Inspection on 06/09/06 for Maple Dene

This inspection was carried out on 6th September 2006.

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 15/12/05

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 Amanda Lyndon Unannounced Inspection 6th September 2006 09:00 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.V310509.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 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.V310509.R01.S.doc Version 5.2 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 Leisha Cooper 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.V310509.R01.S.doc Version 5.2 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 15 December 2005 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. Six older people with dementia care needs can live at the Home. Accommodation is provided in 38 flats, of which 36 provide single accommodation. There is adequate parking to the front of the building. Each flat has a small kitchen area suitable for the preparation of snacks and this includes a fridge. A number of flats have a separate lounge area. There is a call bell facility in each flat for residents to use in order to summon assistance or urgent help in the event of an emergency. Residents are able to smoke in their flats if deemed to be safe to do so. Each flat has 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. Staff are available to provide assistance with bathing as required. Communal facilities consist of a lounge and dining room situated on the ground floor. A spacious conservatory has recently been completed. The internal environment of the Home and external secure garden areas are suitable for wheelchair users. A passenger lift gives access to all areas of the Home and there are aids and adaptations available to meet the needs of residents with disabilities. There are notice boards located throughout the Home displaying forthcoming events and other information of interest to residents and their visitors. The most recent CSCI inspection report was accessible to any interested parties. The weekly fee to live at Maple Dene is between £368 and £435. Items not covered by the fee include hairdressing, chiropody and telephone calls. Maple Dene DS0000016913.V310509.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report reflects the findings of a one day unannounced field work visit undertaken by two Inspectors when there were forty residents living at the Home. Information was gathered by speaking with residents, visitors and staff, case tracking, examining care, medication and health and safety records and observing the staff perform their duties. A tour of the premises was undertaken. Prior to the visit the Registered Manager had completed a pre inspection questionnaire and had returned it to CSCI, giving some information about the Home, residents and staff which was taken into consideration. Comments were received from residents and most of these were very positive in nature about the service provided at Maple Dene, including: “This is a lovely home. I am very happy here, the service is very good and attention could not be better” “I have good friends amongst the staff” “I enjoy the entertainments, sing a longs and acting” “There is a good laundry service here” A small number of negative comments were received including: “I would like a few more outings” “A little more variety of food would be welcome” What the service does well: The admission process is thorough. Prospective residents are invited to spend a day at Maple Dene in order to sample what it would be like to live there. One resident said “I had two tours of the Home before I came to live here. The Home Manager was very willing to answer my questions” Another resident said “ I came and had a meal here when there was a vacancy”. Care staff provide support for the residents to receive the appropriate medical care and monitor any treatments prescribed by the Doctors to ensure that any health problems are improving. Maple Dene DS0000016913.V310509.R01.S.doc Version 5.2 Page 6 One resident said “ Doctors appointments are generally made as soon as possible for me” Residents are provided with a well maintained, clean and comfortable living environment in which they feel safe and secure and visitors are made to feel welcome. One visitor said “ I love it here, it’s just like a hotel. I make a cup of tea when I get here. I know all the carers and speak to all the residents here”. One resident said “ The house keeping staff are very good”. The physical environment of the Home is suitable for residents with physical disabilities and aids and adaptations provided ensure that residents’ needs are met. Residents can personalise their flats to reflect their individual tastes, cultural choices and interests and this ensures that they feel comfortable in their surroundings. One resident said “ My flat is super with all my pictures in”. Residents are cared for in a respectful manner and this ensures that their dignity and self esteem are maintained. Residents have the option of a private telephone line in their flats. Alternatively a payphone is provided in a quiet area of the Home to enable residents to make telephone calls in private. The postman delivers residents’ mail to their individual flats and this ensures that their privacy and independence is maintained. Residents are able to exercise choice over their daily lives and the activities that they choose to participate in which promotes their individuality and independence. There is a wide variety of activities on offer at the Home for the residents to participate in should they choose. One resident said “ I enjoy going to church