Inspection on 12/12/05 for Maple Grove Hostel

This inspection was carried out on 12th 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 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

Maple Grove Hostel 15/05/07

Maple Grove Hostel 15/05/06

Maple Grove Hostel 16/06/05

Maple Grove Hostel 24/11/04

Maple Grove Hostel 28/05/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Maple Grove Hostel 25-27 Maple Grove Bath Bath & N E Somerset BA2 3AF Lead Inspector David Smith Unannounced Inspection 12th December 2005 10:00 Maple Grove Hostel DS0000038861.V271201.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Maple Grove Hostel DS0000038861.V271201.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Maple Grove Hostel DS0000038861.V271201.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Maple Grove Hostel Address 25-27 Maple Grove Bath Bath & N E Somerset BA2 3AF 01225 420548 01225 420548 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) Bath & North East Somerset Council Mrs Ruth Theresa Rowsell Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Maple Grove Hostel DS0000038861.V271201.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th June 2005 Brief Description of the Service: Maple Grove is a Local Authority residential care home for up to ten adults who have a Learning Disability. The home is situated in a quiet location, which provides easy access to local shops on Bear Flat and Moorland Road, Bath. The city centre is approximately one mile away. Maple Grove is two spacious semi detached Victorian houses, which have been connected to form one building. The home has large gardens to both the front and rear of the properties. There are ten single bedrooms, one of which is used to provide respite care to people living in the community, two communal lounges, one dining room, two bathrooms without toilets, one shower room with toilet and two separate toilets. Three of the bedrooms have en-suite facilities. The home does not have adapted bathing facilities or lift between floors. The home is therefore not suitable for people with poor mobility. Support is also provided to four people living in their own flats in the local community and seven people who regularly use the home’s respite service. Maple Grove Hostel DS0000038861.V271201.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over one day. The inspector gathered information for this report from discussions with the Registered Manager, case tracking, inspection of care plans and other records, meeting service users, observing staff interactions with service users, discussions with staff members and a tour of the home. What the service does well: What has improved since the last inspection? Some internal and external decoration work has been completed. This has improved the environment. Epilepsy protocols are now in place for service users. There are also NHS Guidelines in addition to these. Respite care records have been updated and the frequency of visits now clearly recorded. The records of service users who no longer use the respite service have been removed. Maple Grove Hostel DS0000038861.V271201.R01.S.doc Version 5.0 Page 6 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 Grove Hostel DS0000038861.V271201.R01.S.doc Version 5.0 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 Maple Grove Hostel DS0000038861.V271201.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 4. Service users are given the information they need about the home. Service user support is based upon an individual assessment of their needs and the transition to the home is well managed by the team. EVIDENCE: Each service user has their own guide to the service. which can be adapted into a more accessible format if required. This is now also available on audiotape. This details the facilities, services and ethos of the home. This document refers service users to accessing the latest inspection report at a local library. This should be amended. Inspection reports can be accessed via CSCI either by telephone or by accessing the website. One person has moved into the home since the last inspection. Care records examined for this person provided a clear account of the admission process. This person had previously used the home’s respite facilities. A Social Worker organised the placement for this person and they had both a needs and financial assessment prior to admission to the service. One service user told the inspector they chose the décor in their bedroom and had visited the home with their parents prior to moving in. Maple Grove Hostel DS0000038861.V271201.R01.S.doc Version 5.0 Page 9 Maple Grove Hostel DS0000038861.V271201.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, and 9. Maple Grove provides a service focused on the people who live in the home. Service users views are actively sought and acted upon. Risk assessments need to be reviewed and updated in accordance with the home’s policy. EVIDENCE: Interactions observed between staff and service users during the inspection demonstrated the staff were providing the appropriate levels of support. Individual abilities, needs and methods of communication were clearly known and acknowledged by the staff team. Staff actively encouraged service users to make choices, but did provide advice and guidance to support this process. The inspector observed staff discussing the replacement of a broken television with one service user. The method and timescales of replacement were discussed together with the loan of a spare television in the interim. Maple Grove Hostel DS0000038861.V271201.R01.S.doc Version 5.0 Page 11 Service users have regular house meetings, where their views are sought on the general running of the house. They are encouraged to manage their own finances with support from the staff team. Care documents for four service users were examined. These included assessment information, support guidelines, healthcare records, day-to-day records. These care plans were comprehensive and there was a clear process of review in place. There were Risk Assessments in place for each service user. However, the inspector found several of these to be out of date as there was no evidence of these being reviewed. There needs to be a clear review process in place for all Risk Assessments to ensure the safety of service users and staff. Maple Grove Hostel DS0000038861.V271201.