Inspection on 11/04/08 for Maple House

This inspection was carried out on 11th April 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Maple House 17/05/07

Maple House 22/05/06

Maple House 21/11/05

Maple House 18/05/05

Maple House 18/11/04

Maple House 14/06/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Maple House 51 Peveril Road Tibshelf Alfreton Derbyshire DE55 5LR Lead Inspector Tony Barker Unannounced Inspection 11th April 2008 09:40 Maple House DS0000020051.V362278.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 House DS0000020051.V362278.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 House DS0000020051.V362278.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Maple House Address 51 Peveril Road Tibshelf Alfreton Derbyshire DE55 5LR (01773) 872720 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) maplehouse51@hotmail.co.uk Mr Peter South Mr Peter South Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Maple House DS0000020051.V362278.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th May 2007 Brief Description of the Service: Maple House is a care home situated in Tibshelf village near Alfreton. The Home is a semi-detached house on an estate at the edge of the village. It had had an increase in registered service users from 3 to 5 in 2006, following an extension to the premises. The current service users in the Home receive day services for five days of the week and are supported at other times to undertake activities within the local community. Maple House DS0000020051.V362278.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The time spent on this inspection was 7 hours and was a key unannounced inspection. Survey forms had not been posted to service users, their relatives, staff and external professionals at the time of this inspection. One care manager was spoken to on the telephone following this inspection. Maple House’s Manager, Assistant Manager and two of the five service users were spoken to and records were inspected. There was also a tour of the premises. Two service users were case tracked so as to determine the quality of service from their perspective. This inspection focussed on all the key standards and on the progress made towards achieving the requirements and recommendations made at the last inspection. The pre-inspection, Annual Quality Assurance Assessment (AQAA), questionnaire was reviewed prior to this inspection. The Manager stated that the service’s fees ranged from £358 to £442 per week. A copy of the last inspection report from the Commission for Social Care Inspection (CSCI) is available, in the Home, to service users and visitors. What the service does well: What has improved since the last inspection? What they could do better: Further risk assessments must be written to ensure service users’ safety in any activities they are involved in. The Commission must be notified when any Maple House DS0000020051.V362278.R01.S.doc Version 5.2 Page 6 event in the Home adversely affects a service user’s wellbeing or safety so as to ensure we are able to carry out our regulatory responsibilities. Service users’ changing states of health must be thoroughly recorded so as to provide insight into any future health problems. Staff must not be appointed before two written references have been received in order to ensure that the person is fit to work and service users are safe. The Manager must develop and maintain systems for monitoring the quality of care provided at the Home so as to provide the means to measure success in achieving the service’s statement of purpose. 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 House DS0000020051.V362278.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 House DS0000020051.V362278.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An individual written needs assessment was in place at the time of admission of the last service user, so that their diverse needs were identified and planned for. EVIDENCE: The most recently admitted service user was case tracked. This person had a recorded assessment of needs on admission, undertaken by the service. The placing social worker completed a care plan six weeks after admission. A contract between the Home and the placing agency was in place. Maple House DS0000020051.V362278.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Written care plans and risk assessments did not detail how services users’ individual needs, and the risks to which they were exposed, may be addressed. EVIDENCE: There was a set of brief care plans and risk assessments relating to the two case tracked service users. Each care plan had an associated ‘Implementation Sheet’ and ‘Evaluation Sheet’ – the latter showing evidence of regular care plan reviews. Although there had been formal care plan review meetings, initiated by the placing agency, within the past six months for three service users there had been no formal reviews, relating to the other two service users, for three and four years respectively. Derbyshire County Council was clearly not monitoring the care received by these two service users at the Home although the Manager explained that he had attempted to secure such meetings on several occasions. Discussions with the Manager, and Assistant Manager, indicated that the service was taking a ‘person centred’ approach to service users although this was not reflected in the service’s documents. Maple House DS0000020051.V362278.R01.S.doc