Inspection on 15/12/05 for Maple Dene

This inspection was carried out on 15th 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Maple Dene 14/08/07

Maple Dene 06/09/06

Maple Dene 27/06/05

Maple Dene 10/03/05

Maple Dene 28/09/04

Maple Dene 13/01/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Maple Dene 10-14 St Agnes Road Moseley Birmingham West Midlands B13 9PW Lead Inspector Ann Farrell Announced Inspection 15th December 2005 08:10 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Maple Dene DS0000016913.V266036.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Maple Dene DS0000016913.V266036.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Maple Dene Address 10-14 St Agnes Road Moseley Birmingham West Midlands B13 9PW 0121 449 7677 0121 449 6155 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) Anchor Trust Vacant Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40), Physical disability (40) of places Maple Dene DS0000016913.V266036.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to accommodate 40 adults over the age of 65 who are in need of care for reasons of old age, not falling within any other category (40 OP) and Physical Disability over 65 years of age (40 PD(E)) The home can accommodate up to six service users who are in need of care for reasons of dementia. 6 DE(E) In addition to the manager and ancillary staff minimum staffing levels must be maintained to at least 4 care staff at all times during the waking day 27/6/05 2. 3. Date of last inspection Brief Description of the Service: Maple Dene is a large detached three-storey property that is situated in a quiet residential area of Moseley, within easy reach of public transport and other amenities. The home is owned and managed by Anchor Trust. The building has been adapted and extended to provide residential accommodation for 40 people for reason of old age. Accommodation is provided in 38 flats, of which 36 provide single accommodation. There is adequate parking to the front of the building and a mature well maintained garden to the rear. Each flat has a small kitchen area suitable for the preparation of snacks etc plus an en-suite facility that consists of a toilet and low-level bath or shower. There are assisted communal bathing facilities on each floor as the low level baths may not be suitable for all residents. Communal facilities consist of a lounge and dining room on the ground floor and there are plans to provide a conservatory in the near future. A passenger lift gives access to all areas in the home. The main kitchen, where all meals are prepared, is situated on the ground floor. There is also a laundry where all resident’s laundry is undertaken separately. Maple Dene DS0000016913.V266036.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was carried out over one day on 15th December 2005 commencing at 8.10am. This was the second statutory inspection for 2005/2006. This report should be read in conjunction with the report of the inspection conducted in June 2005 to obtain an overall view of the home. The manager was present for the duration of the inspection. During the inspection process the inspector toured the home, undertook case tracking of some residents files in addition to inspection of other documentation. The manager, one member of staff, five residents and the district nurse who was visiting were spoken to on the day of inspection. The Commission also received sixteen written comment cards from relatives, residents and health professionals prior to the inspection, which provided positive feedback about the home and staff. What the service does well: The home has a relaxed, friendly and homely atmosphere. All flats have ensuite and kitchen facilities enabling residents to make drinks and snacks if they wish. Staff are very welcoming and ensure residents privacy and dignity is maintained at all times. Feedback indicated there was a good standard of care and residents are allowed their independence. One resident stated, “ The staff are lovely, people are nice and friendly, you can have visitors at any time and my daughter brings my dog in to see me”. Visiting is flexible and feedback indicated that visitors are always made welcome. There are regular meetings with residents and staff and management respond to suggestions continually looking at ways to improve the service. They respond positively to inspections and try to address requirements promptly. The home is always clean, odour free and well maintained providing a safe environment. There is a hearing loop system in the lounge for those with hearing aids. They have good systems in place for the control of infection with each member of staff having hand gel and all residents clothing is laundered individually. One resident stated “ The laundry is lovely”. Maple Dene DS0000016913.V266036.R01.S.doc Version 5.0 Page 6 Feedback from health professionals was positive and one stated “ “I have always been very impressed with the standard of care and positive attitude of the staff at Mapledene”. There is an externally approved quality assurance process in place and feedback from residents and relatives earlier in the year was very positive. Some of the comments included; “I am very pleased with the progress that my relative is making”. “My mother is well and happy at the home; it is her haven. The staff are great, I have peace of mind. I would be happy to end my days in Mapledene”. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Maple Dene DS0000016913.V266036.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Maple Dene DS0000016913.V266036.