Inspection on 01/12/09 for The Maples Manor Rest Home

This is the latest available inspection report for this service, carried out on 1st December 2009.

CQC has not published a star rating for this report, though using similar criteria we estimate that the report is Not yet rated. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Extracts from inspection reports are licensed from CQC, this page was updated on 14/03/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE The Maples Manor Rest Home 4 Lorne Road Oxton Birkenhead Wirral CH43 1XB Lead Inspector Inger Moynihan and Helen Carton Key Unannounced Inspection 1st December 2009 09:00 DS0000070788.V378814.R01.S.do c Version 5.3 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. The Maples Manor Rest Home DS0000070788.V378814.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 The Maples Manor Rest Home DS0000070788.V378814.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Maples Manor Rest Home Address 4 Lorne Road Oxton Birkenhead Wirral CH43 1XB 0115 877 8891 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) Mr Rizwan Iqbal Manager post vacant Care Home 20 Category(ies) of Dementia (20) registration, with number of places The Maples Manor Rest Home DS0000070788.V378814.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 people of the following gender:- Either. Whose primary care needs on admission to the home are within the following categories: Dementia - Code DE The maximum number of people who can be accommodated is: 20 Date of last inspection 24th November 2009 Brief Description of the Service: The Maples Manor was registered under new ownership in February 2008. The home is registered to provide personal care and support for 20 older people, both male and female over the age of 65, who have dementia. The Maples Manor is situated in the residential area of Oxton, Birkenhead and is in walking distance of shops, post office and recreational facilities. At the front of the building there is a grassed area and a car park. There are well-established trees, which provide the home with some privacy. The rear garden area is enclosed and has flower beds and seating areas. The home provides two lounge areas and a separate dining room. A further room is being developed in to an activities room/quiet lounge but is currently not accessible to the people who use the service. Bedrooms are situated on three floors that are accessible by stairs or a passenger lift. There are 3 double and 14 single bedrooms. There are currently 2 shower rooms and a bathroom with a bathing aid situated over the 4 floors. There are plans to make further bathroom facilities available. Toilets are situated on all floors and are close to bedrooms and communal areas. At the time of the visit the fees for the service were £400.00 per week. The fees do not cover newspapers, hairdressing, chiropody, clothing, toiletries and any items of a luxury or personal nature. A statement of purpose and a service user guide are available for people thinking of using the service, their relatives and health and social care professionals to refer to. The Maples Manor Rest Home DS0000070788.V378814.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The overall quality rating for this service is two star. This means that people who use the service experience good quality outcomes. Information about the home was obtained through discussion with the manager and members of the staff team. Policies, procedures and supporting documentation were also locked out along with a selection of service users case files. We also obtained information from the Annual Quality Assurance Assessment (AQAA). The AQAA if a self assessment document that is filled in once a year by all providers. It is one of the ways that we get information from providers about how they are meeting outcomes for people using the service. A part of the inspection process includes sending surveys to service users, staff and health care professionals in order to obtain their views on the standard of the service provided. Three staff surveys, four service user surveys, one health care professional survey and one relative’s survey were returned to us. Comments made in these surveys are included in the report and contribute to the basis of any judgments made. What the service does well: Service users’ care needs are assessed before a service is offered so they know they will receive the care and support they need. The two staff surveys returned to us indicated they are always given up to date information about the needs of the people they support and care for. The health care professional survey returned to us indicated the service’s assessment arrangements always ensure that accurate information is gathered and that the right service is planned for. A care plan which includes risk assessments, is in place and provides staff with the information they need on how to look after the service users in line with their individual care needs and minimise the risk of accidents happening. The service user surveys returned to us indicated they receive the care and support they need and the staff make sure they get medical care when necessary. When asked what does the service do well, the relative’s survey noted ‘The staff try to cater for individual’s needs’. The health care professional survey noted ‘Staff make appropriate referrals to relevant services as and when required. Staff disseminate advice effectively throughout all staffing levels to coordinate plans of care and management strategies of individual service users. The Maples Manor Rest Home DS0000070788.V378814.R01.S.doc Version 5.2 Page 6 Systems all in place for the administration of service users’ medication. Staff who administer medication are trained so they are aware of their responsibilities and know how to work safely. Service users are treated with respect and their right to privacy is upheld. The health care professional survey returned to us indicated the service always respects service users’ privacy and dignity. It noted ‘The staff create a friendly, homely atmosphere with a relaxed approach. They encourage and maintain service users’ independence and dignity/privacy’. A range of activities are provided including word games, a