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17. Service users are supported by staff to use community facilities, enjoy holidays and visit families and friends. The service develops and reviews each service users care plan. This enables them to participate in a wide range of activities and supports each service user to develop their own service. The home offers a wide choice of a well-balanced and healthy menu. EVIDENCE: Service users have their own timetable of activities. This includes regular access to local community facilities such as shops, cinema, pubs, local church groups as well as Local Authority Day Services. Maple Grove Hostel DS0000038861.V271201.R01.S.doc Version 5.0 Page 13 Service users are supported to maintain close contact with their families and friends. Some regularly visit their families, enjoy weekend stays and visitors are welcomed to the home. Some service users go out independently with friends and family. One service user did telephone the home during the inspection to explain she would use a taxi to return to the home rather than wait for a bus, as it was getting dark. Staff praised her for making a sensible choice. Each service user has access to the kitchen where they can prepare their own drinks, snacks and meals. Staff confirmed they offer the support appropriate for each person. Weekly menus are planed in consultation with the service users. Monthly meetings are held with service users, keeping them involved with the general running of the home. The home was already decorated in preparation for Christmas. There had been a recent fancy dress party, which service users, friends, family and staff had attended. Maple Grove Hostel DS0000038861.V271201.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 19 Service users healthcare needs are closely monitored and prompt action taken to address any concerns. Service users receive personal support in areas most appropriate to them. EVIDENCE: The care plans examined showed that service users were registered with a local GP, dentist, optician and chiropodist. There are varying levels of support from other professionals from the Community Learning Difficulties Team. These include Speech Therapy, Physiotherapy, Psychology, Behavioural Specialist and Occupational Therapy. Epilepsy protocols are now in place for the service users who have this condition. To complement the in house policy, there are also comprehensive NHS Guidelines in place. On the day of inspection one service user was unwell in the morning. An ambulance had been called as a precaution. The inspector observed sensitive Maple Grove Hostel DS0000038861.V271201.R01.S.doc Version 5.0 Page 15 care and support being offered throughout the course of the day and he appeared much improved towards the end of the inspection. He later invited the inspector to view his bedroom. Maple Grove Hostel DS0000038861.V271201.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The home has a satisfactory complaints procedure. Complaints are seen by the home as an opportunity to review practice and to improve the service provided. Protection of Vulnerable Adults and Whistle blowing procedures are in place and known by staff. This promotes the safety and welfare of the service users. EVIDENCE: The home has both a service users complaints procedure together with several generic Local Authority complaints leaflets. There have been two complaints recorded since the last inspection. These were both seen to be responded to in line with procedure and within the relevant timescales. Bath and North East Somerset has an inter agency procedure on the Protection of Vulnerable Adults which is available within the home. Two service users spoken to said they would talk to care staff or the manager if they were unhappy or had a problem. The Local Authority has a confidential reporting policy if staff have any concerns regarding the service they work in. Staff spoken to were aware of the complaints, Protection of Vulnerable Adults and whistle blowing policies. Maple Grove Hostel DS0000038861.V271201.R01.S.doc Version 5.0 Page 17 The Local Authority provides training sessions on both Protection of Vulnerable Adults and Risk Assessments. Maple Grove Hostel DS0000038861.V271201.R01.S.doc Version 5.0 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, and 30. The house was clean and tidy. The redecoration process needs to be completed in some areas of the home. Each person has decorated and furnished their bedrooms to suit their individual tastes and needs. EVIDENCE: Maple Grove is formed by two semi detached Victorian houses which together provide spacious and comfortable accommodation for service users. There are large gardens to both the front and rear of the properties. The inspector did view all of the communal areas of the home and was invited by four service users to view their bedrooms. Each bedroom viewed has been decorated and furnished by the service user to make it personal to them. One service user explained she had chosen the colour scheme and the room was decorated before she moved in. Maple Grove Hostel DS0000038861.V271201.R01.S.doc Version 5.0 Page 19 A cleaner is employed on a part time basis. The back door of No.27 has been replaced and had a handle and lock. There has been both internal and external redecoration completed since the last inspection. Several communal areas have been repainted. This has improved the environment. The home would benefit from this work being completed. The landing areas of both No.25 and 27 need repainting as do the stairwell of No.25 and the doors leading to each service user bedroom. All maintenance and refurbishment work is reported to the Local Authority Property Services Department who approve and organise work required. The Registered Manager commented that she has a good working relationship with this department. Maple Grove Hostel DS0000038861.V271201.R01.S.doc Version 5.0 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36. Staff are provided with comprehensive information in order to carry out their duties and support the service users. There is a full compliment of staff within the home. Staff are offered training by the Local Authority. The staff team meet regularly and provide good levels of support for service users. There