Inspection on 20/12/05 for 14 Maple Way

This inspection was carried out on 20th December 2005.

CSCI 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 CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

14 Maple Way 24/07/08

14 Maple Way 06/03/07

14 Maple Way 11/07/05

14 Maple Way 15/11/04

14 Maple Way 16/06/04

14 Maple Way 16/02/04

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Treloar College

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 14 Maple Way Headley Down Alton Hants GU35 8AZ Lead Inspector Marilyn Lewis Unannounced Inspection 20th December 2005 10:00 14 Maple Way DS0000055527.V269616.R01.S.doc Version 5.0 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 14 Maple Way DS0000055527.V269616.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 14 Maple Way DS0000055527.V269616.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 14 Maple Way Address Headley Down Alton Hants GU35 8AZ 01225 444596 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) The Robinia Group PLC Miss Sally Budd Care Home 1 Category(ies) of Learning disability (1) registration, with number of places 14 Maple Way DS0000055527.V269616.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th July 2005 Brief Description of the Service: 14 Maple Way is a small home registered to provide a service for one person with learning disability. The home is owned and operated by Robinia Care Limited, a service provider since 1995. The home is a three bedroom, semi detached house on a small residential estate in the village of Headley Down, Hampshire. There is a small enclosed garden to the rear of the property and room for off road parking at the front. 14 Maple Way DS0000055527.V269616.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 20th December 2005. The inspector had the opportunity to observe the interaction between two staff members and the resident and to meet with the acting manager. A tour of the home was conducted and records were seen for staff recruitment, staff training, medication, fire safety and fire drills. This was the second unannounced inspection undertaken for the year 2005/2006. Information on the first inspection can be found in the inspection report dated 11th July 2005. What the service does well: On the day of the inspection the home looked clean and had been decorated for the festive season. Good interaction was seen between staff members and the resident, who looked relaxed and happy. Good care plans provide staff with the information they require to fully meet the needs of the resident. Staff support and encourage the resident to make decisions about her life and to take responsible risks as part of an independent lifestyle. Staff know that all information regarding the resident is confidential. The resident has the opportunity for personal development and is able to participate in a variety of leisure activities, both in the home and the community. The resident is offered a choice of balanced, nutritious meals, served in a friendly relaxed atmosphere. The resident receives personal support in the way preferred, her physical and emotional needs are met and she is protected by the home’s clear procedures for dealing with medicines. The home has a clear complaints procedure in place and the resident is protected by staff awareness of abuse issues. 14 Maple Way DS0000055527.V269616.R01.S.doc Version 5.0 Page 6 The home provides a clean, safe environment with a cheerful lounge, suitable personalised bedroom, sufficient bathroom and toilet facilities and a pleasant garden. The resident benefits from the home’s employment of staff who have clear job descriptions and who receive regular supervision. The resident’s best interests are safeguarded by staff awareness of the home’s policies and procedures and the safe working practices operated there. What has improved since the last inspection? What they could do better: The resident’s written contract requires updating to provide accurate information on financial aspects, such as the organisation’s methods for reimbursement of part of the cost for meals taken when away from the home. 14 Maple Way DS0000055527.V269616.R01.S.doc Version 5.0 Page 7 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. 14 Maple Way DS0000055527.V269616.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 14 Maple Way DS0000055527.V269616.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5 The resident has an individual written contract that requires updating to provide accurate information regarding financial issues. EVIDENCE: The resident has a written contract giving details of the terms and conditions for living at the home. The contract states what is included in the fees and services available at an additional cost. The contract requires updating with regard to the organisation’s recent changes to the system for reimbursement of part of the cost of meals if taken when out, for example at a local pub and for the amount that will be paid towards the cost of the first holiday of the year. The resident has her own transport on personal lease. 14 Maple Way DS0000055527.V269616.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 and 10 Good care plans provide staff with the information they require to fully support the resident who is encouraged to make decisions about her life and to take responsible risks as part of an independent lifestyle. EVIDENCE: Care plans seen for the resident were very detailed and gave clear information on the assessed needs and the actions required by staff to meet those needs. All aspects of care needs were documented including communication, nutrition, behaviour, personal and social needs. The plans had been reviewed regularly. It was noted in the care plans that the resident’s weight had not been recorded regularly although the resident was on a reducing weight diet. The acting manager said that this was because on occasions the resident refused to be weighed. The acting manager stated that she would tell staff to record all attempts to weigh the resident so that a clear record was kept. It was evident during the inspection visit that the resident was encouraged to make decisions about daily living activities. Staff worked closely with the resident who communicated by showing items to staff members or by using facial expressions. 14 Maple Way DS0000055527.V269616.R01.S.doc Version 5.0 Page 11 The acting manager said that the resident was involved with choosing the furniture and décor for the home, with pictures and photographs used to aid decision making. Risk assessments have been completed for all daily living and leisure activities. The risk assessments are contained in the care plans. The risk assessments include the identified needs, the identified risks and the actions required to minimise the risks. One risk assessment was for the resident’s wish to spend time alone. It was broken down to which area of the home the resident was in at the time. If the resident was upstairs a member of staff was to remain upstairs and if in the kitchen the cupboard doors were to be locked and any items that could be thrown were to be removed. The home has confidentiality policies in place and each member of staff is given a copy of the policy when they start work at the home. A staff member said that she knew all information regarding the resident was confidential. 