manager stated that this was no longer a problem and agreed staffing levels would be maintained. Staff records showed that five care staff and a manager had been recruited since the last inspection. A senior member of staff said that the improved staffing level meant that staff were less stressed, the home was calmer and staff were able to give better care. She said she now enjoyed coming to work and had job satisfaction. A resident Maple Lodge DS0000018051.V326587.R01.S.doc Version 5.2 Page 18 said she had noticed that there were more staff available and that the new staff were learning quickly. Files of six new staff were studied. Staff recruited after the employment of the acting manager had completed all recruitment checks and references that protected the residents. Gaps in recruitment procedures were noted for staff employed before the present acting manager was in post. Four staff files were seen of staff waiting references and checks and not yet in post. Clearly there has been a vast improvement in recruitment practice since the acting manager has been in post. A training matrix was supplied and studied. This evidenced that not all staff had received mandatory training. More training has been planned and dates fixed for medication administration and manual handling training. Staff are also on waiting lists to undertake Food Hygiene, Protection of Vulnerable Adults, and Care Planning training. To date no arrangements have been made for Fire training. It was very pleasing to note that nine members of staff are to commence NVQ level 2 in Care training. Staff spoken to were very positive about the increased level of training. One member of staff said that she had been promised NVQ training for many years and she was very pleased for it to actually happen. The acting manager was aware that inductions undertaken so far were poor. The acting manager has downloaded from the Internet, Skills For Care guidance and induction programmes/formats. She said that it might take as long as 6 months to fully implement it for all staff. Two new members of staff were spoken to and both have been employed within a care environment previously. They both stated that the induction provide at Maple Lodge was good and that they were made to feel very welcome by staff. Maple Lodge DS0000018051.V326587.R01.S.doc Version 5.2 Page 19 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, 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is being well managed and the needs of the residents are paramount. The management style is direct and open and staff feel well supported. EVIDENCE: The proprietor has recruited a qualified, committed and very competent manager and her application to register with the CSCI is being processed. The home has gone through a very difficult period and poor standards have led to the local authority not placing in the home and the CSCI considering enforcement action. At this inspection a big change was noted and although improvements are very newly implemented morale in the home was high and residents were more positive about life at Maple Lodge. One resident said, Maple Lodge DS0000018051.V326587.R01.S.doc Version 5.2 Page 20 “The new manager is jokey and cheerful”. One member of staff said, “ She is the best one yet. She really cares about getting things right”. A senior member of staff said, “Karin is the best ever! She pushes and supports me and that has given me more confidence”. Another member of staff explained that with the new manager the home was more organised and she had a clear management style. Other staff said that the home used to be regimental, and care was like a conveyer belt, but now things are more relaxed. Two new members of staff were very complimentary about the acting manager and confirmed that they felt supported and if they had any problems they would approach her. At the beginning of the inspection a Quality Section manager from Thurrock Council was visiting the home. She came to discuss the home’s Quality Monitoring systems and to provide guidance and advice. The home has a system which should prove affective when used. The proprietor has undertaken some Regulation 26 visits and sent reports to the CSCI but these have not been regular. Staff and resident meetings have taken place since the acting manager has been was in post. Records of money held in safe custody for residents was studied. Records and receipts for all outgoing money were available and cash and records balanced. The home was advised to obtain a signature or have a receipt for all deposits so that the accounts can be audited. Formal staff supervision is now taking place and evidenced by records and is being conducted by the acting manager. Both the acting manager and deputy manager are to attend supervision and annual appraisal training next month. The Employers Liability Certificate and Registration Certificate were satisfactory and displayed in the hallway. Fire alarms and equipment are tested weekly and emergency lighting monthly. A visit by the Fire Officer has taken place recently and the home’s Fire Risk Assessment needs to be completed. All staff need to undertake fire drills to ensure staff and residents safety. Hot water temperatures have been checked weekly and show temperatures on the low side (35-38°). The acting manager said she is locating a plumber, as she is aware of some problems with the home’s hot water system. The Gas safety certificate available at the time of the inspection was out of date however an up to date Gas Safety Inspection Report was provided after the inspection. The electrical safety certificate runs until September 2007 and portable appliance testing has taken place in the past year. The acting manager said the home did not have any Control of Substances Hazardous to Health policies or data sheets and she was seeking advice. Maple Lodge DS0000018051.V326587.R01.S.doc Version 5.2 Page 21 The accident book was studied and discussed with the acting manager who agreed that more detail was required. Information about how the accident happen (if known) what injury was sustained and what action was taken would enable the home to monitor and reduce the risks. Maple Lodge DS0000018051.V326587.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 X 3 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 2 3 X 2 Maple Lodge DS0000018051.V326587.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP4 Regulation 18(1) Requirement The registered person must promote and make proper provision for the health and welfare of residents. This refers to providing staff with appropriate training to meet the specialist needs of the elderly and ensuring that training is put into action. This requirement has started to be met. (Previous timescale 14.12.05) The registered person must provide a programme of activities and provide facilities for recreation. This refers to providing a wider range and a greater extent of stimulation and pastimes suitable for the needs, abilities and interests of individual residents. (Previous timescale of 10.07.06 not met) The registered person must ensure that residents have access to external grounds that are safe, suitable for them, and appropriately maintained. The registered person must DS0000018051.V326587.R01.S.doc Timescale for action 06/03/07 2 OP12 16(2) 06/03/07 3 OP19 23(2) 06/03/07 4 OP30 18(1) 06/03/07 Page 24 Maple Lodge Version 5.2 5 OP33 26 6 OP38 13(4) ensure that persons employed receive training appropriate to the work that they perform. This refers to induction and mandatory training for all staff. The registered person must 06/03/07 establish and maintain a system for reviewing and improving the quality of care provided. This refers to the monthly proprietors reports. The registered person must 06/03/07 ensure that risks are identified and so far as possible eliminated. This refers to: Risk assessments being in place Fire risk assessment being in place. Appropriate water temperatures maintained. Data sheets for hazardous materials in place. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard OP2 OP28 OP35 OP36 OP38 Good Practice Recommendations Each resident should have a contract/statement of terms and conditions and this should be readily available for inspection. A minimum of 50 of care staff to obtain NVQ level 2 or equivalent. Each transaction of residents’ money should have a receipt for both withdrawals and deposits. Staff should be supervised at least six times per year including the manager. Accident records for residents should be detailed and include information relating to the nature of the injury, staff interventions and outcomes. DS0000018051.V326587.R01.S.doc Version 5.2 Page 25 Maple Lodge Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Maple Lodge DS0000018051.V326587.R01.S.doc Version 5.2 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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