luncheon club, exercises, trips to the local shops, board games and reminiscence discussions. A layperson from the local church visits weekly. There was a relaxed atmosphere in the home and service users seemed comfortable and happy in their environment. Service users’ dietary needs are assessed when they move into the home so that staff can provide meals they enjoy. A complaint procedure is in place so that service users and their carers know what to do if they are unhappy with the care provided. Staff are trained on how to ensure service users are protected from abuse, neglect and self harm. One of these service users spoken to during the visit said the staff are always very kind and polite. Staff chatted and interacted with service users in a relaxed and informal way The manager reported the staffing levels are good and additional staff are provided when necessary. Thorough selection procedures are in place to ensure they are suitably qualified and competent in their role. Staff are provided with ongoing training which is relevant to their role and helps them understand and meet the individual needs of the service users. The manager is qualified, competent and experienced to run the home. Systems are in place to ensure the ongoing improvement of the service. Staff spoken to during the visit said they enjoy their work and feel well supported in their role. They confirmed a senior member of staff is always available for advice and support. What has improved since the last inspection? Since the last inspection improvements have been made to the care plans, the condition of the building and staff training. Health and safety checks have improved and staff are more competent at managing medicines. This contributes to improving the overall service provision. The Maples Manor Rest Home DS0000070788.V378814.R01.S.doc Version 5.2 Page 7 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. The Maples Manor Rest Home DS0000070788.V378814.R01.S.doc Version 5.2 Page 8 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 The Maples Manor Rest Home DS0000070788.V378814.R01.S.doc Version 5.3 Page 9 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 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. Service users’ care needs are assessed before a service is offered so they know they will receive the care and support they need. EVIDENCE: Service users’ care needs are assessed before they move into the home. The service user, their family and any relevant health care professional can contribute to the assessment to ensure staff have all the information they need on how to provide the right level of care. Issues relating to equality and diversity such as service users’ disability, gender, age and religion are addressed to ensure their holistic care needs are met. The staff surveys returned to us indicated they are always given up to date information about the needs of the people they support and care for. The health care professional The Maples Manor Rest Home DS0000070788.V378814.R01.S.doc Version 5.3 Page 10 survey returned to us indicated the service’s assessment arrangements always ensure that accurate information is gathered and that the right service is planned for. Intermediate care is not provided at The Maples Manor. The Maples Manor Rest Home DS0000070788.V378814.R01.S.doc Version 5.3 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9 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. Service users personal care needs are met and they are treated with respect and valued as individuals. EVIDENCE: A care plan which includes risk assessments, is in place and provides staff with the information they need on how to look after the service users in line with their individual care needs and minimise the risk of accidents happening. The manager needs to ensure the impact service uses dementia has in all areas of their life is documented in care plans and risk assessments. Service users’ general welfare is monitored daily and staff seek advice from different health care professionals as required. The service user surveys returned to us indicated they receive the care and support they need and the staff make sure they get medical care when necessary. When asked what does the service do well, the relative’s survey noted ‘The staff try to cater for individual’s needs’. The Maples Manor Rest Home DS0000070788.V378814.R01.S.doc Version 5.3 Page 12 The health care professional survey returned to us noted ‘Staff make appropriate referrals to relevant services as and when required. Staff disseminate advice effectively throughout all staffing levels to coordinate plans of care and management strategies of individual service users. Systems all in place for the administration of service users’ medication and supporting policies and procedures are available to staff if they need clarification on a specific issue. Staff who administer medication are trained so they are aware of their responsibilities and know how to work safely. Medication administration record sheets are accurately maintained and medication is stored securely. Information on medicines should be available to staff so they are aware of any possible negative side effects. This will ensure service user’ welfare and wellbeing. Staff spoken to demonstrated understanding of how they ensure service users are treated with respect and their right to privacy is upheld. The health care professional survey returned to us indicated the service always respects service users’ privacy and dignity. It noted ‘The staff create a friendly, homely atmosphere with a relaxed approach. They encourage and maintain service users’ independence and dignity/privacy’. The Maples Manor Rest Home DS0000070788.V378814.R01.S.doc Version 5.3 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. The home’s routines are flexible and service users are helped to exercise choice and control in their lives. EVIDENCE: An activity co-ordinator is employed for 20 hours per week. A range of activities are provided including word games, a luncheon club, exercises, trips to the local shops, board games and reminiscence discussions. A layperson from the local church visits weekly to give communion. A Christmas party is being organised for service