14 Maple Way DS0000055527.V269616.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 The resident has the opportunity for personal development, is able to participate in a variety of leisure activities both in the home and the community, receive visits from relatives as wished and is offered a choice of nourishing meals. EVIDENCE: The resident attends educational sessions at the organisation’s resource centre located in a nearby town, on three days of the week. Staff from the home support her, while at the resource centre, to give continuity of care. Daily records showed that while at the resource centre the resident has participated in a variety of activities including cookery, painting and craftwork. Staff at the home support the resident to be part of the local community by assisting her to take walks and to visit the local shops and pub. The acting manager said that the resident had enjoyed horse riding in the past and was given the opportunity to go horse riding again at an activities centre in Southampton. However, staff found that although the resident enjoyed the horse riding, the activities centre was not to the resident’s liking. Arrangements were made for the resident to attend riding lessons at a local stables and this has been successful. 14 Maple Way DS0000055527.V269616.R01.S.doc Version 5.0 Page 13 An activities programme has been developed for the resident taking into account likes and dislikes for leisure activities. A flow of the day chart is in place that gives details of activities arranged for the morning, afternoon and evening. While the inspector was at the home the resident was busy making pictures with cut out paper and assisted with preparing the lunch. Records seen document the resident’s enjoyment of helping in the kitchen with tasks such as folding the laundry and clearing the table. While helping in the kitchen the resident appeared to be very relaxed and happy. The resident has been with staff on holiday to the Isle of Wight this year. The organisation paid £500 towards the cost of the holiday. The resident has close contact with relatives and visits them every two weeks. The resident’s parents had recently visited the home and shared a meal with the resident and staff. Plans are in place for the resident to spend Christmas day at home with her parents. Care plans seen indicated that the resident was on a special diet. Advice had been sought from a nutritionist and the diet was kept under review. The resident’s likes and dislikes for food items were recorded and the acting manager said these were taken into account when arranging the daily menus. The resident was shown pictures and food items to help her choose meals. On the day of the inspection, homemade cottage pie and fresh vegetables were prepared for lunch, followed by yoghurt and fresh fruit. 14 Maple Way DS0000055527.V269616.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The resident receives personal support in the way preferred, her physical and emotional needs are met and she is protected by the home’s clear procedures for dealing with medicines. EVIDENCE: The resident’s preferences for the way personal care is provided are documented in the care plans, including the toiletries to be used at bath time and the time preferred for getting up and going to bed. The records seen for the resident indicated that advice is sought from the GP and other health professionals as required. The GP has visited on request and advice has also been sought from the nutritionist and a psychiatrist. The resident had a dental check up in July. The home has clear procedures in place for dealing with medicines. Staff at the home receive training before they are allowed to administer medicines. A recording system is in place for the receipt of medicines into the home and the disposal of unwanted medicines. Medication charts seen had been completed appropriately. 14 Maple Way DS0000055527.V269616.R01.S.doc Version 5.0 Page 15 The acting manager said that it was difficult to ascertain how much awareness the resident has with regard to illness and death. The wishes of the relatives were recorded in the resident’s care plans. 14 Maple Way DS0000055527.V269616.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The home has complaints procedures in place and the resident is protected by staff awareness of abuse issues. EVIDENCE: At the time of the last inspection the home’s complaints procedures did not indicate that a complaint could be made directly to the commission at any time. On this occasion the complaints procedures provided the required information and was available to the resident, visitors and staff. Due to communication issues it was not possible to discuss the complaints procedures with the resident. The home has procedures in place to be followed should abuse be suspected. Two staff members spoken to during the inspection were aware of the procedures and indicated that they would report any concerns immediately. The home keeps a small amount of the resident’s personal money at the home. The money is kept securely and records are kept of all transactions. Records seen matched the amount of money held. One of the receipts was not complete and the acting manager was advised to ensure that all receipts were in one piece and did not have pieces missing. The organisation has a system that reimburses the resident for the first £1.50 spent on the cost of a meal taken when away from the home. The acting manager said that in most instances meals taken when away from the home were paid for out of the housekeeping money. 14 Maple Way DS0000055527.V269616.