and to the tennis club”. Another resident said “ The staff are very willing to save a meal for me and bring it up to my flat” Residents’ individual religious beliefs and cultural preferences are respected. There are opportunities for religious worship and support is provided by staff in this area. There is a comprehensive complaints procedure accessible to residents and visitors should they need to make a complaint. One visitor said “ I have never had to complain here”. Staff receive appropriate training to ensure that they have the knowledge to work competently within their job roles. Residents are invited to regular meetings to discuss the service provided at the Home and there was evidence that any suggestions made are acted upon. Maple Dene DS0000016913.V310509.R01.S.doc Version 5.2 Page 7 There is a friendly and approachable management team at Maple Dene and this promotes a positive living and working environment. Senior External Managers visit the Home regularly and monitoring of the services provided at the Home is undertaken to ensure that they are of a consistently good standard. There is a robust system for the management of residents’ personal allowances should they choose for the Home to hold this on their behalf. What has improved since the last inspection? What they could do better: Maple Dene DS0000016913.V310509.R01.S.doc Version 5.2 Page 8 Residents and/or their families must be involved in the agreeing and reviewing of their plan of care in order to ensure that their preferred routines are maintained. An individualised written plan of the action to be taken should a resident fall must be available in respect of each resident to ensure that the appropriate action is taken by staff to prevent the risk of further injuries being sustained. Medication was left unattended during the field work visit and this poses a risk to the physical health of vulnerable residents. The menus did not identify all of the meal options on offer and this may prevent residents from being served food that they enjoy. Fire doors were wedged open and this would be a risk to the health and safety of people within the Home in the event of a fire. 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.V310509.R01.S.doc Version 5.2 Page 9 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.V310509.R01.S.doc Version 5.2 Page 10 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): 1,3,4 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission and assessment processes and information are comprehensive and this enables residents and their families to make an informed choice about whether they would like to live at the Home. Residents know before admission and during their stay that the Home can meet their care needs and residents are consulted about how these needs will be met. EVIDENCE: Comprehensive statement of purpose and service user guides had been produced in order to provide prospective residents with information about the services provided at Maple Dene. These were available in a large print format for people with poor eyesight. A DVD about the Organisation was available if residents or their families wished to obtain further information. The Registered Manager said that consideration may be given to producing these documents on audiotape for people with hearing impairments. Maple Dene DS0000016913.V310509.R01.S.doc Version 5.2 Page 11 Senior staff undertake a preliminary pre admission assessment of a prospective resident’s care needs in order to prevent inappropriate trial visits to the Home. Following this, prospective residents are invited to spend a day at the Home and have a meal in order to sample what life would be like to live there and make a decision about whether or not they would like to live at Maple Dene. A pre admission assessment is undertaken during this time, however this requires further development in order to cover all aspects of residents’ daily lives as identified in the National Minimum Standards. One resident who recently came to live at the Home expressed her satisfaction about being able to choose her flat during her trial visit to Maple Dene. One resident said “I had two tours of the Home before I came to live here. The Home Manager was very willing to answer my questions” Another resident said “ I came and had a meal here when there was a vacancy”. Residents come to live at the Home on a four week trial period and this can be extended to six weeks if required. Following this time a care review is held involving the resident, their family, care home staff and social worker in order to provide opportunities for discussion about whether the resident is happy living at Maple Dene and to ensure that their care needs are being met. Not all care reviews had been signed or dated to confirm that all parties involved agreed to the content of the review. A number of residents living at the Home had minimal care needs and were supported by the staff to maintain their independence. Intermediate care is not provided at Maple Dene Maple Dene DS0000016913.V310509.R01.S.doc Version 5.2 Page 12 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, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ ongoing health and personal care needs are well met, taking into account residents’ individual preferences in respect of their daily lives. Residents’ care needs are adequately monitored and documented. Medication is administered in a safe manner. Residents are cared for in a respectful manner and this ensures that their dignity and self esteem are maintained. EVIDENCE: Plans were in place for a new care planning system to be introduced at the Home, however the current system