Inspection on 13/06/06 for Maple House

This inspection was carried out on 13th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Maple House 24/04/07

Maple House 05/12/05

Maple House 16/06/05

Maple House 09/12/04

Maple House 13/07/04

Maple House 10/12/02

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Insight - Eastchurch

Southfields

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

CARE HOME ADULTS 18-65 Maple House 32 Julian Road Folkestone Kent CT19 5HW Lead Inspector Wendy Gabriel Unannounced Inspection 13th June 2006 09:30 Maple House DS0000023463.V297362.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 DS0000023463.V297362.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 DS0000023463.V297362.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Maple House Address 32 Julian Road Folkestone Kent CT19 5HW 01303 230131 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) Lothlorien Community Ltd Mr Robert John Muxworthy Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Maple House DS0000023463.V297362.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th December 2005 Brief Description of the Service: Maple House is registered to provide 24hour residential care for up to 6 adults with learning difficulties. The home had 5 service users in residence at the time of the inspectors visit. Maple House is located in a quiet residential area on the outskirts of the costal town Folkestone. There are public amenities and good transport links close by. The property is a substantial detached house with a parking facility to the front for up to 3 cars. The accommodation is arranged over two floors. All of the Service Users have their own bedrooms, 5 of the 6 bedrooms have washbasins in-situ. There are two bathrooms, a large communal lounge, dining room/smaller lounge area and a kitchen. There is a large garden to the rear of the property. Fees are £1081.00. Maple House DS0000023463.V297362.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was undertaken over two days. The second visit to the home was arranged to take place 16th June to complete the visit started on the 13th June. For two hours on the second day of the inspection the Inspector was accompanied by Regulatory Inspector Sue Gaskell. The new manager Mr Andy Ghowry was on duty during the first day but although an appointment was arranged for the next visit, he had to leave the home at that time, but the previous registered manager was able to speak to the Inspectors. The manager said that he mainly took responsibility for staff and the previous manager mainly took responsibility for service users. Some confusion was evidenced that led the inspector to believe that the new manager is not yet fully conversant with the companies’ policies and procedures. There is currently an Adult Protection Alert open on the home. Written information received by the inspector suggested that there is not always enough staff on duty to meet identified 1-1 needs. Some requirements and recommendations were made at this visit. What the service does well: The Inspector was pleased to note the friendly rapport between service users and the support staff. The home is gradually being redecorated and eventually all the service user bedrooms will be decorated to their choice of colour. The previous registered manager stated that he wants the home to eventually present as being a place anyone would like as his or her own home. The owning company has introduce regular conferences for their local group of homes where representatives from service users in each home attend and are enabled to offer their views on the running of the homes. This is good practice. The company has also produced comprehensive induction packages for new staff. Maple House DS0000023463.V297362.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Maple House DS0000023463.V297362.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 DS0000023463.V297362.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There must be evidence of service users having a contract detailing fees charged and other costs. Prospective service users have their needs assessed but consideration must be made for their welfare within existing parameters. EVIDENCE: Two care plans were seen and only one had basic terms and conditions and this did not identify costs. A requirement is made for evidence of this to be seen. The previous manager agreed to forward a copy of the contracts he had requested from head office as evidence of fees and other costs having been given to service users. The manager said that a female service user may be considered for the vacancy in the home. When asked how suitable this would be as all the current service users are male, the manager said that there were no problems with behaviours. However, in one care plan there was evidence in a risk assessment of a service user demonstrating inappropriate sexual behaviour towards staff and peers. When questioned about how this might affect a female service user the manager said it was only undressing and was not a problem. Maple House DS0000023463.V297362.R01.S.doc Version 5.2 Page 9 A requirement is made that when assessing a prospective service user that their welfare is not compromised. No evidence was found of pre assessments on the first day of the visit, however these had been inspected as standard met at a previous inspection. On the second day of the visit, the previous manager explained the system for pre assessments and that the company had now provided a new format for this. The previous manager showed the inspectors a completed pre assessment that covered a wide range of issues. A requirement is made that evidence of these must be included in each care plan. Maple House DS0000023463.V297362.