Version 5.2 Page 10 Two care plans mentioned limitations on the service user’s unsupervised movements outside the Home, although there were no associated risk assessments. The Manager stated that full discussion with, and agreement by, external professionals had taken place with regard to this policy and there was a record, with signatures, to support this. One service user chooses to visit his mother and to shop in Mansfield – using public transport independently, the Manager explained. The Manager and Assistant Manager also stated that the service users’ preferences are taken account of when it comes to which local pub to go to. Service users also choose which activities they get involved in and their going to bed times and rising times at weekends. This was confirmed in discussion with them. Only on weekday mornings is there an expectation to rise in sufficient time to catch the transport to their respective day services. Examples of service users taking responsible risks were given by the Manager. All but one service users use the facilities of the kitchen and risk assessments were in place to reflect this, as well as potential scalding from radiators. However, risk assessments were not in place regarding all possible risks that service users could be exposed to – for example, unsupervised access to the community. The Manager described the individual service users’ pattern of alcohol consumption but it was noted that there was no written policy in place to address regarding the use of alcohol. Maple House DS0000020051.V362278.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service provided activities and services that were age-appropriate and valued by service users and promoted their independence. EVIDENCE: Service users were all attending day services – mostly for five days a week. One service user was attending for two days and going to a local college for the other three days – taking a Life Foundation Skills course. The Manager was listing, in service users’ files, all their social activities in order to maintain an overview. The Manager spoke of listening to service users’ expressed wishes regarding social activities and gave examples of person centred activities being carried out, such as going to Speedway at Sheffield, to York and to craft fairs. The care manager spoken to said that service users were provided with appropriate support to live the life they choose wherever possible. He added that the service was good at providing community based social activities although, at times, these could be more individual focussed. Maple House DS0000020051.V362278.R01.S.doc Version 5.2 Page 12 Two service users were attending a local social club for people with learning disabilities once a week and all service users enjoy ‘Karaoke’ held at a local pub, the Manager said. He added that three service users play in a local Pool League every Wednesday in the pubs in local villages. The two service users spoken to both said, “I like going to the pub” and they confirmed this was a regular trip out. One added, “I like watching football on the television”. One service user has a particular friend seen every day at day services. This service user said this person was their “best friend”. The Manager spoke of the potential benefits to the service user of extending this relationship to the care home but this has not happened, for no lack of encouragement from the Manager. This service user has no family contact but the others were all having good levels of contact. The two service users most established in the Home are well known to local people, the Manager commented, and the others are becoming known. The Manager spoke of close friendships having been developed between two service users and one long established service user, spending time in each other’s bedrooms watching television, for example, and this was confirmed in discussions with them. One service user, when asked what they like about the Home, said, “I like Pete (the Manager)…and going to the pub”. Service users were involved, to varying extents, in domestic activities. They had full access to all parts of the Home other than to the private accommodation belonging to the Manager and his wife and to each other’s bedrooms, unless invited. This showed they were encouraged to be independent within the Home. Further evidence of this lay in three service users having a key to their bedroom door, though the other two had chosen not to. The Manager explained that service users were also independent regarding their personal hygiene, apart from one service user needing help from staff with shaving. This meant that they had full privacy while using the bathroom and toilet. Staff knock on bedroom doors before entering, the Manager said. The care manager spoken to confirmed that the service respected individuals’ privacy and dignity. A good range of meals were described on the Home’s 6-week rolling menu and this was reviewed every six weeks, the Manager stated. Foodstocks in the larder, freezer and refrigerator were good and included fresh fruit and vegetables. Most food was bought ‘on line’ but one service user used the local Co-op store for ‘topping up’ one or two items of food – again, meeting the person’s independence. From discussions with the Assistant Manager, it was clear that she takes a particular interest in meeting service users’ food preferences and care plans included a record of their food dislikes. Mealtimes were very flexible and reflected the activities being carried out at the time. One case tracked service user said, of the food provided, “Nice food”. Maple House DS0000020051.V362278.