Inspection on 24/07/08 for 14 Maple Way

This inspection was carried out on 24th July 2008.

CSCI found this care home to be providing an Good service.

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

14 Maple Way 06/03/07

14 Maple Way 20/12/05

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 07/11/2008.

CARE HOME ADULTS 18-65 14 Maple Way Headley Down Alton Hampshire GU35 8AZ Lead Inspector Peter J McNeillie Unannounced Inspection 24th July 2008 10:00 14 Maple Way DS0000055527.V366930.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 14 Maple Way DS0000055527.V366930.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 14 Maple Way DS0000055527.V366930.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 14 Maple Way Address Headley Down Alton Hampshire GU35 8AZ 01428 717565 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) www.robinia.co.uk The Robinia Group PLC Vacant Care Home 1 Category(ies) of Learning disability (0) registration, with number of places 14 Maple Way DS0000055527.V366930.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD) The maximum number of service users to be accommodated is 1. Date of last inspection 6th March 2007 Brief Description of the Service: 14 Maple Way is a care home owned and run by Robinia Care Limited, registered to provide support care and accommodation for one person with a learning disability. There is no current Registered Manager. A new manager, who is in the process of applying for registration had taken up her position on the day of the inspection but had previously worked in the home and provided support for staff from her previous position as registered manager of another service situated very close to Maple Drive. The home aims to provide a caring, supportive and empowering environment and offers a high staff to service user ratio throughout the day and night to the one resident who is supported to participate in a range of activities, available in-house and in the community, according to her needs and wishes. The property 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. There are some local facilities - a shop and pub, with additional choice in nearby Hindhead. 14 Maple Way DS0000055527.V366930.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is, 2 stars. This means the people who use this service experience good quality outcomes. This report was written after taking into consideration a number of sources of information and evidence. These included, the previous report, a site visit to the service, information obtained from examining residents and staff records, personal observations, talks with staff, management and responses by the manager to a CSCI Annual Quality Assurance Assessment (AQAA) prior to the inspection. This key unannounced visit took place on 24/06/08 between the hours of 10.00 am and 3.30 pm. During which all of the key standards for care homes for younger adults were assessed. We were unable to communicate with the one resident but were able to speak to their relatives by telephone. The results and findings contained in this report will determine the frequency and type of future inspections. What the service does well: What has improved since the last inspection? What they could do better: Following our visit no requirements were made and there were no areas of concern. However, to ensure that the resident to understand documents that concern her including the daily menu, these should be produced in a format or formats she can understand. 14 Maple Way DS0000055527.V366930.R01.S.doc Version 5.2 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 14 Maple Way DS0000055527.V366930.R01.S.doc Version 5.2 Page 7 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.V366930.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a system of assessing and identifying resident’s diverse needs which ensures residents safety and that their assessed needs can be met in a manner that involves residents and their representatives. EVIDENCE: There have been no admissions since the last inspection. We previously reported that prior to admission the resident’s needs were subject to an initial pre placement assessment and the service was set up specifically for her. The service provided is monitored on an ongoing basis and any changing needs are addressed. The Organisation offers staff training to ensure they have the skills to deliver appropriate support. Family contact and input is encouraged and facilitated and the service has developed good links with the community healthcare professionals. This situation remains unchanged. 14 Maple Way DS0000055527.V366930.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a system of planning and reviewing care which reflects residents wishes, aspirations, diversity and ensures residents needs are met within a risk management policy and involves residents, residents representatives or relatives in decisions that affect them. EVIDENCE: The residents support/care plans viewed is reviewed at least monthly and included confirmation that the resident or their representative had been involved in and consulted about the plan which was based on an initial and on going regular assessment of needs and risk which took into consideration resident’s needs, wishes, choices, aspirations, risks, details of any health care professional involved, communication methods, dietary needs and help required with eating and drinking. 