Inspection on 04/08/09 for Maitland House

This is the latest available inspection report for this service, carried out on 4th August 2009.

CQC has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CQC judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Maitland House 03/09/07

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 16/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Maitland House 33 Church Road Clacton On Sea Essex CO15 6AX Lead Inspector Helen Laker Key Unannounced Inspection 4th August 2009 10:00 DS0000068186.V377076.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Maitland House DS0000068186.V377076.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Maitland House DS0000068186.V377076.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Maitland House Address 33 Church Road Clacton On Sea Essex CO15 6AX 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) 01255 421415 maitlandhouse@blackswan.co.uk www.blackswan.co.uk Black Swan International Limited Janet Fairhurst Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Maitland House DS0000068186.V377076.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is 23 26th August 2008 2. Date of last inspection Brief Description of the Service: Maitland House is an established care home situated in a residential area close to the town centre of Clacton on Sea. It is within walking distance of local shops, post office, library, churches, leisure facilities and the railway station. Fees were quoted at this inspection as being £390.39 to £460.00 per week. Additional charges are newspapers, toiletries, chiropodist, dry cleaning and magazines. Maitland House offers accommodation for twenty-three service users, on the ground and first floor, with fourteen single bedrooms and one double room having en-suite facilities (This is used as a single room currently). There is passenger lift access to all floors. The home has gardens to the front and rear. The front garden offers off road parking, with flowerbeds and borders. The rear garden has paved patio, shrubs and flowerbeds. Communal areas are found at the front and rear of the property. The rear lounge has patio doors to the garden. A second lounge and dining room are found at the front of the building. There are bathroom facilities on each floor, including a Parker bath. A call bell system is in place, with handrails, aids and hoists in the home. Maitland House DS0000068186.V377076.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 home is two star. This means that people who use this service experience good quality outcomes. This key unannounced inspection looking at the core standards for care of older people took place on a weekday between 10:00 and 16:00. The registered manager, deputy manager, regional operations director and staff were present throughout and assisted with the inspection process by supplying records and information. This report has been compiled using information available prior to the visit such as surveys sent out, evidence found on the day of inspection and the annual quality assurance assessment (AQAA), which is required by law and is a self assessment completed by the service. The AQAA provides an opportunity for the service to tell us what they do well and areas they are looking to improve and/or develop. It is anticipated that some progress be noted as this contributes to the inspection process and indicates the homes understanding of current requirements, legislation changes and own audited compliance This document will be referred to as the AQAA throughout the report. During the day the care plans and files for three of the residents were seen as well as four staff files, the policy folders, the medication administration records (MAR sheets), some maintenance records and the fire log. The manager also supplied a copy of the duty rota, the menus, and other pertinent documentation which was required. A tour of Maitland House was undertaken and six residents, four members of staff as well as the manager and domestic staff were spoken with. The home was clean and tidy offering homely accommodation to the residents. The residents seen were relaxed and clearly felt at home in the environment using all areas of the building. All the records and files were generally well maintained and easily accessible. Some were not available on the day of inspection such as recruitment files which are stored at Head Office but the home was given twenty four hours to supply the records for review and this was complied with. Interactions between staff and residents were friendly and appropriate. What the service does well: Maitland House DS0000068186.V377076.R01.S.doc Version 5.2 Page 6 The home has a commitment to providing good quality person centred care. Residents are encouraged to maintain their independence, make choices and as far as possible retain control over all aspects of their daily lives. The home provides a good range of social, leisure and educational activities both inside and outside of the home. The environment is homely and comfortable with ongoing improvements and maintenance implemented. On the day of this inspection, the home was maintained in a good condition. Residents were receiving good care and support, and those spoken with enjoyed living at Maitland House and were positive about the staff team. It was clear that the people who live in the home have established friendships amongst themselves and during the inspection we were told of ways in which they support and help each other day by day. One relative spoken with considered that the home had an open and professional caring approach. The manager was described as open and approachable. Staff were described as very good, caring and helpful. Residents were generally very happy with the variety and quality of meals served. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Maitland House DS0000068186.V377076.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 Maitland House DS0000068186.V377076.