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users health and welfare are compromised if identified health and welfare needs are not supported by staff practice. Risk assessments would be improved by more robust information. Confidentiality of documents must be maintained. EVIDENCE: The manager had difficulty finding information in the care plans viewed and eventually found some recent records in an archive file, whilst other, older information remained in the care plan. On the second day of the site visit to the home, the previous manager was able to show the inspectors care plans that he had completed and that were clearer to read. He explained that he had been working through them methodically and was nearing completion. This had been an unmet requirement at the two previous inspections. Daily records did not identify an accident to one service user that had been recorded in the accident book. Maple House DS0000023463.V297362.R01.S.doc Version 5.2 Page 11 Recording must be kept up to date to communicate events accurately to all staff. The manager said that staff did not have writing skills and were to attend training for report writing on the following Friday the 20th June. A person centred plan was seen and was in a simple to read format and invited information about individual choices, likes and dislikes. Only parts of these had been completed as the manager said the company were changing the format. A requirement is made for care plans to be completed and to include recording of all events and incidents to reflect the changing needs and aspirations of service users and to be implemented by staff. There were risk assessments in the care plans and although they identify areas of risk for the individual they need to be more informative to assist staff and should be regularly reviewed. Challenging behaviours must be robustly detailed to enable staff to identify and manage them appropriately and according to given training. The manager said the service users in the home did not have challenging behaviours as he had previously worked with people with severe challenging behaviours. The home uses a mood chart to identify patterns of behaviour for service users using a scale of behaviours individual to the service user and that identifies a scale of behaviours for staff to recognise and record. This was clear to read and understand. There was evidence of outpatient appointments. There were written guidelines for staff in the event of service users having an epileptic seizure. There was written evidence of information from a speech therapist for staff to use for a particular service users needs. The inspector has since received written information that the speech therapist no longer has involvement as the staff did not carry out the tasks she set for the service user. A requirement is made for all identified health and welfare needs to be undertaken as directed. A record of a service users health issues was printed off from the computer for the inspector to view as it was not in the service users care plan. The manager said it had been removed to go to a hospital appointment with the service user the previous week. He said he did not know where it was as it had not been replaced. A requirement is made that all such information must be kept securely a) for staff information and b) so as not to compromise confidentiality. Since the previous inspection the home has improved recording service users weights and the manager said that if a service users weight altered by a given amount the company clinical governance would be informed who would then advise on actions to be taken. Maple House DS0000023463.V297362.R01.S.doc Version 5.2 Page 12 Service users do not maintain their own finances and a member of staff was seen writing receipts’ for expenditure made by a service user that day. Maple House DS0000023463.V297362.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. More opportunities for activities including a promised resource centre would enhance service users daily choice. Better recording of activity changes would assist staff to programme their day for the service users. Opportunities for service users to choose their menus have greatly improved but further advice regarding increasing healthy choices would enhance this. Holidays must be planned around services users choice and not the convenience of the management. EVIDENCE: There was basic evidence of activities undertaken being recorded. The monthly activities record for one service user did not reflect his individual activity chart and there was no evidence of the service user having refused any activity. Activities over a week for one service user for morning, afternoon and Maple House DS0000023463.V297362.R01.S.doc Version 5.2 Page 14 evenings include; walk, ten pin bowling, trip to town for personal shopping, house cleaning, swimming at two different venues, in-house art and