is a robust recruitment and induction process for new staff. Staff need to be supervised on a regular basis. The home needs to improve both the record keeping in relation to staff records and review how to collate and store this information. EVIDENCE: Staff were observed interacting well with service users and those spoken to demonstrated a good understanding of the support needs of each person in the home. The home operates a robust recruitment process and the records examined included application forms, induction checklists, training records, Enhanced Maple Grove Hostel DS0000038861.V271201.R01.S.doc Version 5.0 Page 21 CRB Disclosures, supervision contracts, supervision note books and appraisal documents. There were however several staff where records showed supervisions were not taking place at regular six-week intervals described in the supervision contract. Some of the supervision records were not explicit and it was difficult for the inspector to ascertain what discussions had taken place and what outcomes had been agreed upon. Regular supervision must be provided for all staff. A supervision pro forma needs to be re-introduced and a clear, concise record of each supervision meeting kept, including the agreed outcomes. There are staff development files in place, but records of training attended is not being updated regularly. The Registered Manager confirmed that staff are attending all necessary training but this was difficult for the inspector to track from the training records inspected. A training matrix should be implemented for each member of staff and kept up to date. The home will not have half of the staff team trained to National Vocational Qualification Level 2/3 by the end of 2005, although some staff are qualified and others are working towards this award at present. The home needs to set out a clear strategy describing how it intends to support staff to achieve this level of award. Through both observation and discussions with both service users and staff, there appeared to be good morale within the staff team and this was reflected in the relaxed atmosphere within the home. The staff team meet regularly and have recently attended a team away day to help with the development and improvement of working relationships and work practice. Maple Grove Hostel DS0000038861.V271201.R01.S.doc Version 5.0 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42 and 43. The home is being well run and service users views are sought and acted upon. The views of service users are actively being sought as part of the possible reprovision of the service. The service has benefited from a permanent Registered Manager now being in post and registered with the Commission. The Registered Manager has created an open and inclusive atmosphere within the home, which benefits both the service users and staff team. Regular and comprehensive Health and Safety checks are carried out within the home. This promotes service users welfare. EVIDENCE: Maple Grove Hostel DS0000038861.V271201.R01.S.doc Version 5.0 Page 23 During the last inspection the Deputy Manager was acting as Manager and had applied for Registration with the Commission. The process is now complete. The Registered Manager has completed both NVQ Level 4 in Care and the Registered Managers Award. She is currently working towards her A1 NVQ Assessors Award. Through discussion with the Registered Manager, staff members and service users it was evident there was an open and inclusive atmosphere within the home. There are regular meetings with both the service users and the staff team. The service users are the focus of the service and the Registered Manager is clearly leading and developing the person centred approaches evident within the home. There appears a good understanding of the ‘Valuing People’ guidance. These approaches are being supported by both an external facilitator (Mencap) and a specialist support agency (Paradigm). This is good practice. This has clearly been incorporated within the service user involvement in the future reprovision of the service. Their views of the type of accommodation and levels of staff support they would like are being addressed on an individual basis. Each service user is being provided with sufficient information to make an informed choice. The Registered Manager has provided a clear sense of leadership in this project. There are recording systems in place to support Health and Safety within the home. Records examined included fire alarm system checks, fire fighting equipment checks, fire fighting equipment, water temperature checks, fridge and freezer temperature recording. The Local Authority has central contracts in place for maintenance and servicing of plant and equipment. Maple Grove Hostel DS0000038861.V271201.R01.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X 3 X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 X X X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 2 3 3 X 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Maple Grove Hostel Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score 3 3 3 X X 2 3 DS0000038861.V271201.R01.S.doc Version 5.0 Page 25 Are there any outstanding requirements from the last inspection? NO 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 2 3 Standard 9 23 and 42 32 35 and 36 Regulation 13 18 18 (2) Requirement Timescale for action 31/01/06 Ensure Risk Assessments are reviewed and updated. Provide an action plan to support 31/01/06 staff to achieve NVQ Level 2/3 Ensure all staff are supervised on 12/12/05 a regular basis. 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 Refer to Standard 1 24 35 and 36 Good Practice Recommendations Amend the Service Users Guide to refer the reader to access the latest inspection report via the CSCI office or the CSCI website. Redecorate the landing areas of both No.25 and 27. Redecorate the stairwell of No.25. Repaint the doors to each of the service users bedrooms. Ensure all staff are regularly supervised and maintain a clear record of each meeting. Maintain an up to date record of all staff training. Review both the content and storage of staff files. Maple Grove Hostel DS0000038861.V271201.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Maple Grove Hostel DS0000038861.V271201.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!