in place was deemed to be adequate and well organised. On admission to the Home, comprehensive assessments are undertaken of the individual resident’s care needs including their interests, religious/cultural beliefs, abilities and health care needs. It was pleasing that these included an Maple Dene DS0000016913.V310509.R01.S.doc Version 5.2 Page 13 abundance of the individual preferences of residents in respect of their daily lives in order to ensure that these would be maintained whilst living at the Home. It was evident during the field work visit that the staff were aware of and respected these preferences, providing support as required. It was pleasing that residents were consulted about what they value in order for staff to establish what is important in their lives thus provide the necessary support to maintain these. Comprehensive, individualised care plans had been derived from the information obtained and these identified the specific support required from staff in order to meet the care needs of the individual residents. Although one resident stated that staff had read her care plan to her there was no evidence that residents or their representatives had agreed to the content of these which may prevent individual preferred routines from being maintained. The specific support required by staff regarding communicating with a resident who had impaired speech was recorded in good detail within their care plan and this ensures that staff have the knowledge about how to communicate effectively with this person, maintaining their dignity. The preferred languages of residents were recorded within the care plans and any support required by staff in this area was identified. There was currently no need for interpreter services at the Home. Daily reports were found to be non descriptive and repetitive at times and did not reflect the good standard of care that residents were receiving whilst living at Maple Dene. Residents’ personal risk assessments had been undertaken including comprehensive nutritional screening to ensure that all residents receive a healthy diet. Risk assessments about residents going outside of the Home on their own were undertaken in order to minimise the risks to the well being of the residents whilst maintaining their independence. Comprehensive moving and handling risk assessments were undertaken in order to safeguard both residents and staff and there was evidence that appropriate pendant style call bell equipment was provided for residents who were deemed to be at risk of falls. It was evident that the care staff seek advice from Health and Social Care Professionals as required to ensure that residents’ health and well being are being met. Residents have access to a range of Health and Social Care Professionals including district nurses, community psychiatric nurses, dieticians, chiropodists and dentists. Residents are able to retain their own General Practitioner on admission to the Home (if the GP is in agreement) One resident said “ Doctors appointments are generally made as soon as possible for me” Maple Dene DS0000016913.V310509.R01.S.doc Version 5.2 Page 14 Multi disciplinary care reviews are arranged by the Home if required in order to determine whether residents’ individual care needs were being met whilst living at Maple Dene and to establish if any additional care input was required. A plan of scheduled visits from Health Care Professionals had not been developed and it is recommended that a plan be developed in order to ensure that residents’ health care needs are met. The management of medication was good and the systems for the ordering administration, storage and disposal of medication was robust, safeguarding residents. Medication audits are undertaken regularly by the local Pharmacist in order to ensure that medication is administered in a safe manner. A number of residents had chosen to self administer their own medication and this promotes their independence. Risk assessments are undertaken in order to ensure that the correct medication is administered at the correct time. A liquid medication brought in to the Home by a resident’s relative was left unattended in a resident’s flat and this may be a risk to the health of vulnerable residents if accidentally swallowed. The actual dosage administered in respect of a variable dosage medication had not been recorded preventing accurate auditing and monitoring of the effectiveness of the treatment. Most residents had a private telephone line in their flats and in addition to this the Home provides a pay phone which is located within a private booth in order for residents to make calls in private. All residents are offered the key for their flat door and these could be overridden in the event of an emergency. This ensures that residents’ privacy is respected whilst maintaining their safety. All flats have their own letter box and the postman delivers residents’ mail in person to their individual flats. This is considered to be a unique and positive service which ensures that the independence and privacy of residents are maintained. A risk assessment of persons outside of the Home’s staff team that have access to the residents’ private living areas should be undertaken in order to safeguard residents. Residents appeared to be well supported by staff to maintain their personal hygiene and to choose clothing and jewellery appropriate to their individual tastes, age, gender and the time of year. Maple Dene DS0000016913.V310509.R01.S.doc Version 5.2 Page 15 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, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activities on offer meet the needs and