Inspection on 16/06/05 for Maple House

This inspection was carried out on 16th June 2005.

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 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 House 24/04/07

Maple House 13/06/06

Maple House 05/12/05

Maple House 09/12/04

Maple House 13/07/04

Maple House 10/12/02

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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 Mary Cochrane Announced 16 June 2005 at 09:30 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 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 Stationary 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 H56-H05 S23463 Maple House V223767 140605 Stage 4.doc Version 1.30 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 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 Limited Mr Robert John Muxworthy CRH 6 Category(ies) of Care Home for people with Learning Disabilities. registration, with number of places Maple House H56-H05 S23463 Maple House V223767 140605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 9th December 2004. Brief Description of the Service: Maple House is registered to provide 24hour residential care for up to 6 adults with learning difficulties. The home now has 6 service users in residence. 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 insitu. There are two bathrooms, a large communal lounge, dining room/small lounge area and a kitchen. There is a large garden to the rear of the property, which is well maintained for Service Users to enjoy in the better weather. Maple House is owned by Lothlorien Community Ltd. The registered manager Mr. Robert Muxworthy has been in post since February 04 Maple House H56-H05 S23463 Maple House V223767 140605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection carried out in accordance with the Care Standards Act 2000 and under the new guidance of ‘Inspecting for Better Lives’. The registered manager was available throughout the day. During this visit the Inspector concentrated on the requirements and recommendations that were identified in the unannounced inspection in December of last year. Mr Muxworthy has now become the registered manager of the home and he was seen to be working hard towards meeting the National Minimum Standards. He should be commended on what he has achieved so far. There have been great improvements at the home since his appointment. Mr Muxworthy has shown a clear sense of direction and leadership, which staff and service users understand and are able to relate to. It was very apparent that the needs of the service users come first at all times. The staff the Inspector spoke to are very positive and optimistic about the future of the home. It was observed that the staff have a good relationship with the service users and they were seen to interact in away that was sensitive, caring and respectful. There was seen to be an understanding between the service users and staff and needs of the service users are anticipated and dealt with appropriately. The service users are well kempt and dressed smartly and in keeping with their personalities. At the time of the visit, the Service Users in the home reported that they were happy and content; they were all busy and occupied doing various activities inside and out-side the home. One resident was keen to show me pictures of their recent trip to the zoo and 2 service users had just returned from a visit to Euro-Disney. There was a friendly and relaxed atmosphere and people were busy, motivated and interested in the activities they were undertaking. What the service does well: The home is well managed and has developed a good staff group. The service does provide an active and fulfilling life style for the service users. The home creates a friendly and open atmosphere. It was evidenced that the service users are offered choices about how they live their lives and independence is promoted at all times. Staff are caring and the needs of the service users are put first at all times. All the service users were well cared for and they reported that they liked living at Maple House. The manager has greatly improved the communication between the service users and their families and regular Maple House H56-H05 S23463 Maple House V223767 140605 Stage 4.doc Version 1.30 Page 6 monthly family meetings are now held at the home. The service users bedrooms are all individualised and personal. 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 H56-H05 S23463 Maple House V223767 140605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Maple House H56-H05 S23463 Maple House V223767 140605 Stage 4.doc Version 1.30 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 standard(s) 1,2,5 The homes statement of purpose is in good order. The Service Users Guide does not contain all the required details. There are no signed contracts for the service users therefore service users are not protected. Terms and conditions of residency. EVIDENCE: The home has an updated stated of purpose which contains all the required information, There is a copy on display in the entrance hall of the home and there is also a copy available to each individual service user which is kept in their rooms The Service User Guide has also been developed by Craegmoor Healthcare and each service user has a copy, this has been up-dated by the manager to accurately reflect the present situation within the home. It covers all aspects of care provision and the purpose of the home. All copies have information available in basic sign language and pictorial aids. The Service Users Guide does not contain information on the fees that are charged by the company and the cost of extras. There is a copy of the latest inspection report in each of the service users rooms. (See recommendation no.1). The home has recently been joined by a new service user. There was evidence to show that the service user was only admitted to the home having received a full assessment by a member of the staff competent to do so. In this case, the registered manager did