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4,6 Information has been updated and is available to all residents providing them with information about the facilities and services. Further development of assessments is required to ensure all residents’ needs are identified and met consistently. EVIDENCE: The home provides long term care for residents over 65 years of age. They have a statement of purpose, service users guide and information pack. The service user guide had been updated since the last inspection and it was found to be comprehensive providing a range of information for prospective residents wishing to move into the home. A copy of the statement of purpose was also available in all flats. The home liaises with social workers who provide written assessments/care plans for residents who wish to enter the home. Staff also invite prospective residents to the home enabling them to view the facilities, meet staff and other residents and partake in a meal. At this stage the home is able to undertake an initial assessment to determine if they are able to meet residents needs. Maple Dene DS0000016913.V266036.R01.S.doc Version 5.0 Page 9 Following admission to the home a more comprehensive assessment is undertaken and an individual lifestyle agreement (ILA) is drawn up. There is a trial period of one month when a review is held with the resident, staff and family. On inspection of the records relating to admission it was noted that some lacked detail. It is recommended that staff liaise with the social worker and obtain copies of the assessment undertaken by them, which will assist with identifying resident’s needs. The home is registered to admit a number of residents with dementia and some staff have undertaken training in this area. This needs to be extended to all staff employed in the home. Maple Dene DS0000016913.V266036.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,10 The home has good systems in place to meet resident’s health care needs. Shortfalls in the recording systems need to be addressed to ensure all resident’s needs are being met consistently. EVIDENCE: Staff draw up an individual lifestyle agreement (ILA) for each resident following admission to the home outlining how the resident’s needs are to be met by staff. On inspection of a sample of records they were found to be vague in areas, some had not been signed or dated, they were lacking in detail and all needs had not been included in the plan of care. It was also noted that they had not been reviewed on a monthly basis. Daily records were very basic lacked detail and did not consistently indicate follow up/monitoring of areas of concern. The inspector was informed the organisation is currently reviewing the documents in respect of care planning and some suggestions were made to the manager to assist with compiling the records. In order for a consistent approach to care detailed care plans should be in place for all staff to access. Maple Dene DS0000016913.V266036.R01.S.doc Version 5.0 Page 11 Manual handling assessments had been completed and in some files there was evidence of an assessment in respect of other risks, but the action required to reduce risks were vague. The home has good systems in place for monitoring health and nutrition and liaises with health professionals as required. Written and verbal feedback from health professionals was positive; one stated,” the staff are sensitive to residents needs and supportive to residents and professionals”. Written comments indicated that the staff communicate clearly, have an understanding of the care needs of residents and they were satisfied with the overall care provided. Maple Dene DS0000016913.V266036.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15 There have been improvements in the arrangements for activities and this continues to develop. The arrangements for meals need further review as the quality is variable and there are times when they are not meeting resident’s wishes. EVIDENCE: Residents are free to come and go as they wish and there are no rigid rules. Visiting is flexible and written feedback indicated that visitors were made welcome, they are consulted about changes and kept informed of any matters affecting the resident. Since the last inspection the home has employed a new activities co-ordinator who has maintained a record of individual discussions with residents and some of the activities that have been arranged to date. She was enthusiastic and keen to introduce new ideas. The manager stated that since she has taken up the post some residents have become more involved with activities in the home. This is a pleasing development. There are regular exercise and bingo sessions. The notice board indicated that volunteers visit the home from the local church every two weeks and play games etc. A local string quartet from the community visit the home to give recitals. Maple Dene DS0000016913.V266036.R01.S.doc Version 5.0 Page 13 There is a designated area for books and the library service visit regularly providing a range of books and talking books. A religious service is held in the home each month and ministers of various denominations visit on a regular basis or on request. There is a pleasant enclosed garden and patio to the rear with seating for resident’s use, when the weather permits. Plans have been forwarded for the provision of a conservatory, which will provide an additional communal area for residents to sit and will enhance facilities in the home. Residents take their own furniture into the home enabling them to create a home from home environment. The home employs separate catering staff who provide three full meals per day, which includes a three-course lunch. Verbal and written feedback from residents indicated that the meals were variable and it was good sometimes. This area was discussed with the manager in order that she can follow this up further with residents. Feedback from a customer satisfaction survey undertaken earlier in the year indicated improvements in the food from previously, but this area still needs further work. Maple Dene DS0000016913.V266036.