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 does not apply to this service People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents can expect to have an assessment and assurances that their needs can be met prior to entering the home. EVIDENCE: The assessments of three recent admissions to the home since the last inspection were inspected. Improvements were seen since the last inspection. All of the assessments seen were noted to have been completed prior to the admission date and cover the all areas relating to the health and welfare of individuals. This information was usually supplemented by a social services assessment. Maitland House DS0000068186.V377076.R01.S.doc Version 5.2 Page 9 Attention to dates, times and signatures was discussed with the registered manager, this must be given more prominence so it is consistently maintained on documentation. The registered manager reported that pre-admission assessments were undertaken by her at the prospective resident’s own place of residence or at hospital depending on the needs and circumstances of the individuals at the time. The AQAA states We provide a Service User Guide to each resident and prospective resident which includes the home’s Statement of Purpose, relevant policies within the home, complaints procedure, inspection reports, quality assurance summary, contracts/statement of terms and conditions, individual care plan and homes brochure. An office copy is available to all prospective Residents and their family/representative. We also provide a written contract/terms and conditions on admission to the home and complete a comprehensive pre-admission assessment of needs by way of visits to potential service user, invitation to visit the home, eat at the home, meet staff and other residents, free trial overnight stay at the home.” It also states “We provide a sensitive, supporting re-assurance during the admission process and a trained staff team able to meet the assessed needs of the Resident.” Prospective residents and their families were encouraged to visit and spend time at the home, discussing their needs, before making a decision about admission as part of the initial contact arrangements and respite care may be suggested if required. Residents spoken with reported that they had experienced this approach and found it helpful and reassuring. Relatives for a prospective service user were being shown round the home on the day of inspection. One service user spoken to stated I enjoyed the first visit I knew I wanted to stay. Care plans are generally reviewed in consultation with the resident, families, representatives and the registered manager. Maitland House does not provide intermediate care. Maitland House DS0000068186.V377076.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this care service can be assured that their health care needs will be met and they are supported to access health professionals as needed. EVIDENCE: The care plans relating to three of the people living at Maitland House were examined at this visit to assess how the staff team understands the way in which they should plan and meet their needs. The care plans contain a variety of assessments that identified the level of support the individuals require in their daily lives. These included activities of daily living, equality and diversity, choice and social care. Plans are regularly reviewed and updated to show changes, with clear review notes maintained. Evidence of individuals involvement with developing their own plan of care is available through reviews within the care plans. Maitland House DS0000068186.V377076.R01.S.doc Version 5.2 Page 11 The majority of residents spoken with and surveyed were very satisfied with the standards of care and said that they received the care and support they needed. It was evident from discussions with residents that staff did try to provide person centred care. They confirmed that staff respected their privacy and dignity whilst providing care. One resident described the care staff as lovely and they do so much for me A relative spoken with said that management and staff met the care needs of their relative well and they received the medical support they required and had no complaints. The health care of people living at the home is monitored through the documents contained in care plans, these also include health professional visits and their outcomes, monitoring sheets for weight and dietary intake. The AQAA states “The homes ethos is to treat all residents with dignity, respect and privacy as per the homes Aims and Objectives. Each resident has individual care plans based on assessed needs which is driven by the resident. Independance and choice over personal care is promoted so that residents can live their own lives with dignity and privacy. Residents have the right to choose how their personal care is provided.” The care documentation has been developed and made more person centred and expanded to cover residents abilities, choices and preferences and as well as their physical and psychological health and care needs. It was noted that daily evaluations varied depending on who had completed the entries and repetition was noted indicating that specific care needs had not been referred to in the formulated plan and reported on. This was discussed with the manager and the need for consistency to ensure all staff are aware of how to meet residents needs. Aids and equipment are provided to encourage and promote independence for people living at the home and the risk management framework supports individuals to maximise their independence. The manager confirmed that the home has a variety of aids and equipment to assist with caring for the people living at the care home. They have pressure mattresses in use and the home has one stand-up hoist, three mobile hoists - two electric and one manual available for use. People living at Maitland House use the services of five GP practices in the area. Many have been able to remain with their previous GP as they moved into Maitland House. Community nurses visited the home every day to see residents who needed nursing input. There was evidence in care documentation that residents were referred for hospital consultations and treatment when appropriate The service arranges training on healthcare and topics for staff that are relevant to the people they support. Maitland House DS0000068186.V377076.R01.S.doc Version 5.2 Page 12 A Monitored Dosage System is used for medication. Medication records, storage and administration were sampled and inspected for people living at the home. Photographs were seen in the medication folder of each person on medication and records were found to be in general good order. Medication Administration Records (MAR) sheets were neat