users and their family and friends. Service users’ social interests are assessed as part of the initial assessment. This are of care needs to be developed to ensure the activities reflect service users’ interests and hobbies. Activities are provided both individually and as a group. On the day of the visit staff were seen staff putting up the Christmas decorations with service users. Christmas carols were being played and the television was turned off. There was a relaxed atmosphere and service users seemed comfortable and happy in their environment. Two of the service user surveys The Maples Manor Rest Home DS0000070788.V378814.R01.S.doc Version 5.3 Page 14 returned to us noted there are usually activities they can take part in, two surveys noted activities are always available. Service users’ friends and family can visit at any time so they can maintain personal relationships and continue to be part of family life. Service users can bring their personal belongings into the home if they want in order to make their room more homely and comfortable. Service users’ dietary needs are assessed when they move into the home so that staff can provide meals they enjoy. Staff are available to help service users with their meals if needed and service users can eat in their own room if they want to. Plenty of drinks are provide throughout the day. Three of the service user surveys returned to us indicated they always enjoy the meals provided, one survey indicated they sometimes enjoy the meals. Mealtimes are relaxed and informal. One of the service users said ‘The meals are lovely, the cook is very good’. The Maples Manor Rest Home DS0000070788.V378814.R01.S.doc Version 5.3 Page 15 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. Systems are in place to ensure service users are protected from abuse. EVIDENCE: A complaint procedure is in place so that service users and their carers know what to do if they are unhappy with the care provided. The procedure needs to be updated to reflect the different agencies service users can contact if they wish to make a complaint. We have not received any complaints about the home. Staff are clear on the action they should take in the event of them receiving a complaint. The service user surveys indicated they know who to speak to informally if they are unhappy but they do not know how to make a formal complaint. All service users and their family/carers must be informed of this procedure so that improvements can be made to the service. Staff are trained on how to ensure service users are protected from abuse, neglect and self harm and during discussion they demonstrated an understanding of the different types of abuse that can occur and what they should do if they know or suspect abuse is happening. None of the staff spoken to had any concerns about the safety and welfare of the service users or the care practices of their colleagues. A whistle blowing procedure is available to staff so they can raise concerns and honestly. The manager needs to update The Maples Manor Rest Home DS0000070788.V378814.R01.S.doc Version 5.3 Page 16 her knowledge of the Wirral adult protection procedures to ensure allegations of abuse are managed correctly. One of the service users spoken to during the visit said the staff are always very kind and polite. The Maples Manor Rest Home DS0000070788.V378814.R01.S.doc Version 5.3 Page 17 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements need to be made to the environment to ensure service users have a comfortable and homely place to live. EVIDENCE: The standard of the facilities is mixed. Overall bedrooms are well maintained and furnished in a comfortable and homely way, although some furniture was worn and damaged. Service users had personalised their rooms with their own belongings. There are four lounge areas offering service users plenty of choice as to where to sit and who to sit with. All areas had pictures and ornaments to promote a homely environment. Furniture was in a good state of repair however the carpet was not fitted properly and was badly worn. This should be replaced or repaired to prevent the risk of accidents. The Maples Manor Rest Home DS0000070788.V378814.R01.S.doc Version 5.3 Page 18 Improvements need to be made to some of the bathrooms and toilets. One bathroom was out of use as it requires work to improve its appearance. Another bathroom had no sink, light shades were not always provided and one bathroom had damp on the ceiling. In another bathroom there was no toilet roll holder or soap. The lino in one bathroom was stained and the toilet by the lounge had damaged floor covering and wall tiles were missing. The Maple suite, which is decorated and furnished as a bar in a pub and is used for activities needs, redecorating as it appeared shabby. Paint work was chipped and damaged and the light level was poor. There were exposed wires by the telephone and TV area. Systems are in place to prevent the spread of infection and policies and procedures are available to support staff in their role. There are sufficient laundry facilities for the number of service users living at the home. The service user surveys indicated the home is kept clean and tidy. The Maples Manor Rest Home DS0000070788.V378814.R01.S.doc Version 5.3 Page 19 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. The recruitment and selection procedures ensure suitably qualified and competent staff are employed. EVIDENCE: The manager reported the staffing levels are good and additional staff are provided when necessary. The relative’s surveys returned to us stated ‘The staff are always hard working and show a great deal of care and attention to service users. However I do feel that they are under pressure due to low staffing levels sometimes, and this cannot be good for the service users or staff’. The staff surveys returned to us indicated there are always enough staff to meet the individual needs of the service users. There is a programme of training to the National Vocational Qualification standards which means staff are clear on their responsibilities and keep up to date with new ways of working. Thorough recruitment and selection procedures are in place. Staff records indicated that the necessary checks