expectations of the majority of residents living at the Home. Residents are supported to maintain contacts with their friends and families and are given choice and freedom to make decisions regarding their daily lives and this promotes their individuality and independence. The choice of wholesome and well presented meals meet any special dietary needs of residents for reasons of health or cultural/religious beliefs. However the menus do not reflect the full choice of food available at mealtimes and this may prevent residents from being served a variety of meals that they enjoy. EVIDENCE: The Home employs an activities organiser and in addition to this, all of the staff team are responsible for arranging activities at other times. There was a range of activities that residents could choose to participate in including entertainers, food tasting, reminiscence, gardening, quizzes, manicures and some trips out side of the Home. Residents’ birthdays are celebrated and the hair salon is open twice a week. Maple Dene DS0000016913.V310509.R01.S.doc Version 5.2 Page 16 One resident said “ I enjoy the pub lunches” Another resident said “I would like a few more outings” A record of activities arranged and the success of each of these was maintained in order to plan forthcoming events to meet the interests of residents living at the Home. The activities organiser spends time with residents who either choose or are not able to participate in group activities, ensuring that they are socially and mentally stimulated. There were notice boards located throughout the Home displaying forthcoming events and other information of interest to residents, including details of advocacy services. A residents’ newsletter is published four times a year and this ensures that residents are kept informed about any news relating to their lives at Maple Dene. There were opportunities for religious worship both within and outside of the Home. A church service is held at Maple Dene every month and Holy Communion is also held. A number of residents choose to visit their local church in order to maintain their independence and links with the community. There were currently no residents of other faiths living at the Home, however the management team stated that they would provide support in this area as and when required. A number of residents had chosen to have a newspaper of their choice delivered and in addition to this a communal newspaper is also delivered funded by the Home in order to keep residents abreast of current affairs. There is a library for residents to choose books that may be of interest to them. There is an open visiting policy at the Home and visitors are welcome to have a meal at the Home for a small charge. This ensures that residents are supported to maintain links with the people important to them. One visitor said “ I love it here, it’s just like a hotel. I make a cup of tea when I get here. I know all the carers and speak to all the residents here”. Residents are able to exercise their control over their daily lives and how they choose to spend their time. One resident said “ I don’t take part in activities because I like being in my flat reading and watching television” Residents are able to go outside on their own or with their families and friends as they choose following individual assessments. One resident said “ I enjoy going to church and to the tennis club”. There were no rigid rules or routines at Maple Dene. Residents can choose the time that they get up in the morning and the time that they go to bed at night. One resident said “ The staff are very willing to save a meal for me and bring it up to my flat” Maple Dene DS0000016913.V310509.R01.S.doc Version 5.2 Page 17 A resident satisfaction questionnaire had recently been distributed in respect of the choice of meals available at the Home and any suggestions put forward by residents were introduced. Residents stated that they choose what they would like to eat for the following day from a menu option list. The menus identified a good range of wholesome meals, however two fish dishes were on offer on a Friday and despite alternatives being available, these were not identified on the menu. A snack meal was available at supper time however this was not identified on the menu. The menus did not identify the sweet options on offer however these were displayed on a black board in the dining room. The menu on display in the reception area of the Home did not reflect the meals of the day. A three course meal is served at lunch time and the main meal options on the day of the field work visit were liver or macaroni cheese and these were well presented and appetising. One resident said “ The liver is really tender” The portions of soft diets were served individually to enable residents to choose which elements of their meal they wished to eat. Appropriate lipped plates were available to maintain the independence of residents and staff were assisting other residents with their meal as required in a respectful manner, thus maintaining their dignity. There were good social interactions between the residents and the residents and staff during the meal making it an enjoyable social event. One resident said “ A good choice of food is usually on offer” Another resident said “A little more variety of food would be welcome” Special diets can be arranged for reasons of taste, health, religious or cultural preferences. Diabetic and soft diets are currently being prepared. Maple Dene DS0000016913.V310509.R01.S.doc Version 5.2 Page 18 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): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure is comprehensive