craft, music session, trip to buy food, foot massage, drive and walk, disco, martello ball games, gateway, takeaway and house-meeting, pub trip, DVD night, free time. Although housekeeping was written on activity sheets there was no detailed programme for service users, this would be useful to assist staff plan their day to meet service users activity assessments. An activity record indicated that the walks lasted from 1/2 an hour to 1 hour. This is not enough activity each day to keep service users occupied and interested. Two service users attend college once a week supported by a member of staff who told the inspector that they seem to enjoy the experience. The activity plan for one service user written by the care manager at his review in January was different to the plan on display in the home. The manager said he had changed it to meet the service users needs and that the care manager had been informed. A requirement was made for any alterations to the activity plans to be recorded with reasons given for the change. This could be a useful guide for staff when planning activities for the future. One support worker spent some time revising the afternoon plans for the service users as he had had notice of the planned venue not being available for that afternoon. The support worker was able to explain his reasoning for making new plans including awareness of the individual service users choices and current behavioural pattern. This was good practice. At the previous inspection, the inspector had been informed that there were plans for an alternative day centre to the one then just closed by the company, to be provided by January 2006. The company has not provided this and the service users are missing out on a valuable resource including meeting other people. This also puts increased pressure on staff to source and manage suitable facilities. A recommendation is made for suitable provision to be provided by the company. The home has a vehicle for the service users The manager said the home was currently discussing annual holidays for the service users and that some had expressed a desire to go abroad. However the manager said he thought it would be better if they go to the same venue as last year as this would help with the organisation of staff. Holidays must be planned around services users choice and not the convenience of the management. The inspector observed a good rapport between support staff and service users. On the first day of the inspection, a service user regularly visited the office and the manager told him each time to go somewhere else while he was talking. The preferred practice would be to find a member of staff or activity for him to be diverted by. Maple House DS0000023463.V297362.R01.S.doc Version 5.2 Page 15 Families and friends are welcome to visit at any time. Service users are free to access all communal parts of the building. Service users have a weekly meeting where they choose the menus for the following week, this is good practice and was recorded. The manager showed the inspector a list of different foods that service users could choose from but said that they usually chose the same things. The freezer and fridge contained items such as pizzas, chips, burgers, and sausages. Written information was received by the inspector that food is sometimes the cheaper option. There was fresh salad in the fridge and crisps, oranges and apples in a locked cupboard. The manager removed the fruit and put it into a dish in the kitchen. Many of the cupboards in the kitchen were padlocked and the manager said he might remove some of them. Service users are able to freely access the kitchen. The inspector suggested that the manager seek advice on increasing choice of the menus for variety and nutritional value. The inspector suggested that if service users had no experience of a wider variety of meals then their choice is limited. Maple House DS0000023463.V297362.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of medication administration needs to improve to avoid potential risk to services users. EVIDENCE: Two member of staff confirmed that there is a key worker system in place and one explained that the manager changes key workers occasionally to different service users. Both members of staff were able to explain their roles as key workers. The manager confirmed that the GP reviews service users annually and pointed out an appointment for this in a daily report but the inspector noted this to be for another issue. The manager again said this was because the staff did not have good writing skills. A previous requirement for PRN medication administration to be fully detailed had commenced for each service user, but should include more details for staff to recognise and record outcomes. There have been instances of medication being incorrectly given since the previous inspection. (Detailed in standard 22). The manager said the staff had not checked the administration records thoroughly and when asked, said a record of changes to medication had not been handed over to staff or Maple House DS0000023463.V297362.R01.S.doc Version 5.2 Page 17 recorded. It is a requirement that management of medication administration must be according to National Minimum Standards and the Royal Pharmaceutical Society of Great Britain. Management responsibility must be undertaken as well as head office policy to enable support workers to maintain the health and welfare of the service users. Since the last inspection the shift leader now carries the keys to the medication facility and this is good practice. A bottle of diazepam tablets was stored dated 18th December 2004, the manager agreed to contact the pharmacy regarding their usage. Maple House DS0000023463.V297362.