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service was providing service users with personal support in the way they preferred and required and was meeting their physical and emotional health needs. The delivery of health care to individuals was not being adequately recorded in order to provide insight into any future health problems. EVIDENCE: The Manager explained that the service users’ level of dependency was such that they seldom needing prompting or guidance on day to day matters. One service user needed assistance with shaving. Two bath rails had been provided to improve one service user’s independence when using one of the service’s two baths. An additional step, outside the front door, also addressed this person’s mobility needs. Service users were encouraged to choose their own clothes each day, although guidance was needed when out clothes shopping. They were each able to make their needs known verbally and they told us that they rise in the mornings later at weekends, which was their choice. There was brief documentary evidence of service users receiving medical checks and of medical appointments being kept. Records of appointments with Maple House DS0000020051.V362278.R01.S.doc Version 5.2 Page 14 appropriate health professionals indicated their wide ranging health needs were being met. The care manager spoken to confirmed that individuals’ health needs were properly monitored and attended to. One service user’s health condition was well controlled by diet and was on no medication. Two service users had been hospital in-patients for several weeks, since the last inspection. We had not been informed by the service of these individuals’ serious medical state in order for us to carry out our regulatory responsibilities. The Manager said he was not aware of the need to do this. One of these two service users was case tracked and it was noted that, although the ‘Evaluation Sheet’ recorded the hospital admission, there was no record of discharge or of further, ongoing assessment of the person’s health. The Manager stated that no further symptoms had been displayed since discharge. It was pointed out to the Manager that these incomplete records failed to provide an accurate account of these important events and insight into any future health problems could be compromised. The Manager commented that he was still not being kept informed by Social Services who had referred two service users for specialist health input relating to an aspect of their behaviour. They were also attending six monthly appointments with a consultant psychiatrist who was continuing to maintain limitations on their unsupervised movements outside the Home. The Manager said he felt the particular behaviours concerned were no longer a problem and did not feel these restrictions were still necessary. He thought that the liberty of one service user was being curtailed inappropriately. He said he had written to the Local Authority, on these matters, expressing his concerns. Three service users were in receipt of prescribed medication. This was being securely stored. The Medication Administration Record (MAR) sheets of the two case tracked service users were examined and were satisfactory. The Deputy Manager and care assistant had both undertaken a training course in the safe use of medication. The care manager spoken to confirmed that service users’ medication was managed safely. Maple House DS0000020051.V362278.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Most procedures for handling complaints and abuse were in place to make sure that service users were being protected. Existing records did not fully support the process of maintaining service users’ personal safety. EVIDENCE: The Home’s complaints procedure was kept outside a cabinet in the entrance hall - in a prominent position for visitors to see. It was not available in a format understandable to service users and so they may not be aware of how to complain about the service if they so wished. The Manager had stated in the AQAA questionnaire that he plans to make relatives and other stakeholders aware of the complaints procedure. A satisfactory record of complaints received had been developed so that the quality of the service provided could be monitored. The Manager stated that there had never been any complaints. The care manager spoken to confirmed that the service responds appropriately to any concerns raised. Certificates were seen to support the Manager’s statement that he and the Assistant Manager had attended a half-day training course on ‘Safeguarding Adults’ run by a private company. There was also a DCC Policy and Procedures document and a training CD Rom from Derbyshire County Council. The Manager said that the new member of staff was working through this CD Rom. The Manager was advised to draw up a policy on ‘Sexuality and Relationships’ for the service, as well as an individual risk assessment in relation to the most recently admitted service user, to address the change in gender balance within the Home. He stated that these issues had been fully considered before Maple House DS0000020051.V362278.R01.S.doc Version 5.2 Page 16 admission but accepted that they had not been recorded. Both case tracked service users’ financial records were examined