and accessible to residents and their visitors should they need to make a complaint so that complaints are dealt with in an appropriate and timely manner. Staff knowledge in respect of adult protection procedures is good and this safeguards residents. EVIDENCE: CSCI have not received any concerns, complaints or allegations about Maple Dene since the last field work visit. The complaints register held at the Home identified eight concerns/complaints made directly to the Home since January 2006 regarding the cleanliness of the Home, poor staff attitude and personal possessions of residents missing. These were all investigated by the management team in a timely manner to the satisfaction of the complainants and care practices had been reviewed in response to these. A comprehensive complaints procedure was on display in a prominent place of the Home in order for residents or their visitors to refer to should they need to make a complaint. This was also available in a large print format. A copy of this procedure was included within the service user guides distributed to all residents on arrival to the Home. Maple Dene DS0000016913.V310509.R01.S.doc Version 5.2 Page 19 One visitor said “ I have never had to complain here”. A number of compliments had been received by the Home about the standard of care and services provided there. Staff had undertaken training about the protection of vulnerable adults and staff met during the visit were aware of the local procedures regarding this. The adult protection policy included local multi-agency guidelines in order to safeguard residents. Maple Dene DS0000016913.V310509.R01.S.doc Version 5.2 Page 20 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, 22, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, comfortable, homely and well maintained environment and the Home is designed to respect the privacy of all residents living there. The physical environment of the Home is suitable for residents with physical disabilities and the aids and adaptations provided ensure that residents’ needs are met. Residents feel comfortable, safe and secure in their flats. EVIDENCE: The internal environment of the Home is homely, well maintained and suitable for wheelchair users. There was a rolling programme of refurbishment and redecoration in place in order to ensure that residents had a safe and comfortable environment in which to live. Maple Dene DS0000016913.V310509.R01.S.doc Version 5.2 Page 21 There was ramped access in to the well maintained and attractive secure garden ensuring that this area was suitable for wheelchair users and residents with physical disabilities. There was an attractive fish pond which was securely positioned behind railings and good quality garden furniture for residents to use whilst enjoying this facility. A spacious and light conservatory had recently been completed and this was furnished to a high standard. This could be used for residents who wished to entertain their families and provided an alternative quiet seating area for residents to enjoy if they chose. One resident said “ I like to sit in the conservatory after tea and read my book” It was noted that the flooring in one area of the conservatory “dipped” and this may pose as a trip hazard for some residents. Specialist advice was sought by the Registered Manager regarding this shortly after the field work visit. There were small seating areas located throughout the Home providing residents with a choice of areas in which to relax. The main lounge had recently been redecorated and the residents had helped to choose the wall coverings in order to feel comfortable whilst relaxing in this area. In addition to en suite bathing facilities there were two assisted baths and two assisted shower facilities that met the needs of residents living at the Home. The majority of residents required the support of staff during bathing. However, if deemed safe to do so residents may bath or shower on their own in order to maintain their independence and dignity. Call bells were in easy reach of the bathing facilities in order for residents to summon assistance in an emergency. Pressure relieving mattresses and cushions were provided by the district nursing team for all residents deemed to be at risk of developing sore skin. There were two hoists available for residents with physical disabilities in order to safeguard both residents and staff. Raised toilet seats and hand rails were provided near to toilets and in corridors in order to promote the independence of residents and maintain their dignity and safety. Residents are encouraged to bring their own furniture in to the Home and decorate their flats to reflect their individual interests and tastes in order to feel comfortable in their surroundings. Residents’ flats contained many personal belongings. One resident said “ My flat is super with all my pictures in”. There is a call bell facility in each flat for residents to use in order to summon assistance or urgent help in the event of an emergency. The internal temperature within the Home was comfortable on the day of the inspection. The ceiling fan and window and ceiling blinds were in use in the conservatory in order to make the temperature in this area comfortable for residents to use and staff were monitoring the temperature within this area. One resident said “ The conservatory is very hot at times”. Maple Dene DS0000016913.V310509.R01.S.doc Version 5.2 Page 22 The Home was clean and fresh on the day of the inspection and hygienic hand washing facilities were provided. One resident said “ The house keeping staff are very good”. One visitor said “ The flats are immaculate