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 and 30 The home provides a safe, clean environment with a cheerful lounge, suitable kitchen, personalised bedroom, sufficient bathroom and toilet facilities and pleasant garden area. EVIDENCE: The home is a three bed roomed property situated in a residential area of Headley Down. A keypad entry system is in place restricting admission to staff and visitors who are admitted by staff. All visitors are requested to complete the record book when entering and leaving the property. On the day of the inspection the home looked clean and homely and had been decorated for the festive season. On the ground floor there is a comfortable lounge with television, video and audio equipment and a kitchen with fitted units and a dining area. The cupboards and drawers in the kitchen are lockable and items that could be dangerous to the resident such as knives and scissors are kept locked away. There is a cupboard in the kitchen that fits under the stairs and houses the tumble dryer. At the time of the last inspection concerns were raised regarding the heat generated in the room by the tumble dryer. Following the inspection the commission was notified by the organisation, of the fire proofing of the cupboard walls. Since the last inspection additional ventilation has been provided to reduce the heat in the room and discussions 14 Maple Way DS0000055527.V269616.R01.S.doc Version 5.0 Page 18 are taking place with regard to moving the tumble dryer to another area of the home. On the first floor the resident has a large bedroom that is suitable for the resident’s needs and contains personal items such as photographs and pictures. There is also an activities room, an office and a bathroom. At the time of the last inspection the floor in the activities room was uneven and the carpet in some of the rooms was worn. Since then the floor has been made level and new carpeting has been fitted in all rooms on the first floor and the landing and stairs. The bathroom and toilet facilities looked clean and tidy at the time of the inspection. Doors to the bathroom and bedroom are not locked as the resident has been assessed as not able to hold the keys. The resident is able to manage the stairs independently and does not require any specialist equipment. There is a small garden to the rear of the property where a specially adapted swing has been fitted for the use of the resident. At the time of the last inspection the pathway alongside the house leading to a gate that is used as a fire exit was very uneven and not wide enough for the resident to walk along safely. This has since been replaced with large paving stones that now provide the resident and staff with a level walkway to the gate. 14 Maple Way DS0000055527.V269616.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 and 36 The resident benefits from the home’s employment of staff who receive regular supervision and have clear job descriptions. EVIDENCE: The home employs a registered manager, an acting manager, two senior support workers and five support workers. Staff have clear job descriptions provided when they commence work at the home and one of the two support workers, in the home at the time of the inspection, spoke of the support and encouragement she received from the acting manager. The second support worker who has only commenced work at the home the day before said that staff she had worked with had been very supportive. The acting manager and one of the senior support workers have received training in providing supervision for staff and supervision sessions are arranged every six weeks. The supervision meetings are arranged at a time suitable for both parties and records are kept of the discussions. Supervision covers all aspects of care provision and includes training needs and opportunities. One of the support workers at the home confirmed she received regular supervision. The new support worker had not yet attended a supervision session but was involved with an induction course, which included mentoring and support. 14 Maple Way DS0000055527.V269616.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 41 and 42 The resident’s rights and best interests are safeguarded by the home’s up to date policies and procedures and her health, safety and welfare are promoted by the safe working practices operated at the home. EVIDENCE: The registered manager is currently on leave from the home and a senior support worker, who was a shift leader, has been given the responsibility of acting manager. She has many years experience in providing care for people with learning disabilities and has completed a City and Guilds foundation course in Care Management. She is currently working towards NVQ level 3. She is supported and supervised by the organisation’s area manager. The home has policies and procedures that are developed at the organisation’s headquarters. Policies and procedures include those for health and safety, confidentiality, admission of a resident, staff recruitment and financial issues. The acting manager said that she is in the process of reviewing the home’s policies and procedures. Some documents seen had been recently reviewed. The acting manager said that as she reviewed the documents she asked staff 14 Maple Way DS0000055527.V269616.R01.S.doc Version 5.0 Page 21 to read them and they were discussed in supervision meetings to ensure they were understood. Records seen indicated that emergency lighting and fire safety equipment has been checked regularly and all staff have attended fire drills. Checks had been completed on electrical appliances recently and the water system was tested for Legionella on the day of the inspection. At the time of the inspection visit, the kitchen looked clean and in good order, with food stored appropriately. Records were seen for the monitoring of the temperature of the fridge and freezer and cooked foods. Hazardous substances such as cleaning fluids were stored securely. 14 Maple Way DS0000055527.V269616.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x 2 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 x x x x 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 14 Maple Way Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score x x x x 3 3 x DS0000055527.V269616.R01.S.doc Version 5.0 Page 23 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA22 Regulation 22 Requirement The complaints procedures must be updated to include accurate, relevant information. This is an outstanding requirement of the inspection dated 15/11/04 The flooring in the activities room must be made even and the worn carpet replaced. The pathway used as a fire exit leading from the rear of the house to the side gate must be made wider and level to allow the resident safe use. The registered person is to remove the tumble dryer from under the stairs. The registered person must ensure that all policies and procedures contain accurate, up to date information and are signed, dated and reviewed annually. Timescale for action 31/08/05 2. 3. YA24 YA42 16(2)(c) 23(4)(b) 31/08/05 31/08/05 4. 5. YA42 YA40 23(4)(a) 17 31/08/05 31/08/05 14 Maple Way DS0000055527.V269616.R01.S.doc Version 5.0 Page 24 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 Good Practice Recommendations 14 Maple Way DS0000055527.V269616.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 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 14 Maple Way DS0000055527.V269616.R01.S.doc Version 5.0 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. 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!