14 Maple Way DS0000055527.V366930.R01.S.doc Version 5.2 Page 10 The residents right, and the opportunity to take risks is seen as fundamental, however it was clear from records the resident would have difficulty in totally understanding the concept of risk and risk taking. Despite this, the resident was supported to make decisions within a risk assessment framework with the help of staff who were skilled in communicating with the resident using methods that were recorded in care plans. Should restrictions need to be imposed these would be agreed with the resident and or the residents representative and recorded in the care plans. Staff who had a good understanding of the contents of the care plans and risk assessments and were able to explain how the care plan was put into day-today practice. To promote equality and diversity and to ensure that race, gender identity, disability, sexual orientation, age, religion and belief are promoted and incorporated into what they do, in their AQAA completed by the previous manager the home told us:” Staff within the service have either attended the course for equality and diversity or have booked on the future courses as they become available. The Robina equal opportunities mission statement is followed by all staff and any form of discrimination is dealt with either supervision or training requirements. There is an anti discriminatory policy in place, which all staff are aware of and use as guidance to what the company expects from staff in their treatment of others. As the home is for one service user, the service has always be run on the ethos of person centred planning as we are here primarily to meet her needs and develop her skills for more independent living. Our principles are based on Robina values they are respect, privacy, dignity, independence, choice, rights, and inclusion”. 14 Maple Way DS0000055527.V366930.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The social activities family contacts and the provision of varied and nutritious meals were well managed and reflected the residents interests and choices. EVIDENCE: Staff works positively with the resident to establish interests, likes and dislikes and to offer a wide range of formal and informal activities both recreational and therapeutic. Activities available include, arts and craft, trips and bowling. We were informed it is hoped to re introduce the resident to horse riding and swimming. The resident maintains close contact with family and visits them every two weeks. Her parents are welcome to visit without restriction and are consulted and included in all decisions affecting their daughter’s lifestyle. 14 Maple Way DS0000055527.V366930.R01.S.doc Version 5.2 Page 12 During the week the resident also attends sessions at the organisation’s resource centre in a nearby town on four days during which she is accompanied and supported by staff from the home to ensure continuity of care. 14 Maple Way DS0000055527.V366930.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Satisfactory arrangements are in place, ensuring the personal emotional, health care and medication needs of the resident are met. EVIDENCE: The resident requires assistance and support with all aspects of her personal care. As a consequence a great deal of training is given to staff to ensure this care is given in a sensitive manner that takes into consideration the residents wishes which are all clearly documented in the care plan. Records seen indicated that any special medical or health or social care needs would be provided following consultation with the appropriate professional, these might include the local learning disability team, doctors, district nurses, physiotherapists, occupational therapists, speech and language therapists, and care managers. Records were kept of appointments with all health and social care professionals and included details of any advice and treatment given. 14 Maple Way DS0000055527.V366930.R01.S.doc Version 5.2 Page 14 Medication records confirmed that all prescribed drugs and medicines, which are securely stored and administered in accordance with a medication policy and procedure by trained staff who confirmed they were aware of and had read the procedure. The record of drugs and medicines administered to the resident and unwanted drugs disposed of were complete and accurate. The manager informed us that a new medication policy is to be adopted that will provide a clearer audit trail. The new procedure will include external scrutiny/audits to ensure all staff stick strictly to the agreed guidelines. 14 Maple Way DS0000055527.V366930.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear policies and procedures in place which ensures residents are able to complain and are protected from abuse. EVIDENCE: A corporate whistle blowing and Adult Protection Policy and Procedure have been implemented to work in tandem with the procedure developed by Hampshire County Council. All management and staff spoken with demonstrated they were aware of the procedure to follow should they witness or suspect the abuse of a resident. The complaints procedure, which was also included in the service users guide included information on how to contact The Commission for Social Care Inspection (C.S.C.I), was seen, as was record of complaints. CSCI has received no complaints since the last inspection. Due to difficulties with communication we were unable to ascertain whether the resident felt comfortable in raising any concerns they had but her parents in a telephone conversation and staff did state they felt comfortable in discussing issues with management and were confident any concerns raised on behalf of the resident would be dealt with promptly and in a fair manner. 