the initial assessment. The service user was visited Maple House H56-H05 S23463 Maple House V223767 140605 Stage 4.doc Version 1.30 Page 9 several times in his old residence. The assessment is undertaken over a period of time with the Service Users being invited to spend time at the home before making a decision as to whether or not they wish to stay permanently and this also allows staff to get a true picture of the service users needs and make an informed decision as to whether or not the home can meet them. There is a 3month probationary period before a final decision about permanency is made. All the information gathered is then incorporated into the individuals care plan and risk assessment. Each service user has information on terms and conditions, but each require an individual contract which should include fees charged, what they cover and when they must be paid and by whom and the cost of facilities or services not covered by the fees. The contract should be in a format/language appropriate to each service user, and needs to be signed by the service users and the registered manager. (See requirement no .1) Maple House H56-H05 S23463 Maple House V223767 140605 Stage 4.doc Version 1.30 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 standard(s) 6,7,9, There is a consistent care planning system in place to adequately provide staff with the information they need to satisfactorily meet service users needs. Not all risks are identified, recorded and minimised .This leaves service users at risk. Service users are able to make decisions about their own lives. EVIDENCE: There are individual care plans in place for each of the Service Users, and there is a key worker system operating within the home. The care plans have improved and developed since the last inspection. 4 plans were looked at. They are of a good standard and reflect the individual and changing needs of the service users. The plans contain all the necessary information on the action that is required of the care staff to ensure that needs are met. They also contain information on likes and dislikes, how to manage challenging behaviours and. There are also plans on, eating and drinking needs, personal Maple House H56-H05 S23463 Maple House V223767 140605 Stage 4.doc Version 1.30 Page 11 hygiene care, medical and specialist needs, and individual management. The plans contain progress and evaluation sheets are up-dated regularly. 6 monthly reviews are undertaken. The plans are used as a working document by the staff. Through observation and talking to service users and staff there was evidence to support that Service Users are involved in making decisions on how they live their lives and any limitations and restrictions are recorded in the individuals care plan. There are monthly residents meetings, minutes are kept and any suggestions and ideas are acted on. The Home manages personal allowances for all the Service Users. The registered manager and care staff actively encourage and support the service users to live an independent lifestyle as their abilities allow. There are risk assessments in place, which identify and provide information on how to minimise most risks, some of these could be further developed. At the time of the visit it was evidenced and confirmed by the registered manager that on a regular bases up to 4 service users are transported in a 5 seater vehicle with the only carer being the driver. This is very unsafe practise considering that many of the service users display episodes of erratic, and unpredictable behaviours. This was discussed with the registered manager at the time of the inspection and he is going to take immediate steps to rectify the situation. It needs to be ensured that there are robust risk assessments in place for all service users prior to them using any transport and that they have access to support and direction of the care staff should they require it. An immediate requirement was made at the inspection. (See requirement no.2) Maple House H56-H05 S23463 Maple House V223767 140605 Stage 4.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15,16,17 Service users are able to maintain and develop an appropriate and fulfilling life-style both in-side and out-side the home. The service users are provided with a balanced, healthy, nutritious and varied diet. EVIDENCE: It was evidenced through speaking with service users, staff and observation that service users are encouraged to participate in many different activities and attend local education courses. Each Service Users has an indiviual activities programme, which has been developed in conjunction with needs and preferences. The Service Users the Inspector spoke to enjoyed all aspects of the activities. All Service Users were very busy and occupied on the day of the inspection. A record of activities undertaken is documented. Most days the service users are out and about and all service spoken to were very happy with their life style. Service Users are very much part of the local community and make use of all the local facilities. The home also has the use of a mini-bus to transport the Service Users to various day-centres and activities within the area. There are also trips to the shops, pubs, local clubs, discos, sports centre and church. The Maple House H56-H05 S23463 Maple House V223767 140605 Stage 4.doc Version 1.30 Page 13 residents talked about a recent trip to the zoo and showed pictures of their day out The next planned outing is a day trip to France. 