Inspection on 15/05/07 for Maple Grove Hostel

This inspection was carried out on 15th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 15/05/06

Maple Grove Hostel 12/12/05

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 Key Unannounced Inspection 15th May 2007 10:00 Maple Grove Hostel DS0000038861.V340363.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Maple Grove Hostel DS0000038861.V340363.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Maple Grove Hostel DS0000038861.V340363.R01.S.doc Version 5.2 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 319728 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.V340363.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th May 2006 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 and 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. The current fee for this service is £561.60 per week. Maple Grove Hostel DS0000038861.V340363.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit as part of a Key Inspection of this service. I gathered information through discussions with service users, the Registered Manager and Assistant Managers. Interaction and communication between staff and people who live in the home was also observed during the course of my visit. Care plans and associated records were examined together with medication administration, Risk Assessments, accident/incident reports, complaints log, staffing and health and safety records. I was also provided with a tour of the communal areas of the home and some service users showed me their own rooms. Other sources of evidence have been used as part of the Key Inspection process. These include the home’s action plan in response to the last CSCI inspection, the providers own monthly auditing of the service and notifications of significant events which have occurred within the home. The Commission also provided the home with a Pre-inspection Questionnaire, which was completed and returned prior to my visit. What the service does well: Each service user I spoke with said they were very happy living at Maple Grove and were able to choose the things they wished to do. The relatives I spoke with said the home was “excellent” and were very impressed by the progress their relative had made since living in the home. The service remains focused on the people who live in the home. The use of person centred planning tools is prominent. This ensures each service user is supported to determine their own service. The home is very well run. The ethos of the service is clear, well communicated and remains focused on positive outcomes for each service user. The care planning system is person centred and comprehensive. This ensures service users receive appropriate levels of support. Maple Grove Hostel DS0000038861.V340363.R01.S.doc Version 5.2 Page 6 The administrative systems are very efficient and enable quick and easy access to any documentation required. This ensures a safe and accountable system of support for service users and staff. The manager and her team continue to develop information relevant to service users in a format which is accessible to them. The staff team are friendly, professional, and very confident and were observed to engage well with service users and others who visit the home. The home actively seeks support from other professionals to help improve the quality of the service it provides to each person. Maple Grove offers clean, pleasant and homely accommodation with good quality furniture, fixtures and fittings. Maple Grove will be subject to future reprovision. The staff team continue to ensure that all service users and other stakeholders are actively involved in these discussions. 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. The summary of this inspection report can be made available in other formats on request. Maple Grove Hostel DS0000038861.V340363.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Maple Grove Hostel DS0000038861.V340363.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users and their relatives have access to detailed information in order to make informed choices about where to live. Each service user knows the home will meet their needs and aspirations, that their introduction to the home will be tailored to them and that the terms and conditions will be clearly explained. EVIDENCE: The home has a comprehensive Statement of Purpose, which has been recently updated. Each service user also has their own guide to the service, which the home has tried to adapt into an accessible format in accordance with the person centred philosophy of the home. Both documents detail the facilities, services and ethos of the home. One service user has moved into the home since the last inspection. This individual’s care records showed that the home had a good knowledge of their support needs, as they previously used the home’s respite service. Maple Grove Hostel DS0000038861.V340363.R01.S.doc Version 5.2 Page 9 These records also contained a care plan, health action plan, comprehensive assessments and information from a range of health care professionals. All of this information had been used to ensure the support needs for this person could be met by the home. The home ensures that each person’s transition into the home is managed in a person centred way. This process is determined through discussion with the service user, their family, funding authority and the home’s staff team. Each service user is provided with a house contract, which describes each person’s service, the review process, medication procedures, confidentiality, payment of fees and rights and responsibilities whilst living in the home. This document is signed by each service user and the home’s manager. This is good practice. Maple Grove Hostel DS0000038861.V340363.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 and 10. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home ensures that the service provided to each individual takes into account their personal preferences, supported by both written information in care plans which are subject to ongoing review and a long standing and experienced staff team. Service users are consulted on, and participate in, all aspects of life in the home. The risk assessment process supports each person to take risks as part of their lifestyle. Each service user is assured that information about them remains confidential. Maple Grove Hostel DS0000038861.V340363.R01.S.doc Version 5.2 Page 11 EVIDENCE: Three service user care plans were examined in detail and these provided comprehensive information on the areas of support each person required. Each care plan had been written in an individual way and covered key areas of support people required. Whilst each care plans was detailed and up to date, some may benefit from the removal of historical information as this may make them slightly easier to navigate at times. The home continues to adapt information within the care plans into a format which each service user can access. For example, care plans are written in plain English and contain picture symbols or photographs which help each person understand their content. The Manager also showed me a revised daily living skills assessment, which is being developed by one member of staff. This is written in plain English and has many picture symbols. It s hoped this can be used to replace the existing document currently used in each care plan. Regular formal review meetings are held, which include service users, their families, staff members, Social Workers and Keyworkers. Each service user is supported to prepare for, plan and attend their review meeting. The home ensures each person sets their own agenda, chooses the venue and invites the people they feel should attend. For example one person had only chosen to invite three people to their review meeting, as they did not like “big and formal meetings”. These meetings are clearly recorded and the outcomes used to update individual care plans. Two reviews were held on the day of my visit, one in the home and one at another venue. The last review for each person used a person centred planning style known as a ‘path’. This process focuses on the dreams/wishes of each person and then uses a staged approach to work towards these. These contained both written and pictorial information. The progress of individuals working towards their goals is monitored closely by each person’s keyworker. Service users have a copy of their path and discussed with me what these meant to them. Between each formal review, Keyworkers make sure care plans are kept up to date. Each care plan I examined had evidence to show that they are being reviewed on a monthly basis. Any changes to the plans are clearly recorded and communicated throughout the staff team. This is good practice. Interactions between staff and service users were observed at various times during the inspection. These demonstrated the staff had a good knowledge of the support needs of service users and how to communicate effectively. Discussion between the manager, staff members and myself also confirmed this. Maple Grove Hostel DS0000038861.V340363.R01.S.doc Version 5.2 Page 12 Each service user I spoke with said they decided what they would like to do and that staff members always listened to them and acted on what they said. There are regular service user house meetings, the last of which was held on 11/04/07. The records of these meetings show that attendance is good, with a wide variety of topics discussed. The views of service users are taken seriously and acted upon wherever possible. Care and support is provided within a risk assessment framework. Healthy risk taking continues to be encouraged and supported, as evidenced within the wide range of opportunities and activities service users are able to enjoy. Each of the person centred risk assessments I examined were detailed and have been regularly reviewed. Each service user has a document describing the right of access to their personal records, which forms part of their care plan. This ensures confidentiality is promoted and explained to each service user. All records relating to service users are stored securely in the main office. Maple Grove Hostel DS0000038861.V340363.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Each service user has opportunities and appropriate support to develop, access work, leisure and educational facilities both locally and in the wider community including holidays, day trips and visits to family and friends. Service users rights and responsibilities are recognised in their daily lives. A healthy and balanced diet for each individual is promoted. EVIDENCE: The home has a person centred approach in supporting each service user to develop. The records maintained within the home enable each persons progress towards their goals/dreams to be assessed and the support provided adapted accordingly. Maple Grove Hostel DS0000038861.V340363.R01.S.doc Version 5.2 Page 14 Each service user has their own timetable of activities. These show regular access to local community facilities such as Local Authority Day Services, shops, cinema, pubs and local church groups. It was evident that several service users had made significant progress since moving into the home. Some were attending more varied day services or longer sessions. Others access the community independently, attend college courses and make use of public transport. The home has made significant progress in supporting a number of people who live in the home to access work placements in the local community. Currently, five service users have work placements. Three work at the Salvation Army, one at a local hospital and one is training to be a hairdresser. One service user I spoke with who has a work placement told me they were doing well and recently had their working days increased from two to three, due to the progress they had made. They hoped this would lead to a permanent job in the future. Staff spoken with explained that they work hard to ensure each person is provided with opportunities to do things which they enjoy. Each person is seen as an individual and is respected as such. Staff feel that each person’s ‘path’ helps and that each individual does decide what they would like their service to be. Individual’s rights and responsibilities are made clear and