but there were some missing signatures and some hand written prescriptions without two signatures. A signature audit may be of value to keep this issue in check. Staff need to make better use of the omissions code. Items are checked into the home and a returns system is in place. No residents are presently self-administering and controlled medications checked on the day of inspection were in order. A list of staff who administer medication with their signatures and initials is used. During the inspection, staff were seen to treat all of the people living at Maitland House with respect and dignity. There was evidence within care planning notes of the person’s preferred names, which some people wished to be called. It was also evident that the people living at Maitland House were able to express their individuality in their accommodation, and there was evidence of personal possessions, small pieces of furniture and photographs in their rooms. During the inspection we were able to observe staff going about their duties and as they approached and spoke with the people living at Maitland House, it was observed that they were both respectful and sensitive to the people’s needs and there was lots of friendly chatting and joking going on between staff and residents. Staff approach to privacy is good and relatives confirmed this on the day. Interaction between staff and residents was seen and heard to be friendly, caring and respectful. Residents spoken with said that ‘They really look after me well’ and ‘staff are very kind and they care’. Maitland House DS0000068186.V377076.R01.S.doc Version 5.2 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents living at Maitland House are able to make choices about their lifestyles and the social, cultural and recreational activities meet their expectations. EVIDENCE: Throughout the day of the inspection, the people who live at Maitland House were seen to come and go as they pleased. Some people chose to sit in the lounge areas, whilst others sat in their rooms listening to the radio, watching television or reading. One person living at the home said that they ‘I stay in my room but come out when I need to I like my own space’ as they found it comforting’. Other residents enjoyed sitting in the small lounge with the TV in the background with the company of the caged birds. Maitland House DS0000068186.V377076.R01.S.doc Version 5.2 Page 14 A weekly programme of activities was on display in the hall of the home and on the day of the inspection. The manager confirmed that normal staffing levels in the afternoon are three care staff, a reduction from the morning staffing levels of four care staff. Care staff take part in activity provision and a discussion took place regarding the provision of extra staff if required to cover external activities. Care plans were noted to be linking activities to personal choices to provide a more person centred approach. For instance one resident who enjoyed gardening would be offered opportunities of visiting local garden centres and another service user had an interest in brass bands, so the home was talking to the Salvation Army to try and meet their choice. Another resident who liked to go to the betting shop had an entry in the care plan stating “Likes to have a flutter on the horses, staff to make sure scooter is available at all times.” The AQAA states “Residents choices of activities, interests, food, drink, religion, personal care and personal relationships are listened to and respected. Residents can feel free to request changes which affect their lifestyle. Staff are approachable and are trained to treat residents with dignity and privacy. Contacts with family friends and the community are encouraged and supported and independence and personal preference is always encouraged.” Evidence of activities taking place and who was taking part in them was available as a file is kept but more one to one recordings on resident’s individual daily notes would help evidence the clarity of choices. Within the home’s completed Annual Quality Assurance Assessment, it was acknowledged that the home has “developed and increased activities and entertainment in the home and now have day trips and outings as part of the activity diary.” Activities include Chairobics, singalongs, Zoo lab, themed lunches, musical bingo, keep fit, quizzes, theatre visits, pottery ceramics, cake and sherry mornings. One response from a person living at the home said that they took part in the activities but would like to venture out a bit more especially in the summer months and another stated “I do stay in my room but I do know what is going on and if I feel like doing something I do they don’t force you” When asked in the residents survey – ‘Are there activities arranged by the home that you can take part in?’ – Two said that there was always activities arranged, two said there were usually activities arranged and one said there were sometimes activities arranged by the home. Maitland House has a policy on visiting arrangements in the home. There was said to be no restriction on visiting, the choice being up to the resident. The manager said that family and friends are involved in assisting the people who live at Maitland House to manage their financial affairs. Should this not Maitland House DS0000068186.V377076.R01.S.doc Version 5.2 Page 15 be possible then the home would assist the individual to find an independent financial advisor and/or advocate. A three-week rotation menu is used to plan meals at Maitland House. At least two sometimes three choices are offered at both the lunch and teatime meal, with a choice of a cooked or cereal and toast for breakfast. Record sheets were seen of the meals selected and food supplies were plentiful to ensure that choice was on offer. Fridge and freezer space was available inside the home and in the outside food storage area. The outside storage area is a metal shed, this can become hot in summer sometimes but the home now monitors the temperature of the external storage shed to ensure food is stored at safe temperatures. It was also noted that some cleaning products were stored in the same shed and although at opposite ends this is not considered general good practice. Residents spoken with stated “I have no complaints about the food.” and another stated “You can even have more if you ask for it so we must like it”. Menus are placed on the tables a day in advance to help with resident choices. The AQAA states “We continually develop menus to become totally seasonal where possible.” Maitland House DS0000068186.V377076.