are completed before staff are employed to ensure they are suitably qualified and competent in their role. The staff The Maples Manor Rest Home DS0000070788.V378814.R01.S.doc Version 5.3 Page 20 surveys returned to us indicated their induction training covered everything they needed to know to do their job when they started. Staff are provided with induction and ongoing training which is relevant to their role and helps them understand and meet the individual needs of the service users. This was confirmed in the staff surveys returned to us. The manager should consider carrying out a staff training need analysis. The outcome of this should then formulate the basis of next year’s training plan. This will ensure the training provided accurately reflects service users’ care needs and staff training requirements. The induction training programme needs to be developed to ensure it is in line with Skills for Care, which is the recognised training programme for staff involved in the care profession. The health care professional survey returned to us indicated the home’s manager and staff have the right skills and experience to support service users’ social and health care needs. The relative’s survey noted staff usually have the right skills and experience to look after service users properly. The Maples Manor Rest Home DS0000070788.V378814.R01.S.doc Version 5.3 Page 21 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. The management systems ensure the home is run efficiently and for service users’ best interest. EVIDENCE: The manager is qualified, competent and experienced to run the home. The management structure reflects the size of the home and there are clear lines of accountability within the staff structure. The manager has an open and positive approach which provide staff with clear direction and leadership. The staff spoken to during the visit said the manager is very supportive and always available advice. The Maples Manor Rest Home DS0000070788.V378814.R01.S.doc Version 5.3 Page 22 Systems are in place to ensure the ongoing improvement of the service. This includes monitoring and supporting staff, reviewing administrative procedures and consulting with service users and their carers about the care provided. Questionnaires should also be sent to visiting health care professionals and staff as to how the home is achieving goals for the people who live there. To further improve this area of care a formal plan for the development of the service should be drawn up. Also the audit form completed by the by the owner should be developed to ensure it includes more information about the way the home is being managed and how it can be improved. The manager looks after the personal allowance for several people who use the service. All records were accurately maintained. Staff spoken to during the visit said they enjoy their work and feel well supported in their role. A system of formal supervision is now in place and gives staff an opportunity to meet with their line manager and discuss their development in their role. One of the staff surveys return to us noted ‘Since being taken over by the new owners there have been major improvements which are still ongoing. It is now a nicer environment for the people who live here and also the staff who work at the home’. Health, safety and welfare of service users and staff are promoted by way of health and safety checks around the building, staff training and supporting policies and procedures. The Maples Manor Rest Home DS0000070788.V378814.R01.S.doc Version 5.3 Page 23 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 3 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 2 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 3 X 3 The Maples Manor Rest Home DS0000070788.V378814.R01.S.doc Version 5.3 Page 24 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 OP18 Regulation 13 Requirement The registered manager must up date her knowledge on how to manage an allegation of abuse. This will ensure allegations of abuse are managed correctly and service users’ safety and welfare is promoted. 2. OP19 23 The registered person must provide the CQC with a plan of the works to be undertaken (with timescales) to improve the standards of decoration and furnishings at the home. This will ensure service users have a more homely and comfortable environment to live in. 3. OP31 9 The responsible individual must ensure that an application is made to the CQC to register the appointed manager for the home. This is to enable the CQC to ensure that there is a person accountable for the day-to-day The Maples Manor Rest Home DS0000070788.V378814.R01.S.doc Version 5.3 Page 25 Timescale for action 29/01/10 29/01/10 29/01/10 operation of the service. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard 1. OP9 Good Practice Recommendations Information on medicines should be available to staff so they are aware of any possible negative side effects. This will ensure service user’ welfare and wellbeing. The complaint procedure should be developed to include information on the different agencies service users and their family/carers can contact if they want to make a formal complaint. A training need analysis should be carried out with each member of staff. This will ensure next year’s training plan accurately reflects service users’ care needs and staff training requirements. A more detailed evidence based recording system should be put in place to demonstrate that staff have understood the induction training and any further training needs. Questionnaires should be sent to visiting health care professionals and staff as to how the home is achieving goals for the people who live there. The audit form completed by the owner should be developed. This will ensure more information is collated about the way the home is being managed and how it can be improved. 2. OP16 3. OP30 4. OP30 5. OP33 6. OP33 The Maples Manor Rest Home DS0000070788.V378814.R01.S.doc Version 5.3 Page 26 Care Quality Commission North West 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. 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. The Maples Manor Rest Home DS0000070788.V378814.R01.S.doc Version 5.3 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!