2 service users had recently returned from 3 days at Euro-Disney. The home are also planning an annual holiday to Centre Parks in Norfolk in September. The registered manager has made great improvements in developing communications with the Service Users families and documentation was in place to evidence this. The Manager has developed a monitoring system to ensure that telephone calls to home are regularly made and Service Users are actively encouraged to maintain contact with their family and friends. Family and friends are welcome at The Maples at all times. The registered manager has implemented monthly family meetings which are very successful. Service users can choose who they wish to see in the privacy of their own rooms or in the communal areas. Staff make visitors and family welcome in the home and they are invited to stay for as long as they wish and become involved in the daily routines and activities within the home. Three meals are provided daily, Meal times are flexible and menus are organised over a six-week period. Menus are also flexible and subject to change on request, any variation from the menu is recorded in the individuals care file. All food eaten is also recorded. The care staff within the home undertake the task of cooking and service users are encouraged to participate in the preparation of meals. Drinks and snacks were available throughout the day on request. It was noted that the fridge and some cupboards had locks, it was explained that this was because certain service users had been raiding the fridge and storing excess amounts of food in their bedroom in inappropriate conditions. Care plans describe the reasons for this restriction and risk assessments are in place. Maple House H56-H05 S23463 Maple House V223767 140605 Stage 4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20 The home provides appropriate personal and healthcare support care for the service users. EVIDENCE: The Home operates a key worker system to provide sensitive and individual support to service users. Personal care, life skills and dignity are promoted. Service users are assisted to choose their own clothes and are supported to shop. There is a flexible approach to daily living activities e.g. getting up, bed, bath and mealtimes. Staff were seen to approach Service users in a caring and nurturing manner. It was observed that the service users privacy and dignity was maximised allowing them independence and control of their own lives. The home ensures that the service users have access to healthcare facilities and routine checks are carried out frequently. Service users health care needs are monitored and they are promptly referred to professionals when necessary. A member of staff accompanies Service users when they are attending appointments and visits from healthcare professionals are conducted in private A medical report sheet is maintained by the home to evidence dental, chiropody, G.P. and other health care appointments. It was reported by the Maple House H56-H05 S23463 Maple House V223767 140605 Stage 4.doc Version 1.30 Page 15 staff that the challenging behaviours of the service users have improved considerably The home uses a Monitored Dosage System (MDS) from Boots and all staff who administer medication have received appropriate training. A list of staff competent to administer medication is kept. Sample signatures are also available. The medication is stored in a locked cupboard and the keys to this are kept on the person who is in charge of the shift. MDS were crossreferenced with MAR sheets and at the time of the visit these tallied. There are now PRN protocols in place. They do need some more information to instruct staff on when the medication/cream need to be administered. The registered manager has ensured that the service users medication has been reviewed and changed. It was evidenced that service users are now receiving less psychotropic medication. Maple House H56-H05 S23463 Maple House V223767 140605 Stage 4.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 The home has a satisfactory complaints system. Service users are protected from all forms of abuse EVIDENCE: Each service user has a copy of the complaints procedure, which is also written in a suitable format. On discussion with service users they were aware of what they had to do if they wished to make a complaint. There is a copy of the complaints procedure on display in entrance hall which contains all the relevant information and how to contact the CSCI, and an assurance that the complaint will be responded to within 28 days. A record is kept of all complaints. The home has the appropriate Adult Abuse policies in place and also a Whistle Blowing Policy. The staff were aware of the policy, felt confident to use if necessary and knew the appropriate action to take if they had to do so. Any incident pertaining to abuse would be followed up immediately and all action taken recorded. The Manager is aware of the POVA lists. The home has developed a system of managing service users monies, which protects them from abuse. The home provides a safe place for the storage of monies and valuables. Maple House H56-H05 S23463 Maple House V223767 140605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26,27,28,30 The standard of the environment within this home has improved. The home needs to continue with its on-going maintenance and refurbishment plans so as to create an environment that is homely and comfortable. EVIDENCE: The home now has an on-going maintenance and re-furbishing plans with timescales and home has made good progress in re-decorating and up-grading the communal areas and bed-rooms of the service users. The home is now more comfortable, homely, cheerful and bright. Maintenance and redecoration need to continue. (See recommendation no.2) All the bedrooms in the home have been greatly improve since the last visit They are now individually furnished and personalised reflecting the style of each service user. Some of the rooms have new furnishings and fittings 5 of the 6 rooms have a washbasin facility and television points. Most of the service users have TV’s and music systems. The bedrooms are now comfortable and homely but some carpets are worn and stained, the registered manager has just received carpet samples to allow service users to choose new carpets. An action plan has been submitted to the CSCI with time-scales for refurbishment. Maple House H56-H05 S23463 Maple House V223767 140605 Stage 4.doc Version 1.30 Page 18 5 of the 6 rooms do have locks on the doors, which service users can use if they wish. One service