Inspection on 18/05/05 for Maple House

This inspection was carried out on 18th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 11/04/08

Maple House 17/05/07

Maple House 22/05/06

Maple House 21/11/05

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 Eileen McHale Unannounced 18 May 2005 15:30 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 C52 C02 S20051 Maple House V225890 180505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Maple House Address 51 Peveril Road, Tibshelf, Alfreton, Derbyshire, DE55 5LR 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) (01773) 872720 Mr Peter South Mr Peter South Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Maple House C52 C02 S20051 Maple House V225890 180505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: N/A Date of last inspection 18/11/04 Brief Description of the Service: Maple House is a small care Home situated in Tibshelf village near Alfreton. The home is a semi-detached house on an estate at the edge of the village. Although registered for 3 service users the home has accommodated only two service users for more than a year as the home has been in the process of extension for this period. The residents 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 C52 C02 S20051 Maple House V225890 180505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The service was inspected on the 18 and 19th May 2005. The visit on the 18th May was unannounced. The inspector spent some time with one service user and met the manager and a member of staff. Both residents were however due to go out that evening on planned outings and the inspection was completed the following day. Case and other records were inspected and an inspection of the building was carried out. No visits had taken place since the last inspection. Issues of the cleanliness of the home had been brought to the attention of the Commission and these were addressed at the time of the inspection. What the service does well: What has improved since the last inspection? Some requirements have been met since the last inspection as a result of changes made to the building. These include washbasins in bedrooms and window restrictors for first floor windows. Other items such as locks on doors are to be addressed as building work is completed. Maple House C52 C02 S20051 Maple House V225890 180505 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Maple House C52 C02 S20051 Maple House V225890 180505 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 C52 C02 S20051 Maple House V225890 180505 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) 2 There were full assessments of service users. EVIDENCE: Documentary evidence was seen to demonstrate that care managers placed both service users in the home, and full assessments and care plans were in place on admission. Detailed amendments to care plans had been provided for both residents to address their special needs. These had involved input from relevant health service professionals. The service users’ care managers, implemented formal reviews. Maple House C52 C02 S20051 Maple House V225890 180505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,9 Service users were active participants in determining how their needs were met but records of actions taken were poorly maintained. EVIDENCE: Care plans were seen and one service user agreed to speak to the inspector and gave information about his day-to-day life. It was noted that he had a easy and joking relationship with the manager and staff member on duty and expressed his opinions in an assertive manner to them and to the inspector. His description of his routines and activities coincided with his care plan. As a result of detailed risk assessments and a multidisciplinary decision, neither service user was allowed out alone. However service user did take part in a range of activities, which enhanced their skills and experiences. Discussion took place with the registered person on the level of routine records, which were infrequent and gave scant evidence of how care plans were implemented. Maple House C52 C02 S20051 Maple House V225890 180505 Stage 4.doc Version 1.30 Page 10 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 Service users had access to a good range of activities, which met their personal preferences. EVIDENCE: Both residents attended day services five days per week. One resident attended a traditional day service but the second had a more varied pattern, with two days work based service and two days based at an equestrian centre. The residents had both shared and separate activities. One resident was a keen distance cyclist and was supported in this by the manager. The other enjoyed football. Both attended clubs for people with a learning disability and enjoyed Karaoke in the local pubs. The resident who gave information on activities reported that both had been to Majorca for their holidays. One resident had no family links, but the other was in regular contact with his family being visited regularly at the day service near to the family home. It was noted that in one instance there was an extensive flow of information between the home and the day service. Maple House C52 C02 S20051 Maple House V225890 180505 Stage 4.doc Version 1.30 Page 11 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 The manager was well aware of the need to provide a healthy lifestyle and had promoted a significant improvement in the health of one resident. EVIDENCE: Neither resident received personal care but did require support and prompting to maintain their own personal care. At the time of the inspection neither resident was taking medication. The manager did indicate that one resident had previously taken medication for diabetes but with a change in diet and significant weight loss now required no medication. The manager was well aware of the importance of diet and exercise in maintaining good health. Records were maintained of dental and optical care. The manager had recently sought medical advice and investigation for a change in behaviour experienced by one resident. Maple House C52 C02 S20051 Maple House V225890 180505 Stage 4.doc Version 1.30 Page 12 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 Systems were not in place in the home to protect residents from financial or other forms of abuse. EVIDENCE: The manager indicated that the complaints procedure was in place and that time had been taken to ensure that residents understood their right to complain. Neither resident had made a complaint and there was no record of complaints. Neither the manager nor the staff member employed had received any training in the protection of vulnerable adults. The manager indicated that the costs of providing staff cover were prohibitive. This matter was outstanding from a previous inspection. The manager had failed to implement any procedures for the safe administration of monies held on the service users behalf. The last individual records of the management of monies on behalf of residents had been made in June 2004. This was made subject to an immediate requirement. Maple House C52 C02 S20051 Maple House V225890 180505 Stage 4.doc Version 1.30 Page 13 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) 24,26,30 The accommodation was not maintained to a clean, comfortable and suitable condition. EVIDENCE: As at the previous two inspections the home was being extended with a view to providing additional