confirmed in writing in both their contract and guide to the service. Each service user has a key to their bedroom and individuals I spoke with said they could lock their bedroom door if they chose to do so. They also told me staff always knocked on their door and waited for a response before entering their room. Each person is 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. On the day of my visit I spoke with relatives of one service user, who were visiting the home to attend a review meeting. They said the progress their relative had made since living at the home was “remarkable”. They also felt the home should be described by the CSCI as ‘excellent’ and confirmed their relative was very happy living at Maple Grove. Each individual is supported to organise and attend a holiday. There has been a recent trip to Weymouth with another holiday planned to Butlins. The records I examined showed that some service user also go on holidays with their friends or family members. Maple Grove Hostel DS0000038861.V340363.R01.S.doc Version 5.2 Page 15 Each service user has access to the kitchen where they can prepare their own drinks, snacks and meals. Weekly menus are planed in consultation with the service users and these show a wide range of food, which provide both a healthy and balanced diet. Service users likes, dislikes and allergies in relation to food are known and clearly recorded. Each individual now has a ‘Fit To Eat’ file, which has been developed jointly by the Food Standards Agency, the Local Authority, Connections Day Services and ‘Lifeskills’ teams. This provides ‘easy read’ guides for cooking, cleaning, chilling, healthy living and includes menu cards and a DVD about healthy living and food safety in the home. All of the information includes ‘step-by-step’ guides, pictures or picture symbols to help each person understand the content. This is good practice. Maple Grove Hostel DS0000038861.V340363.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported in their preferred manner and their personal and healthcare support needs are very well met. Service users retain and administer their own medication where possible and the policy relating to administration of medication ensures their welfare and safety. EVIDENCE: The care documentation in place for service users provided clear guidance for staff on how they should support those living at the home with their personal care. The care plans examined showed that service users were registered with a local GP, dentist, optician and chiropodist. Maple Grove Hostel DS0000038861.V340363.R01.S.doc Version 5.2 Page 17 Other specialist services are accessed when an identified need arises. These are provided by Bridges Community Learning Disability Team. Care records show the home is regularly supported by the Consultant Psychiatrist, Physiotherapists, Speech and Language Therapists, Occupational Therapists and other relevant health care professionals. Contact with each professional is recorded and forms part of each persons care plan. Each Individual now has a ‘Health Action Plan’. These contain a photograph of each person, details of any medical conditions, medication, contact with health care professionals (including their photograph), weight records and general information explaining what each person requires to help them lead a healthy lifestyle. Each individual’s plan was different and contained information which each person considers to be important about them. There is a core of experienced staff who have a good knowledge of service users healthcare needs. Any changes, which may cause staff concern, are noted and acted upon. It remains evident that the management and staff spoken with are sensitive to the personal/healthcare and emotional needs of those using the service. The home uses the Boots Monitored Dosage System of medicine administration. This system is well managed. The medication administration file contains details of each service users GP, a photograph of service users, profiles of prescribed medication, guidance on expiry dates of medication and information relating to returning medication. Each service user medication record was correctly completed, signed by staff with no gaps evident in the records. Six individuals currently self-medicate. There are Risk Assessments in place to support this practice, which are regularly reviewed. The Manager explained that the pharmacy does dispense some medication in weekly boxes, as this is both easier and safer for some service users. All staff receive formal medication training, ‘Protocol Training’, which is accredited by the City of Bath College. This is in the style of an NVQ unit and contains four elements; introduction to medicines, care workers role, administration and medicines of differing client groups. Staff are also provided with ‘Protocol Training’ in Infection Control and Contamination. This consists of three units; infection control in healthcare environments, personal healthcare and hygiene and decontamination. Maple Grove Hostel DS0000038861.V340363.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to communicate their views and they can be confident that they will be listened to and their views acted on if necessary. Clear policies and procedures are in place in order to protect service users from the likelihood of abuse, neglect and self-harm. EVIDENCE: Each service user has their own complaints procedure, which is available in both written form and on audiotape. Families and other stakeholders are also provided with a copy of the home’s complaints procedure. Several generic Local Authority complaints leaflets supplement these documents and it also has a confidential reporting policy if staff have any concerns regarding the service they work in. Each service user I spoke with said they knew who to speak to if they were unhappy, but they also said they ‘really liked’ living at Maple Grove and were ‘happy’ here. Maple Grove Hostel DS0000038861.V340363.R01.S.doc Version 5.2 Page 19 I examined the home’s concerns and complaints log. This shows there have been three complaints since the last inspection. On each occasion the issues had been taken seriously by the