14 Maple Way DS0000055527.V366930.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A safe, well maintained, clean and suitably furnished home is provided for resident which met their needs. EVIDENCE: The home, which blends in with neighbouring properties and has no stigmatising signage, is situated in a pleasant residential area in the village of Headley Down. A keypad entry system is in place restricting admission to staff and visitors who can only gain admittance via staff. All areas of the home were clean and free from unpleasant odours and obvious hazards. Furniture was comfortable, homely and in a good state of repair, in keeping with the décor and met the residents needs. All communal areas were accessible by the resident including the well-tended established and safe garden. 14 Maple Way DS0000055527.V366930.R01.S.doc Version 5.2 Page 17 Apart from any personal aids some areas of the home had been adapted to stop the resident injuring herself. There is a rolling programme of maintenance to ensure that the building is well maintained, decorated and kept safe for the resident and staff. 14 Maple Way DS0000055527.V366930.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs are met by sufficient numbers of well trained and supported staff who are recruited and selected using a procedure designed to protect all residents. EVIDENCE: The planned daily staffing levels for the home each at least two members of staff on duty at all times during the daytime hours and one member of staff and one on call sleeping member at night. At the time of our visit, in our view the number of management, care and available met the residents’ needs, a view supported by the manager and staff. We viewed three staff recruitment and training files selected at random. All files viewed included evidence that staff are employed in accordance with a robust corporate recruitment and selection procedure, which is designed to protect residents. 14 Maple Way DS0000055527.V366930.R01.S.doc Version 5.2 Page 19 This involves the completion of an application form, the signing of a rehabilitation of offender’s declaration, an interview, and satisfactory Criminal Record Bureau (CRB) disclosure, Protection of Vulnerable Adults (POVA) and reference checks. Following their appointment, records seen confirmed that all staff are subject to an in house and corporate “Skills for Care” induction and compulsory training programme that include first aid, handling medication, food handling, moving and handling, POVA, and infection control. All staff are expected to undertake a National Vocational Qualification (N .V. Q.) Course. Information provided by the previous manager in the AQAA indicated that 71.4 of staff has been trained to at least NVQ level two, with a further 14.3 currently on a course leading to a level two qualification. To demonstrate their commitment to staff and training, the organisation had previously been accredited with Investors in People status. 14 Maple Way DS0000055527.V366930.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home ensures the health, safety and welfare of residents and staff are promoted and the home is run in the best interests of the residents whose views about living in the home are formally sought through their representatives. EVIDENCE: The previous manager (who had been in post since 2006) had left her post the day prior to our visit. A new Manager who is also registered as the Manager of a similar resource very close to Maple Way has been appointed and is in the process of applying for registration. Prior to her appointment the new manager had worked in Maple Way and was familiar with the workings of the home and therefore in a position to produce 14 Maple Way DS0000055527.V366930.R01.S.doc Version 5.2 Page 21 an action plan where she felt improvements could be made. These include changes to one to one staff supervision, on going resident’s assessments and care planning, quality monitoring to include the views of visiting health and social care professionals and improved monitoring of medication. We also discussed with the new manager the production of documents in a format that the resident could understand among these being menus. This would also demonstrate the resident was able to exercise choice regarding meals taken. An in house health and safety policy was in place to ensure the day-to-day safety of staff and residents. Procedures include, weekly health/ safety checks, the regular servicing of equipment, staff training in the techniques of moving and handling infection control, control of substances hazardous to health (C.O.S.H.H.) first aid, health and safety, reporting accidents, procedures to follow in the event of fire (including evacuation). All of the hot water supplies to baths were fitted with thermostatic controls set at 43 degrees centigrade and all radiators and hot pipes were covered to prevent a resident or staff being burnt. 14 Maple Way DS0000055527.V366930.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 X 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 x 14 Maple Way DS0000055527.V366930.R01.S.doc Version 5.2 Page 23 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. 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. Refer to Standard Good Practice Recommendations 14 Maple Way DS0000055527.V366930.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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