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management of complaints must be robustly undertaken to ensure the welfare of service users. Staff training has improved which may protect service users from abuse. EVIDENCE: When asked about the homes relationship with near neighbours the manager said that he had received a complaint via the homes head office about noise made in the garden by service users. The manager stated that he had not recorded this in a complaints book as it was not true. He showed the inspector a small book with handwritten notes of other complaints received but no evidence of action taken. The inspector required that a suitable complaint recording system be provided and used and that stating something is not true without investigating is poor practice. The previous manager, on the second day of the visit, was able to confirm that there is a recording format for the complaints system including details of action taken and that all complaints must be written in. A procedure for making a complaint is on display in the home. The CSCI has received information via regulation 37, of three separate incidents regarding medication errors. A complaint was raised by parents of one service user via his care manager about the care in the home. An Adult protection alert is still open. Maple House DS0000023463.V297362.R01.S.doc Version 5.2 Page 19 The inspector had previously written to the company area manager for clarification about two of the issues, the concerns raised by parents of a service user who has since moved from the home and the instance of a service user not receiving the correct amount of prescribed medication on four occasions and asked for an update on the findings of investigations. At the time of the inspection no response had been received. There are adult abuse policies in place and all but three staff has received training in understanding adult abuse. These were programmed for the month following the inspection. Maple House DS0000023463.V297362.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A programme of redecoration and refurbishment is gradually improving the appearance of the environment to the benefit of the service users. Some maintenance issues are to be undertaken to improve health and safety. EVIDENCE: All bedroom doors have locks but service users do not hold the keys. One bedroom door and frame was badly damaged and the manager said a service user had accidentaly locked himself in when something had gone wrong with the lock and had broken the door and frame when calling for help. The manager said this door and some other door areas to bedrooms were due to be replaced or repaired. Bedroom doors and locks were of varying designs and did not create a homely feel. A requirement is made for locks to be suitable and safe for purpose and a recommendation for doors when being replaced to be domestic in appearance and all to match. During the tour of the premises the manager stated that the smoking room will eventually become a staff room. The inspector was pleased to be told of the ongoing changes planned for the home. The lounge has been decorated and Maple House DS0000023463.V297362.R01.S.doc Version 5.2 Page 21 there is to be a new carpet and sofas in the room. The door to the room is to be replaced as the manager pointed out a wide gap in the doorjamb that could be a hazard if anyone trapped their fingers in it. The dining/activity room is to be repainted and have new carpet and curtains. The curtains were not all hooked onto the curtain rail; the manager said this was due to a behaviour pattern by a service user. The inspector suggested that a programme be devised to support the service user that may be more beneficial to his needs at that time. The kitchen is basic and most of the cupboards had padlocks on. The manager said this is because of COSHHE and that other cupboards contained food that service users would help themselves to. He said he is planning to remove some of the locks. All the bedrooms were individual and the manager said that all were to be redecorated and new carpeting laid. A broken light fitting over the sink in another bedroom is to be replaced. The doorframe in this room is damaged and is to be repaired. A dimplex heater in the upstairs bathroom is to be removed, as it is not working. The airing cupboard contained old disorganised linen, a suitcase, broken table and other items and is to be cleared for fire safety. This is a requirement. The vacant bedroom contained a mattress on the floor and a grubby duvet and pillows with no covers. The room also contained a small empty wardrobe, a drawer on the floor with an empty folder of the service user who had previously lived there. The manager said the carpet was to be replaced. On the second day of the visit the previous manager said that if a service user was displaying any identified behaviours, a second member of staff would be on sleep-in