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can feel confident they will be listened to and their concerns acted upon and also be assured that all carers are adequately trained to safeguard their welfare. EVIDENCE: The residents at Maitland House are supported by the homes robust complaints policy and practices. The complaints records included details of any issues raised by residents or their representatives. None from record of complaints were observed to present any risk to residents health and safety however were generally treated with appropriate sensitivity and respect. There was evidence that complaints had been investigated and appropriate action taken when necessary. The AQAA informs us that We provide a complaints procedure to each resident and put one on the wall at entrance for visitors. We have an open door policy of welcoming suggestions and complaints which will be acted upon. And we keep a record of complaints. All staff read, sign and understand the homes policy on Protection of Vulnerable Adults and are trained in Safeguarding of Vulnerable Adults. It also states that two complaints have Maitland House DS0000068186.V377076.R01.S.doc Version 5.2 Page 17 been received since the last inspection and that no safeguarding referrals have been made. This statement concurs with the home’s complaint records and these were seen to have been dealt with professionally and appropriately. Feedback from one visiting professional indicated that The home is very professional in its approach. Records provided evidence that staff members had attended annual training in the Protection of Vulnerable Adults. There was evidence that the manager reinforced the training by discussing areas such as the types of poor care that could constitute abuse during staff meetings. The manager said that all staff are aware of the whistle blowing policy and the Essex County Council POVA guidelines. The AQAA informs us that CRB and POVA checks are carried out on all staff prior to commencing employment. Staff spoken with were able to demonstrate a good awareness of safeguarding procedures and practice including whistleblowing. Maitland House DS0000068186.V377076.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Resident’s live in a home that is well maintained and their independence is encouraged EVIDENCE: A tour of the home was conducted at the inspection. There was evidence of ongoing decoration, maintenance and repair, with maintenance records completed as a task is done. The AQAA states “We have refurbished and redecorated main dining room and both lounges and continued to upgrade resident’s bedrooms when they become available. We have also added plants and baskets to the front of the home.” Residents spoken with spoke favourably of their surroundings one stated “I have my own personal things here so it Maitland House DS0000068186.V377076.R01.S.doc Version 5.2 Page 19 feels like home”. The rear garden has been paved over and seating provided. At the last inspection it was highlighted that the staff needed to introduce some shade and shelter provision in the garden area and it was noted at this inspection that an umbrella has now been purchased. On the tour of the premises it was evident that there was a range of personal belongings in the home. People living in the home had items of furniture including chairs, storage units, bookcases and small tables. In addition there was evidence of pictures, photographs and ornaments on display in the bedrooms. The home accommodated this by hanging the pictures and putting up shelves, as needed. Lockable facilities are also available in all rooms. The AQAA acknowledges that the kitchen is to be completely refurbished and this has now been done and a register of planned work and refurbishment is in place. Maitland House has an in-house laundry room. Residents were very complimentary about the quality of cleaning in the home. One resident said Its kept very clean. They also reported that there was a good laundry service. Two washers and two dryers are in place with care staff responsible for laundry both day and night. There were areas for hanging clothes to dry and air and individual baskets are used to ensure individual laundry items are returned to the people living at Maitland House. Maitland House DS0000068186.V377076.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are looked after by a staff team who are aware of their needs and wishes and are subject to a thorough recruitment process. EVIDENCE: Staffing levels are maintained appropriate to the needs and number of people living there. Individuals consulted felt that there are generally always sufficient staff available when they need them, and relatives consulted felt that staff have the right skills and experience to look after residents properly. Some staff members stated that at busy times it would be beneficial to have extra members of staff on duty at times as it can become very busy. Throughout the inspection visit the atmosphere was calm and peaceful. People consulted with also commented that they did not feel rushed at any time of the day, they were given time to get up and did not feel that staff were overly stretched. The staff interacted with residents in a respectful and pleasant manner. Maitland House DS0000068186.V377076.R01.S.doc Version 5.2 Page 21 People living at the home and their relatives gave very positive feedback about the staff employed to work at the home. One resident stated Staff are helpful and very caring and another commented They know what they are doing and I am happy with that. Discussion with the registered manager and scrutiny of records confirmed that the service is proactive in its staffing, recruitment and training, with planning for the potential needs of people who may use the service in the future. Staff files were examined to determine how the service carried out its recruitment process. These documents on the files seen demonstrated a robust approach with checks made on the persons Criminal Records Bureau (CRB) check, and the Department of Health Safeguarding POVA first list, as well as two written references, and proof of the person’s identity. These with the