users does not have a lock on the door but reasons for this have been documented in his risk assessment. (See recommendation no.3). The home offers suitable amount of toilets and bathrooms, which are conveniently situated within the home. The cupboard under the sink is old and worn and requires replacing. The large mirror in this bathroom has now been made safe. The water temperature in this bathroom at the time of the inspection was erratic and the plumbing was very noisy. The bathrooms have recently been painted however the bathroom suites are old and worn and the flooring past its best. The staff toilet was not seen at this visit as it was being painted at the time of the inspection. The bathrooms now have locks on the doors. Plans and Timescales for this work have been forwarded to the CSCI. Bathrooms are due to be replaced in August ‘05 (See requirement no.3) The home has 1 large communal lounge and a dining area, which also has the facilities to be used as a second quieter lounge area. Both of these rooms have recently been repainted and it has made a great improvement. The lounge has new paintings on the wall, and 2 new settees have been purchased, the home hope to be able to purchase more chairs in the not too distant future. The deputy manager plans to make the room more homely and welcoming. Both rooms now need new carpets to complete the refurbishing. The home does have a small ‘smoking room’ on the ground floor, which is used by one Service User. There is a large garden to the rear of the property, which is reasonably well maintained, and a gardener is employed by the company to tend to it. The home has purchased a football net and a wooden swing seat for service users to use in the better weather. The kitchen is a good size, serviceable and has recently been repainted but the surfaces and kitchen cupboards do require up grading as they are past their best. the formica on the work surfaces had peeled in places. (See recommendation no.4) There is a room available for staff for sleeping in duty, which has recently been redecorated. The staff do not have a secure place in which to store their personal belongings while they are at work (See requirement no.4). Since the last inspection the laundry room has been made sound and has been redecorated. The flooring is old and past it’s best and does need replacing. The floor finish needs to impermeable (see recommendation no.5). Hand washing facilities are sited in areas where they are needed. The care staff within the home tend to all the cleaning duties and service users are encouraged to keep their own rooms tidy. The standard of cleanliness in the home has improved since the last visit and the registered manager is monitoring the situation to ensure work is done to an acceptable standard. Maple House H56-H05 S23463 Maple House V223767 140605 Stage 4.doc Version 1.30 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35 The staff have a good understanding of the service users and positive relationships have been formed. The staff group within the home is now stable The arrangements for the induction of staff are good. Staff require NVQ and further specialist trainings. The procedures for recruitment are not robust and could leave the service users at risk. EVIDENCE: The care staff employed by the home are all issued with a job description on starting employment. The turn over of staff has reduced and the work force is more static, there was evidence to show that the staff were able to promote the main objectives of the home and were aware of their role and responsibilities and that of the other staff. The staff reported that they had developed good relationships with the service users and they were able to anticipate and meet the individual needs of the client group. The staff reported a good working relationship with the manager. There are no volunteers going into the home at the present time. It was observed that the staff are accessible and approachable to the service users and are able to exhibit good listening and communication skills. It was evidenced that the staff on duty put the needs of the service users first. At this visit it was evidenced that none of the staff employed are NVQ trained. 5 staff are undertaking NVQ training at the present time. The remaining staff Maple House H56-H05 S23463 Maple House V223767 140605 Stage 4.doc Version 1.30 Page 20 are yet to commence training. The home are unable to meet the targets within the time -scales Until 50 of staff obtain NVQ level 2 or above a requirement will be made. (See requirement No.5) The home has 9 members of staff employed at the moment and they also have 4 flexi staff. 2 more staff are waiting to start at the home and are just for paper work to clear. There are 3 care staff on duty for the a.m and p.m shifts, at night there is one waking staff member the manager or deputy are on call 24hours if any problems arise. Staff numbers depend upon the needs of the service users. It was evidenced through observation and looking at the duty rota that there are sufficient numbers and skill mix of staff on duty to meet the needs of the service users through-out the day and night. The staff spoken to reported that the home continues to improve under the guidance and direction of the manager. Staff meetings take place at regular intervals and suggestions and ideas are actioned. 