duty (in addition to the wake member of staff) and that is why the room had been used. The inspector advised that suitable overnight accommodation is to be provided for staff including a bed. The garden is large enough for service users to kick around a football if they wish and which one service user said he enjoyed doing. A metal table frame with no top was supporting a pole that was holding up the washing line. This could be a health hazard as well as looking unsightly and should be removed. Steps to a lower area in the garden, is to be fenced off for safety the manager confirmed. A gas fuelled, bar-b-que was in the garden and the manager said it was for a bar-b-que that afternoon and it had been brought in that day just for that event. The manager agreed to remedy all the health and safety issues. The laundry was small and contained a washing machine with facility for washing at high temperatures. The manager said service users brought their own laundry to the room and used baskets for this. There was an item of clothing on the floor and linen baskets were stacked on a high shelf, the manager reached up and removed them to the floor and picked up the clothing and put it in one. The manager assured the inspector that staff when handling laundry used personal protective items. A member of staff was seen later that day wearing a plastic apron when in the kitchen preparing lunch. The manager was unable to find evidence that the services comply with the Water supply (water fittings) regulations 1999 and agreed to send a copy to Maple House DS0000023463.V297362.R01.S.doc Version 5.2 Page 22 the inspector when it had been found. The manager confirmed that the hot water system is on a thermostat. Radiators were covered. The previous manager said he hoped that the company would allow him to renew the kitchen as it was old and not particularly homely, he stated that his aim was for the home to present as somewhere anyone would like as their own home. Maple House DS0000023463.V297362.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The company now provides suitable formatted induction and supervision formats and a robust training facility. However these must be used as directed to ensure staff receive appropriate induction and training and supervision. NVQ training is to improve to meet the 50 of staff required to hold this qualification. EVIDENCE: Manager said there was 1 person on wake duty at night. The previous manager said that if a service user had been identified as undergoing a behavioural episode than an extra member of staff would be on duty at night. A member of staff confirmed that there were usually 3 members of staff on duty plus the manager. Written information has been received by the inspector that there has sometimes been only 2 members of staff on duty and that a service user with 1-1 needs is not receiving the assessed allocated time. A requirement is made that there are sufficient staff in the home at any given time to meet the assessed needs of the service users. There has been four changes of staff this past year. This has compromised the level of NVQs’ undertaken in the home that currently is only 2 members of Maple House DS0000023463.V297362.R01.S.doc Version 5.2 Page 24 staff undertaking level 2 and 3. A requirement is made for 50 of staff to hold NVQ. Since the previous inspection, the company has improved training opportunities and the staff training matrix indicated that updating of mandatory training is well underway. Two members of staff confirmed that there was training that week and on the 1st day of the inspection. The manager said he had given basic food hygiene training but that no-one passed and it would have to be retaken. At the last inspection the then registered manager had been unable to undertake supervision for staff due to being removed from the home most of the time to oversee another home within the company in addition to managing Maple House. The current manager has been in post since February. Staff each has a formatted supervision booklet and several were seen and completed monthly. The newest member of staff did not have a booklet and has not yet received supervision. The company has provided a comprehensive induction package for all staff. A file for the newest member of staff who commenced work 25th April 2006 was viewed. It was noted that only one day of the induction procedure was signed as being completed i.e. the 25th April. The manager said he wanted to give the member of staff more time as he is new and that his CRB check has not been returned yet. The company statement suggests that induction is completed within four weeks of start. The manager stated he had asked a shift leader to undertake the induction. A requirement is made for new staff to receive induction to enable their fitness for the job. The previous manager confirmed that no personal tasks were undertaken until the CRB check was received. The manager said he did not use the format provided by the company for interviewing. This could compromise the homes recruitment procedure and the protection of service users. Maple House DS0000023463.V297362.R01.S.doc Version 5.2 Page 25 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The company has improved quality assurance to benefit the service users in the home. Management of the home does not