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: This area was not assessed at the time of inspection. Maple Dene DS0000016913.V266036.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,24,25,26 The standard of décor and furnishings in the home is good, providing residents with a pleasant and homely environment to live. EVIDENCE: Maple Dene DS0000016913.V266036.R01.S.doc Version 5.0 Page 16 The home is a detached three-storey building, which is clean, odour free and well maintained. There is adequate parking to the front and a pleasant mature garden to the rear. There are plans to improve access to the property for larger vehicles such as ambulances. There is one large lounge, which is adjacent to the dining room on the ground floor. The ground floor corridor has recently been re-decorated and there are plans to re-decorate the lounge and remaining corridors and also to provide a conservatory. All flats are provided with locks and letterboxes to doors; they are carpeted and generally residents provide all their own furnishings, although furniture is available if required. Accommodation is provided in the form of 8 bed-sits and 28 flats with a separate bedroom and lounge/kitchen area, of which two are double. All flats are fitted with en-suite facilities; eight flats are fitted with showers and the remaining have baths, which are very low and may not suitable for the client group. There are assisted shower rooms and bathrooms on each floor, which are pleasantly dressed enabling residents to have a choice of bathing facility. Staff have a master key to flats in the event of an emergency and they are in the process of providing lockable facilities in each room. Flats are individually and naturally ventilated and windows are provided with restrainers. The home is in the process of providing covers to radiators and water from hot water outlets are regulated. Laundry facilities were appropriately sited with a washing machine with sluice cycle. Part of the laundry area is segregated to provide sluice facilities. Maple Dene DS0000016913.V266036.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Staffing levels were being maintained to satisfactory levels to meet resident’s needs. There are robust recruitment procedures in place ensuring the protection of residents. EVIDENCE: The staffing rotas indicated that there were adequate numbers of staff on duty. There is one senior carer and four care staff during the morning, one senior carer and three carers on duty during the evening and two carers overnight. A small number of staff files were examined, which demonstrated a robust recruitment procedure. Approximately 60 of staff are trained to NVQ level and the manager is waiting for the updated induction training to be forwarded. Maple Dene DS0000016913.V266036.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 The new manager is enthusiastic and has commenced introducing some changes with the support of staff. There are good systems in place and the home is managed in the interests of the residents. Their health, safety and welfare are protected. EVIDENCE: Since the last inspection the manager has been appointed permanently and she has forwarded an application form to the Commission for registration. The outstanding maintenance issues from the last inspection have been addressed. All staff had undertaken one fire drill and arrangements were being made for remaining staff to undertake the second drill as required. Also first aid training has been arranged for January. The home holds money on behalf of some residents in a secure facility. On inspection of records it was found to be satisfactory. Maple Dene DS0000016913.V266036.R01.S.doc Version 5.0 Page 19 The home has a quality assurance system in place and a visit is undertaken annually from an external company. Earlier in the year another company undertook a customer satisfaction survey obtaining feed back from residents and relatives. A report was produced following the survey and it produced very positive feedback with many stating they would recommend the home. Comments included “ My relative is happy in the home”. “ The home is fantastic”. The staff in the home have followed the survey up and have addressed some areas identified such as the lighting in bathrooms and are hoping to re-decorate in the future. Maple Dene DS0000016913.V266036.R01.S.doc Version 5.0 Page 20 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 2 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 3 3 3 3 4 3 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 2 X 3 X 3 X X 3 Maple Dene DS0000016913.V266036.R01.S.doc Version 5.0 Page 21 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 OP3 Regulation 14 Requirement The registered person must ensure an assessment is completed for all residents entering the home to cover all areas outlined in standard 3 of the National Minimum Standards. All assessments must be signed and dated. Timescale of 28/8/03 not met. The registered person must ensure that ILA/care plan includes all areas of need/risk identified and record in detail the action required by staff to meet the needs of residents. They must be reviewed on a monthly basis and updated where appropriate. Timescale of 30/9/03 not met. The manager should consult with residents about the meals to determine their needs/likes and address any issues identified. Timescale for action 30/03/06 2. OP7 15 30/03/06 3. OP15 16(2)(i) 30/01/06 Maple Dene DS0000016913.V266036.R01.S.doc Version 5.0 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP3 Good Practice Recommendations It is recommended that staff obtain copies of assessments completed by social workers where possible to assist with drawing up care plans Maple Dene DS0000016913.V266036.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. 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