4 staff files were looked at. The company has an equal opportunities policy and two references are required prior to commencement of employment, these were evidenced in the files. Some concerns were highlighted over the quality of the reference format used. There should be evidence on at least one of the references that it is from a previous employer. On one of the files the reference obtained was not the same as those given by the member of staff on their application form. All gaps in employment history need to explored and reasons for gaps documented on the staff file at the time of interview. It is also advised that verbal contact is made to verify and validate the content of at least one of the reference given. On the sample of files looked at there was no evidence of identification, this needs to be addressed. Terms and condition of employment are in place. All staff appointments are subject to a minimum probationary period of 3 months. CRB checks are in place (See requirement no.6) All staff within the home have now received mandatory training, and dates have been identified to ensure staff are up-dated within the required timescales. Specialist training is now being developed. There is a training matrix in place. There is an induction programme at the home and all staff employed by the home receive the appropriate training to induct them safely into the home within the stated time limits. The Manager continues to see staff training as a priority and continues to very pro-active in ensuring the staff receive the training they require to meet the individual needs of the Service Users. The manager needs to ensure that individual staff training records are maintained and that each member of staff requires an individual training and development assessment profile. Maple House H56-H05 S23463 Maple House V223767 140605 Stage 4.doc Version 1.30 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38,42, The home has leadership guidance and direction, which ensures the service users receive a consistent quality of care. The health, safety and welfare of the service users is promoted and protected. EVIDENCE: At the time of the inspection the manager was able to communicate a clear sense of direction and leadership, which the staff and the service users responded to. The staff and service users reported that they were well supported and responded in a positive, relaxed manner in the presence of the manager. Opportunities for change and development are on going. The home provides a safe environment for service users to live in and staff to work in. Good working practices ensure the home is free of hazards. The company’ has an induction programme which is in line with TOPSS. Mandatory training up to date and on-going. The Safe working Practices in the home are satisfactory. Maple House H56-H05 S23463 Maple House V223767 140605 Stage 4.doc Version 1.30 Page 22 Policies are in place to strengthen safe practices. All the relevant checks and inspection of equipment and system have been undertaken and were evidenced on the day of the inspection. An accident book is maintained by the Home and supplementary in-depth forms are completed in addition to this. The fire book was seen evidencing regular drills are performed and equipment is duly maintained. Water temperatures are taken and comply with regulations. Legionella tests have also been done. Drug cupboard and fridge temperatures were also evidence and were within the stated ranges. The Manager is aware of RIDDOR and reporting incidences to the Commission under Regulation 37. COSSH products are locked away safely. All radiators now have guards. Environmental Risk Assessments are in place and have been extended to the unguarded radiators. Maple House H56-H05 S23463 Maple House V223767 140605 Stage 4.doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 x x 1 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 1 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 2 1 x 1 2 Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score 3 1 3 1 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Maple House Score x x x x Standard No 37 38 39 40 41 42 43 Score x x x x x x x H56-H05 S23463 Maple House V223767 140605 Stage 4.doc Version 1.30 Page 24 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 5 Regulation 5(b)(c) Requirement Timescale for action 30/09/05 2. 9 Terms and conditions in respect of accommodation to be provided for service users including the amount and method of payments. Also a form of contract for the provisions of services and facilities provided 13(4)(b)(c The registered person shall 12(1)(b) ensure that any activities, which the service users participate, are so far as reasonably practicable free from avoidable risks. Unnecessary risks to the health and safety of service users are identified and so far as possible eliminated. The registered person shall ensure that the care home is conducted so as to make proper provision for care and were appropriate, supervision of service users. Immediate 3. 27 23(2)(j) The registered person provides Service Users with toilet and bathroom facilities, which meet their assessed needs and that, are of a good quality and standard 30/09/05 Maple House H56-H05 S23463 Maple House V223767 140605 Stage 4.doc Version 1.30 Page 25 4. 5. 28 32 23(3)(a) 18(1)(a) 6. 34 19 The registered person shall provide safe storage facilities for staff who work at the home Staff have the competencies and qualities required to meet service users’ needs and achieve Sector Skills Council workforce strategy targets within the required time-scales 50 of the care require to be NVQ trained.(Out-standing requirement from the previous 2 inspection Timescale of the 01/05/05 not met) .. The registered person operates a thorough recruitment procedure ensuring the protection of service users. 31/07/05 30/11/05 30/06/05 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. 2. 3. 4. 5. Refer to Standard 1 24 26 28 30 Good Practice Recommendations The service users guide needs to contain information on fees charged, what they cover and the cost of any extras The home needs to continue its on-going renewal and maintenance plans The carpets in the service users bedrooms need replacing The carpets in the lounge and dining area need replacing and.the kitchen area needs up-grading l The flooring in the laundry room needs replacing. Floor finishes need to be impermeable. Maple House H56-H05 S23463 Maple House V223767 140605 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection 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 H56-H05 S23463 Maple House V223767 140605 Stage 4.doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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