home, investigated in accordance with the relevant policy and the outcomes clearly recorded. I did note that the complainants had written to the home to say they were happy with the way their complaint had been dealt with and the outcome. The home also records any ‘concerns’ which are raised. This is where the formal complaints procedure is not used, but the home shows that it takes any concerns seriously and looks upon any complaint or concern as an opportunity to review or improve the service they provide. Bath and North East Somerset has a policy relating to Control and Restraint and an inter agency procedure on the Protection of Vulnerable Adults which are both available within the home, as is The Department of Health’s ‘No Secrets’ guidance. The home also has its own Protection of Vulnerable Adults policy, which gives clear, concise information and instructions to staff members if they witness or suspect abuse or have any concerns. There is very little challenging behaviour displayed by people who live in the home. It was evident that some individuals have seen a significant reduction in incidents such as these since moving into the home. The Manager said that the home worked extremely hard to enable each person to communicate appropriately and effectively and provide them with a stable home life. She felt this had a significant effect on individuals who had previously displayed varying levels of behaviour, which were seen as challenging. Staff are provided with appropriate training, such as Protection of Vulnerable Adults and are subject to enhanced Criminal Record Bureau disclosures. The home maintains records of accidents and incidents. It also notifies the CSCI of any significant event which occurs within the home. I noted that the home continues to receive letters and comments from families which are extremely complimentary regarding the service their relative receives and about the home and staff team more generally. Maple Grove Hostel DS0000038861.V340363.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Maple Grove provides a homely, comfortable and safe environment for service users to live in. EVIDENCE: Maple Grove is formed by two semi detached Victorian houses, which together provide spacious and comfortable accommodation for service users. There are car parking spaces to the front and large gardens to both the front and rear of the properties. The home blends in well with the local community and is situated in a very quiet location which provides easy access to local shops and public transport. Bath city centre is approximately one mile away. Maple Grove Hostel DS0000038861.V340363.R01.S.doc Version 5.2 Page 21 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 and therefore is not suitable for people with poor mobility. I did view all of the communal areas of the home during my visit, along with three of the service user’s rooms. All areas of the home were clean and tidy and furnishings and fittings are of a good quality. The house is tastefully decorated and there are many photographs of service users displayed, which help to personalise the home. Each service user is expected to help keep their home clean and tidy, with each person’s responsibilities clearly reflected in their care plan. The home also employs a domestic assistant, who helps keep all areas of the home clean. This member of staff was working in the home on the day of my visit. Each person’s bedroom has been decorated and furnished to make it personal to them. There were lots or personal effects, pictures and photographs which added to this. Two people who live in the home told me they chose the way they wanted their rooms to be decorated and one person helped to paint theirs. Some areas of the home have been redecorated since my last visit. One person’s room was being painted and contractors were working in the garden on the day I visited. All maintenance and refurbishment work continues to reported to the Local Authority Property Services Department who approve and organise work required. This department carried out a ‘Condition Survey’ on the home in December 2005 and the Manager told me this process is due to be repeated shortly. Maple Grove Hostel DS0000038861.V340363.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each person that lives in the home is supported by a cohesive staff team that is committed to providing a good service. The clarity of staff roles and responsibilities along with staff training and supervision helps to provide a consistent approach to the support of staff and service users. EVIDENCE: There remains a core of well-established staff with varying abilities who are skilled and experienced to meet the needs of those living in the home. During the last few months two new staff have also joined the team and the home now has a full compliment of staff. The personnel records for the new staff members showed that they had received a comprehensive formal induction to the home. A record of each topic covered during this process is kept and signed by the staff member. Maple Grove Hostel DS0000038861.V340363.R01.S.doc Version 5.2 Page 23 Staff spoken with were able to demonstrate a clear understanding of their role and responsibilities within the team and their own personal role and accountability. Staff members I spoke with said that the staff team continues to be very open, honest and supportive. Each commented on how nice it is to work in the home. They felt well supported by the management team and were able to discuss issues in an open and honest way. Staff were observed interacting well with service users and those spoken with demonstrated a good understanding of the support needs of each person in the home. The service users I spoke with said they like the staff and felt they are supported well by them to live the life they wanted. One person told me of the very positive relationship they have with their Keyworker. The staff team meets regularly. All meetings are recorded and appropriate subjects are discussed in order to guide and direct staff practice. The Manager told me that occasionally team meetings were also used to deliver training to staff in certain