and were cross-referenced to monies held. They were satisfactory. The Assistant Manager said that she checks balances on these records at each transaction and there was recorded evidence of regular audits. There was no written policy of staff receiving gifts and this could potentially leave service users and staff vulnerable. We had received information, before this inspection, about an incident of theft within the Home in which the police were involved. This was discussed with the Manager and he provided evidence of appropriate measures being taken. However, he had not informed us of this event and this was a further example of poor communication between the service and the Commission. The service’s ‘whistle blowing’ policy was satisfactory. Service users spoken to confirmed that staff treated them appropriately and that they felt safe living in the Home. One reported that, “Staff treat me OK”. Maple House DS0000020051.V362278.R01.S.doc Version 5.2 Page 17 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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were living in a homely and hygienic environment, which was furnished and decorated to a good standard. EVIDENCE: The Home was well decorated and furnished and homely. Each of the five bedrooms had appropriate lockable doors. All five bedrooms were examined and were found to be well-personalised and providing evidence of the interests held by each service user. Work on the building and garden had been completed: paths and steps had been built to improve service users’ access around the premises. The Home was clean and hygienic, with no unpleasant odours. The Control of Infection policy was found to be satisfactory – indicating that service users’ health was being well considered. There was a dedicated sink in the utility room that could be used for pre-washing any items of soiled clothing. There was no need for sluicing facilities as service users were fully continent. Maple House DS0000020051.V362278.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff had received some training to ensure that service users were safe. Service users may be at risk through the service not fully meeting safe recruitment practices. EVIDENCE: The staff at the Home comprised the Manager, Assistant Manager and one newly appointed full time care assistant. The Manager and Assistant Manager displayed appropriate commitment to the service users and had a comfortable relationship with them. The care assistant was not on duty at the time of this inspection. The Home did not meet the National Minimum Standard to maintain a staff group with at least 50 qualified staff. The newly appointed care assistant was working full time in the Home. Her hours were being recorded on the Service’s calendar which was not considered to be a suitable, formal record. There was a discussion with the Manager about contingency plans when this member of staff is on duty on her own. He said she has access to relevant telephone numbers but these contingency plans had not been made explicit through the recording of a risk assessment. Maple House DS0000020051.V362278.R01.S.doc Version 5.2 Page 19 The file of the care assistant, appointed in March 2008, was examined. Required documents were in place, to ensure service users’ safety, but there were no written references that would provide a view of the person’s suitability and fitness for this post. The Manager said these were still awaited. He stated that he had not requested them himself and accepted that their authenticity could therefore not be fully established. He pointed out that the member of staff was related to the Assistant Manager who could vouch for the care assistant’s employment history. An employment contract was in place, and a recruitment policy, but there was no grievance policy or disciplinary policy to give staff information about these aspects of their employment. The Manager had provided an induction to the care assistant but this was not to nationally recognised Learning Disability Award Framework (LDAF) standards. At the last inspection the Manager was recommended to approach a suitable organisation, such as the British Institute for Learning Disabilities (BILD), for advice on providing such induction but he had not done this. It was therefore not possible to assess the quality of this induction. The Manager and Assistant Manager had attended training courses on Fire Safety, Basic Food Hygiene and First Aid in order to ensure the safety of service users. The care assistant had attended Basic Food Hygiene and First Aid training and was awaiting fire training through an on-line course. Maple House DS0000020051.V362278.