here”. Residents have the option of using a commode in their bedroom, however only a few have chosen to do this. Used commode pots are manually cleaned by staff and a risk assessment should be undertaken and practical procedure written regarding this in order to safeguard staff and prevent the spread of infection. There was a hygienic and effective system in place for the laundry of residents’ personal clothing and bed linen. Maple Dene DS0000016913.V310509.R01.S.doc Version 5.2 Page 23 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Home has an appropriate skill mix and allocated numbers of staff to offer a good consistent standard of care to meet the assessed needs of residents. There is a generally robust system for staff recruitment in place, however lapses in procedures on occasions does not safeguard residents. Staff had received training to ensure that they perform within their job roles in a competent manner in order to meet the needs of residents. EVIDENCE: Following the recent recruitment of staff there were no staff vacancies at the Home. The care staffing level during the morning had recently been increased to meet the care needs of residents living at the Home. Five care staff including a senior carer are available during the mornings, four care staff including a senior carer are available during the afternoons and two care staff are available during the night. The staffing rotas identified that the Home were working within these levels for the vast majority of the time and agency staff were used on occasion. In addition kitchen, housekeeping and laundry staff are employed ensuring that residents receive the appropriate support in all aspect of their daily lives. Maple Dene DS0000016913.V310509.R01.S.doc Version 5.2 Page 24 The Management team and senior staff provide on call support to the person in charge of the shift and this ensures that the staff on duty feel supported at all times. One resident said “ All of the care and kitchen staff are very pleasant and helpful” Another resident said “ The staff are often very busy and sometimes have to keep me waiting if they are dealing with someone else” Another resident said “ I have a good relationship with the staff although the turnaround of staff can sometimes disrupt the routine”. Plans were in place to address these concerns. Staff recruitment files included all of the information required by Regulations with the exception of a new member of staff that had been scheduled to commence employment at the Home the day after this visit. Two satisfactory written references had not been obtained about this person and the Registered Manager postponed the staff member’s start date until all relevant information had been obtained. Staff working at the Home were deemed by the Organisation to be safe to work with vulnerable people, however risk assessments in respect of this had not always been undertaken. This was addressed by the Registered Manager during the visit. Interview notes were kept, however it was not always possible to evidence that any gaps in information provided on staff application forms had been explored and this may pose a risk to residents’ safety. New staff undertake comprehensive “Skills For Care” induction training and this ensures that they have the appropriate knowledge to support residents in a competent manner. Staff had undertaken recent training relevant to their job roles including safe management of medication, dementia care, performance management and death and dying. Plans are in place for a number of staff to undertake further dementia care training in order to meet the specific care needs of these residents. Over 50 of care staff had achieved an NVQ Level 2 and other staff members were currently working towards this ensuring that residents receive a good standard of care. Maple Dene DS0000016913.V310509.R01.S.doc Version 5.2 Page 25 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, 32, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This is a well managed Home and is run in the best interests of the residents living there. The systems for resident consultation are good and there is evidence that the residents’ views sought are acted upon. There were systems in place to monitor the quality of the service on offer to the residents. Staff are trained in health and safety issues to ensure that residents’ safety and welfare are protected. EVIDENCE: Maple Dene DS0000016913.V310509.R01.S.doc Version 5.2 Page 26 The Registered Manager has been in post for nearly one year and has had over six years of experience of working within a deputy managerial role at Maple Dene. This ensured that there was continuity for residents, visitors and the staff team when coming in to her current post. The Manager holds a number of appropriate qualifications enabling her to assess the competence of staff members whilst performing their duties and is currently working towards the Registered Manager’s Award, in order to lead the team. This will ensure that residents receive a good standard of care at Maple Dene. One resident said “ The Manager is always willing to answer any questions” The Registered Manager is supported by a Deputy Manager and Administrator and it was apparent that this team works well together in the best interests of the residents living at the Home. Quality monitoring visits are undertaken regularly by Senior External Managers to ensure that the Home provides a good standard of service. Group meetings are held regularly in order for residents to put forward their views about the service provide at Maple Dene. Copies of the minutes of these are distributed for residents who were unable to attend