completed application form assist the service to determine whether the person is of a suitable background to work with vulnerable people. Staff are provided with relevant training that is targeted on improving outcomes for people living at the home. The registered manager maintains a list to ensure that all staff training/refresher training is delivered promptly. The staff training programme demonstrated that staff undertook a variety of courses pertinent to their work including first aid, medication, infection control, fire safety, food hygiene, moving and handling and POVA. Training needs are documented and staff can identify their own training needs. The majority of care staff fifteen in total had completed National Vocational Qualification (NVQ) at level 2 and four had achieved NVQ at level 3 or equivalent with a further two staff working towards it. The manager was aware of staff training needs and organised training on a regular basis. Evidence was available to confirm that staff meetings and staff supervisions take place regularly where training, activities, new staff and policies and procedures are some of the things discussed, the outcomes of these meetings are cascaded through individual departments and areas to ensure good communication throughout the service. The AQAA indicates, the staff team considers itself capable of keeping abreast of changes in legislation. They analyze results of Quality Assurance questionnaires and compile from that the development of the service. The staff believe that they provide a service that meets the needs of the service users in their care. The service has a commitment to listening to both staff and service users and regularly making changes to their practice when offered best practice recommendations to promote improvement. Maitland House DS0000068186.V377076.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be confident that the home is run in their best interests and it ensures their safety and welfare. EVIDENCE: The home does have a registered manager. The manager currently in post has held the post for nearly two years and prior to that had worked at Maitland House for some years in another position. The AQAA informs us that there are plans for her undertake the Registered Managers’ Award (NVQ level 4 in management) and that she has applied for the course. She confirmed that she Maitland House DS0000068186.V377076.R01.S.doc Version 5.2 Page 23 did feel supported in her role and that staff had supported her and that they all worked well together. The regional manager visits at least three times a week and this included one to one sessions with the manager. She demonstrated a good knowledge and understanding of the service and of care and management practices, and training records showed that she attended training to update her skills and knowledge. Residents and staff spoken with reported that the manager was supportive and approachable, and it was noted that she spends time working alongside staff in the home, and therefore provides a good level of support and was able to monitor practices. Survey work has been completed using quality assurance assessments, the ‘Living in the Home’ format. Service Users had completed surveys and the results of the survey work are shared with Service Users via residents meetings. In addition the outcome of the survey work is published and placed on the home’s notice board. This took the form of a tick box analysis and some dialogue summary. Changes have been made as a result of these surveys for example one male residents who preferred a barber instead of a female hairdresser had been facilitated. The AQAA states that improvements include “More detailed company audit system. A Regional Manager has been appointed. Current manager has received extensive training in care planning and paperwork procedures. Improved monthly audits. Increased senior management attendance within the home. Improved Quality Assurance Systems. And redeveloped every policy and procedure.” Minutes of staff meetings were seen previously at the home’s last inspection where reference had been made to implementing the key worker system. This has now been implemented. Records and monies held by the home were sampled and checked for two people living at the care home. They were found to be in good order. Records required for the protection of service users and for the efficient and effective running of the care home were inspected and reviewed during this inspection. Schedule 2 records, Information and Documentation in Respect of Persons Carrying on, Managing or Working at a Care Home, were generally found to have improved and be in good order. – see National Minimum Standard - Standard 29 for detail. Systems are in place to maintain the health and safety of the home, and a clear policy statement of the arrangements to maintain health and safety in the home, including employer and employee responsibilities. Staff training records showed that staff had received training in relevant health and safety Maitland House DS0000068186.V377076.R01.S.doc Version 5.2 Page 24 topics, including the moving and handling of people. The home maintains records to show that equipment and utilities are regularly serviced, and that appropriate internal checks are carried out (e.g. routine testing of fire alarms and emergency lighting, checking of bath and shower hot tap temperatures, checks on central hot water temperatures re risk of Legionella. The home has a range of risk assessments on safe working practices, including fire risk assessments and the use/storage of chemicals (with hazard sheets available for the chemicals used). Fire drills have been implemented on a more regular basis now to safeguard residents and ensure staff are aware of the appropriate actions to take and the last one recorded was noted to be on the 3/03/2009. Maitland House DS0000068186.V377076.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 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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Maitland House DS0000068186.V377076.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 OP9 Good Practice Recommendations Maitland House DS0000068186.V377076.R01.S.doc Version 5.2 Page 27 Care Quality Commission Care Quality Commission East Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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