areas. There is a strong commitment by the home to provide staff with a variety of training opportunities, which are provided either by the organisation or external training providers. There have been numerous training sessions for staff since my last visit such as Manual Handling, Infection Control, Food Hygiene, Fire Safety, Mental Capacity Act and Finance. Planned training includes Aspergers Syndrome and Mental Health Awareness. Staff have also completed the Learning Disability Award Framework (known as ‘LDAF’) before completing a National Vocational Qualification (NVQ). From discussions with staff members and the records I examined, the home has all members of staff either qualified or actively working towards an NVQ. This is commended. Regular formal supervision is provided for all staff. The Registered Manager and Deputy Manager generally supervise staff, however one Assistant Manager now has supervision responsibilities as part of their professional development. This staff member was provided with appropriate training prior to commencing these duties. Records examined show that staff are supervised every four weeks and a clear record of each meeting is maintained, which is signed by both parties. Staff are also appraised on an annual basis, described by the home as a ‘Performance Review’. Staff I spoke with find supervision and the appraisal process helpful and supportive. The quality of staff support in the home is commended. Maple Grove Hostel DS0000038861.V340363.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41, 42 and 43. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is very well run and has effective procedures in place to provide service users with the support they require to lead fulfilling lives. The manager is qualified and competent to run Maple Grove, and meet its statement of purpose, aims & objectives. Service users views are central to the monitoring and review of the service provided by the home. Service users rights and best interests are promoted by the quality of the home’s record keeping. The health, safety and welfare of the service users is promoted and protected. Maple Grove Hostel DS0000038861.V340363.R01.S.doc Version 5.2 Page 25 EVIDENCE: The Registered Manager, Mrs.Rowsell, has completed both NVQ Level 4 in Care and the Registered Managers Award. She is currently working towards her A1 NVQ Assessors Award. She also undertakes periodic training to maintain her knowledge and update her skills and level of competence. The management approach remains open and positive, with a clear sense of direction and leadership. The ethos of the service is person centred with evidence of relevant tools such as ‘paths’ and ‘essential lifestyle planning’ in use. Staff spoken with said their views are listened to, and that they are well supported by the manager. Through discussion with the Registered Manager, staff members and service users it was evident there continues to be an inclusive atmosphere within the home. The service users remain the focus of the service and the Registered Manager is clearly leading and developing the person centred approaches. Since my last visit the Manager has continued to develop and improve systems within the home. The quality of record keeping in the home is now of a high standard, with all records required during my visit easy to access and stored securely. The involvement of service users in both the day-to-day running of the home and in the proposed reprovision of the service remains high. There are regular house meetings, where a variety of topics are discussed such as the home’s complaints procedure, person centred planning, the proposed move, parties, holidays and social events. Each person’s ‘path’ continues to make reference to the plans to move into new accommodation and how this is to be supported/achieved. Family consultation meetings also continue to be held and the home is using Paradigm’s ‘Standards in Supported Living’ to guide their practice. The home encourages the use of advocacy to support each person’s involvement and to help them make informed decisions. Some individual’s friends or family members act in this role, but specialist advocacy organisations such as “Eye to Eye” also support people and the home has used trained facilitators to lead service user meetings and reviews. The home has its own Quality Assurance guide. This describes the service values, principles and goals and how these are to be achieved. All staff have signed to say they agree with these principles. This document has now been amended to refer readers to the Commission for Social Care Inspection rather than the National Care Standards Commission. Maple Grove Hostel DS0000038861.V340363.R01.S.doc Version 5.2 Page 26 The registered provider’s representative makes regular visits to the home, and produces a comprehensive report of her findings, which is send to the Commission on a monthly basis. There are recording systems in place to support Health and Safety within the home, which are being used consistently. Records examined included fire drills, fire alarm system checks, fire fighting equipment checks, water temperature checks, hazardous products which are used in the home, risk assessments, gas safety, portable electrical appliance testing and fridge/freezer temperature recording. All of these records were in order and checks were up to date. Maple Grove Hostel DS0000038861.V340363.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 X 35 4 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 4 4 3 LIFESTYLES Standard No Score 11 4 12 3 13 4 14 3 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 4 X 4 4 4 X 4 3 3 Maple Grove Hostel DS0000038861.V340363.R01.S.doc Version 5.2 Page 28 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations The home should consider removing some historical information from service users records to make them easier to navigate. Maple Grove Hostel DS0000038861.V340363.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Maple Grove Hostel DS0000038861.V340363.R01.S.doc Version 5.2 Page 30 - 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. 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