in order to keep them informed about any changes in the service provided or forthcoming events. Staff meetings are also held regularly in order to ensure that staff are informed about any relevant changes in the services provided and to enable staff to put forward their suggestions in respect of the running of the Home. Service satisfaction surveys had been distributed to residents and a full report on the findings of these had been produced. The report was accessible to residents and their visitors in order to keep them informed about the progress of the Home. The findings of the most recent audit were mainly positive in nature. However negative feedback was received about the food provided and the bathrooms. Following this, food satisfaction questionnaires had been distributed to residents and this had been discussed during residents’ meetings in order for residents to put their suggestions forward in this area. Bathrooms had been decorated in response to the negative comments received about them in order to improve the living environment for the residents. The Home do not manage the personal finances of residents and the majority of residents are supported in this area by their families. As previously agreed with CSCI, residents’ personal allowances are paid into one general bank account and individual electronic and paper records of this were well maintained safeguarding residents who choose to use this facility. Residents are able to access small amounts of money at short notice. In order to protect residents, all staff had received training in health and safety, back care, food hygiene, first aid and fire safety. Maple Dene DS0000016913.V310509.R01.S.doc Version 5.2 Page 27 Health and safety checks and servicing of equipment and facilities used at the Home were undertaken regularly in order to safeguard residents. A positive health and safety audit had recently been undertaken by the Organisation. Remedial action of requirements set by the Fire Officer were being undertaken in order to safeguard all people within the Home. The fire door to the unoccupied hair salon had been wedged open as an appropriate magnetic closer had not been fitted and the laundry door was also wedged open. These areas would be a risk to the safety of all people in the building in the event of a fire. A member of staff was found to be smoking a cigarette within a high risk area of the Home posing a risk to the safety of all people within the building and this was addressed by the Registered Manager without delay. The records of accidents involving residents living at the Home were well maintained and identified that the appropriate medical advice was promptly sought if required. The management team audit any accidents that have occurred in order to minimise the risk of further occurrences of the same and thus safeguard residents. However a number of accident reports were not signed by the staff member completing them in order to confirm the content of these. Maple Dene DS0000016913.V310509.R01.S.doc Version 5.2 Page 28 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 3 x 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 x 3 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 3 3 3 x 3 x x 2 Maple Dene DS0000016913.V310509.R01.S.doc Version 5.2 Page 29 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 Comprehensive pre admission assessments must be 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. Timescales of 28/8/03 and 30/03/06 not met. 2. OP7 15 Care plans must be written, agreed and reviewed with the involvement of the resident and/or their representative Daily reports must include detail of the activities that the resident has engaged in during that day and be less repetitive 3. OP9 13(2)(4) All medication must be stored securely at all times The actual dose administered in respect of variable dosages must be recorded on the medication administration chart Maple Dene DS0000016913.V310509.R01.S.doc Version 5.2 Page 30 Timescale for action 06/10/06 31/10/06 06/09/06 4. OP15 16(2)(i) 5. OP38 23(4) Menus must be revised to identify the alternatives to the main meal options. The menu on display must reflect the meal options of the day. Fire doors must not be held open unless by suitable means that are activated in the event of a fire. 15/11/06 06/09/06 6. OP38 23(4) The Registered Manager received this in the form of an immediate requirement Staff must adhere to the 06/09/06 Organisation’s policy on smoking within the Home in order to safeguard residents The Registered Manager received this in the form of an immediate requirement Accident reports must be signed 06/09/06 by the staff member completing them 7. OP38 17(1)(a) 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. 2. 3. 4. 5. Refer to Standard OP4 OP8 OP10 OP12 OP26 Good Practice Recommendations Care reviews should be signed and dated as confirmation of the content of these. It is recommended that a plan of scheduled visits from Health Professionals be developed. A risk assessment of persons outside of the Home’s staff team that have access to the residents’ private living areas should be undertaken. Residents should be further consulted about the frequency of outings arranged by the Home. A risk assessment should be undertaken and practical procedure written regarding the manual cleaning of used DS0000016913.V310509.R01.S.doc Version 5.2 Page 31 Maple Dene 6. OP29 commode pots. Gaps in information provided on staff application forms should be explored Maple Dene DS0000016913.V310509.R01.S.doc Version 5.2 Page 32 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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