yet meet all the National Minimum Standards. EVIDENCE: The manager has been in post since February 27th 2006. CSCI have not yet received a fully completed registration application form. The manager confirmed he was due to commence Registered managers Award training in August and that he did not have NVQ4. Some contradicitons evidenced during the inspection indicated that the manager was not conversant with important policies and procedures regarding responses to complaints and concerns. Maple House DS0000023463.V297362.R01.S.doc Version 5.2 Page 26 The manager needs to ensure there are enough staff on duty at all times to meet the assessed needs of the service users, some of whom present with unpredictable behaviours. The company hold regular conferences among the area homes in the group that is represented by a service user from each home, supported by a member of staff. The service users are encouraged to offer opinions on their lifestyle in the homes. This is very good practice and promotes quality assurance. Maple house has weekly meetings for service users to choose their menus for the coming week. This is good practice. There are also meetings for parents and families. Staff have regular meetings. Maple House DS0000023463.V297362.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 X 2 X 3 2 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 1 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 2 2 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 2 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 1 x X X 4 X X 2 X Maple House DS0000023463.V297362.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA16 Regulation 23(2)(b) Requirement Locks on bedroom doors are to be safe and fit for purpose. Timescale for action 20/07/07 2 3 4 YA24 23(4)(a) 23(4)(a) 12 YA24 YA22 5 6 YA10 YA3 5 14(1)(d) 7 YA5 5(b)(c) Airing cupboard to be cleared of clutter as precaution against fire. Metal table frame supporting washing line is to be removed for safety. All complaints must be investigated or passed to the appropriate authority for investigating and a record kept of action taken and the outcome. Confidential information is to be respected and secured appropriately. The registered person must be able to demonstrate the capacity to meet the needs of a prospective service user. Evidence of assessments are to be included in each service users plan. Terms and conditions in DS0000023463.V297362.R01.S.doc 20/06/06 16/06/06 16/06/06 16/06/06 16/06/06 01/07/06 Page 29 Maple House Version 5.2 respect of accommodation to be provided for service users including the amount and method of payments. Information needs to be provided on what the fees cover and if there are any additional extras. (Outstanding requirement from the previous 2 inspections. Time scale of the 30/09/05 and 28/02/06 not met.) 8 YA6 15 The registered manager needs to ensure that the care plans of the service users are kept up to date and reflect the changing needs and aspirations of the service users. The care plans also need to be used as a working document and daily recording of all events or incidents must be implemented by the staff team. 01/07/06 9 YA9 20/07/06 13(4)(b)(c)12(1)(b) The registered person shall ensure that challenging behaviours are managed appropriately by robust written information for staff. 16(2)(n) The home needs to ensure that the programme of activities arranged for each service user is implemented and accurate records kept of activities undertaken or reasons to be given if not implemented. 16/06/06 10 YA12 Maple House DS0000023463.V297362.R01.S.doc Version 5.2 Page 30 11 YA14 16(2)(m) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities including being enabled to participate in annual holidays of their choosing. 30/06/06 12 YA19 12(1)(a) Service users must receive 01/07/06 the necessary health care interventions identified by Health care professionals. Management of 16/06/06 medication administration must conform to National Minimum Standards and the Royal Pharmaceutical Society of Great Britain. 50 of staff need to be 01/09/06 trained to NVQ level 2 and above. Staff to be enrolled on NVQ training course by set timescale. (Out-standing requirement from the previous 2 inspections. Timescale of the 30/11/05 and 28/02/06 not met) All staff receive induction training within six weeks of appointment. The manager is to be enrolled on a suitable course to gain qualifications in line with the National Minimum Standards. There must be sufficient staff working at the home at all times in such numbers as are DS0000023463.V297362.R01.S.doc 13 YA20 13(2) 14 YA32 18(1)Sch. 2 (4) 15 16 YA35 YA37 18(1) 9(2)(i) 30/06/06 01/09/06 17 YA33 18(1)(a) 16/06/06 Maple House Version 5.2 Page 31 appropriate for the health and welfare of the service users. (this was a requirement at 31/12/05). 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 YA13 Good Practice Recommendations A suitable resource/day centre to be provided by the company for service users to enjoy activities and meet other people. Maple House DS0000023463.V297362.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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 House DS0000023463.V297362.R01.S.doc Version 5.2 Page 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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