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40,41 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ welfare was being potentially compromised through inadequate assurance measures and the Manager’s lack of a managerial qualification. EVIDENCE: The Manager is a nurse qualified in work with adults with a learning disability and with 18 years experience with this client group. He said he had not applied to attend an NVQ course in Management at level 4. He was therefore not able to evidence a full commitment to managing this service. Satisfaction questionnaires, completed by three of the service users in Autumn 2006, were seen at the last inspection. These had been completed with support from the Manager and from the respective day services attended by these service users. Responses were generally positive and gave some indication that the Manager was seeking to measure success in achieving the Maple House DS0000020051.V362278.R01.S.doc Version 5.2 Page 21 aims of the service. However, there had been no recent questionnaires and none had been developed for other stakeholders such as relatives and external professionals, as recommended at the last inspection. The Manager had been developing a National Minimum Standard (NMS) based check-list of the Home’s services although he had made no progress beyond NMS 1, as at the last inspection. The Home still had no Annual Development Plan to reflect any monitoring of the service. All sections of the AQAA were completed although more supporting evidence would have been useful to illustrate what the service had done in the last year and how it is planning to improve. There was evidence, as noted previously in this report, of some records and policies, required by Regulation or good, safe practice, not being in place. There was evidence of good food hygiene practices in the kitchen. The Home was using a Food Standards Agency record each day to record food temperatures, menu sheets and any problems occurring. Cleaning materials were being stored in a locked cupboard. Product Data sheets, as required by the Control Of Substances Hazardous to Health (COSHH) Regulations, were in place. There was documentary evidence of Portable Appliance Tests (PAT) being undertaken recently and of a current Electrical Installation Certificate. Records of regular fire alarm tests and fire drills were being kept. The gas safety certificate was current. There was a limited element of environmental risk recorded in individual service users’ risk assessments and the Manager was recommended to review all potential risks in and around the Home environment. This was a recommendation from the last inspection. Maple House DS0000020051.V362278.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 X 2 2 2 3 X Maple House DS0000020051.V362278.R01.S.doc Version 5.2 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA9 Regulation 13(4)(c) Requirement Timescale for action 01/06/08 2. YA19 YA23 3. YA19 4. YA34 Risk assessments must be written regarding all possible risks that service users could be exposed to. This is to ensure their safety in any activities they are involved in. 01/05/08 37 The Commission must be notified, without delay, when a service user is seriously ill or when any other event in the Home adversely affects the wellbeing or safety of any service user, such as theft within the Home. This ensures the Commission is able to carry out its regulatory responsibilities. 17(1)(a) Service users’ changing states 01/05/08 Sch.3.3(m) of health must be more thoroughly recorded. This would ensure that an accurate health record is in place to provide insight into any future health problems. 19(1)(b) Staff must not be appointed 01/05/08 Sch.2.5 before two written references 19(1)(c) have been received by the service following a written request for these references. This ensures that all efforts have DS0000020051.V362278.R01.S.doc Version 5.2 Maple House Page 24 5. YA39 24 been made to satisfy the service that the person is fit to work and service users are safe. The Manager must develop and maintain systems for monitoring the quality of care provided by the service, such as service user and stakeholder satisfaction questionnaires and an annual development plan. This will provide the means to measure success in achieving the service’s statement of purpose. (This was a recommendation at the last two inspections) 01/06/08 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 service should continue to encourage Derbyshire County Council to hold formal review meetings, with external professionals, the service user and relatives as appropriate, at least every six months. Recorded care plans and risk assessments should reflect a ‘person centred’ approach. A policy should be written regarding service users’ use of alcohol. Efforts should be continued to find out what specialist health services are being provided to two service users. A record of these details should then be maintained on care plans. A policy on ‘Sexuality and Relationships’ for the service should be written. A policy on staff receiving gifts should be written. 50 of care staff should be trained to at least NVQ 2 standards. (This was a previous recommendation) All staff hours, including the Managers, should be recorded on a proper staff rota. A risk assessment, addressing the potential risks associated with the care assistant working on her own, should be recorded. DS0000020051.V362278.R01.S.doc Version 5.2 Page 25 2. 3. 4. YA6 YA9 YA19 5. 6. 7. 8. 9. YA23 YA23 YA32 YA33 YA33 Maple House 10. 11. 12. 13. YA34 YA35 YA37 YA42 A grievance policy and disciplinary policy should be written. All new staff should receive induction and foundation training that meets the specifications laid down by Skills for Care. (This was a previous recommendation) The registered manager should enrol on NVQ Level 4 in management, or equivalent. (This was a previous requirement) Environmental risk assessments should be recorded. (This was a previous recommendation) Maple House DS0000020051.V362278.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 House DS0000020051.V362278.R01.S.doc Version 5.2 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. 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