capacity. For the duration of the extension the occupancy had been two rather than the registered number of three beds, as suitable accommodation was not being provided for the third resident. The work to extend the home was being completed by the manager/proprietor during times when service users were attending day services. The external shell of the extension was complete but considerable internal work was still required to make the building habitable. The implications of the work for the two residents living in the home were considerable and had been raised at previous inspections. Important works to provide a suitable and safe environment for the residents had not been carried out. The need to clean, decorate and upgrade the existing accommodation had been ignored or put on hold until the building work was finished. Maple House C52 C02 S20051 Maple House V225890 180505 Stage 4.doc Version 1.30 Page 14 Since the last inspection washbasins had been provided in bedrooms but no redecoration had taken place in those bedrooms. In one instance there was no paint or wallpaper on the walls. This was made subject to an immediate requirement at the time of the inspection. Locks had not been fitted on bedroom doors as the home was in the process of being fitted with new fire doors as required by the Fire Officer. Although some cleaning had taken place, the dust and dirt created by the building work had spread throughout the home as the extension could not be sealed off. Similarly the rear garden was in an unsafe condition being filled with builder’s rubble and equipment. Maple House C52 C02 S20051 Maple House V225890 180505 Stage 4.doc Version 1.30 Page 15 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) 34,35, The manager and staff member are not appropriately trained to ensure the safety of service users. EVIDENCE: The manager worked alongside one member of staff. He indicated that he had undertaken CRB checks and taken up references but could not put his hands on the documentary evidence due to disruption by the building works. The staff member had received induction, in that she had been introduced to key workers within the day service. There was no claim that this complied with LDAF (the training framework for staff working with people with learning disabilities) The appointment of a staff member had enabled the manager to provide one to one support for residents so that they might undertake separate and preferred activities. The manager admitted that he and the staff member had undertaken neither mandatory training nor any other training since the last inspection. An immediate requirement was made with regard to fire training. Maple House C52 C02 S20051 Maple House V225890 180505 Stage 4.doc Version 1.30 Page 16 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) 37,39,41,42 The registered manager/proprietor had undertaken work on the extension of the home at the expense of maintaining good management , administrative and health and safety systems, thereby putting residents at risk. EVIDENCE: The proprietor /manager is a first level nurse who in the past had undertaken an introductory NEBBSM course but had not undertaken the registered manager’s qualification (NVQ4). The manager had clearly invested a great deal of time and money in the building of an extension to the home. Although he had maintained the activities of service users, he had failed to maintain the records and administration of the home and the environmental standards that should be enjoyed by residents. He stated that he was unable to budget for required staff training. It was noted by the proprietor, that although he had additional contracted hours for activities, in one instance the payment was unreliable and often late, and in the other instance the contract had not been reviewed and Maple House C52 C02 S20051 Maple House V225890 180505 Stage 4.doc Version 1.30 Page 17 he was expected to provide additional hours at a cost of £3.00 per hour. (below national minimum wage) The home had no systems in place for measuring quality although this had been raised at previous inspections. The manager and staff member had received no training or updates on health and safety training. There was no evidence in the home of fire training, fire drills or practices and alarm checks. This was made subject to an immediate requirement. Since the last inspection window restrictors had been fitted to first floor windows and arrangements were in place to store chemical safely in accordance with COSHH Regulations. Data sheets were not available on all chemical used. Although radiators within the new extension had low surface temperatures, those in the existing home did not. The manager asserted that the existing residents were at no risk from these, but had not completed risk assessments as required at the previous inspection. An immediate requirement was made on this matter. The manager had ensured that PAT testing had been completed on all electrical equipment used in the home. There was not a certificate of electrical installation but this it was said would be available when the building was completed. Work had begun to fit a kitchen door as required by the Environmental Health Officer and the manager indicated that a second wash basin would be fitted when the laundry area was complete and a washing machine was moved. Maple House C52 C02 S20051 Maple House V225890 180505 Stage 4.doc Version 1.30 Page 18 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 x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x 1 x x x 1 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 x x Standard No 31 32 33 34 35 36 Score x x x 2 1 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Maple House Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 2 x x x 1 1 x C52 C02 S20051 Maple House V225890 180505 Stage 4.doc Version 1.30 Page 19 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 6 Regulation 17(1)(a) Schedule 3 Timescale for action records must be maintined of the 31 July implementation and review of 2005 any care plans in accordance with Schedule 3 of the Regulations. Oustanding from previous inspections. The registered manager and staff 31 August member must undertake training 2005 in adult protection. This requirement is outstanding from previous inspections. The registered manager must Immediate establish and maintain records of Requirment all monies received on behalf of service users and their return or use on behalf of service users with receipts of purchases made on their behalf. The registered manager must 30 June produce a timed plan for the 2005 completion of all outstanding works and repairs and refurbishment of the original building. The registered manager must 31 July replace the stairs and landing 2005 carpet. This is outstanding from previous inspections. The registered manager must 31 July ensure that external grounds are 2005 suitable and safe for use by Version 1.30 Page 20 Requirement 2. 23 13(6) 3. 23 17(1)(a) Schedule 4 4. 24 23(2)(b) 5. 24 16(2)(c 6. 24 23(2)(o) Maple House C52 C02 S20051 Maple House V225890 180505 Stage 4.doc 7. 26 8. 30 9. 34 10. 35 11. 39 12. 13. 37 41 14. 42 15. 42 service users. This requirement is outstanding from previous inspections. 12(4)(a) Locks must be fitted on each residents door following consultation with the Fire Officer.This requirement is outstanding from previous inspections. 16(2)(j) The registered manager must ensure that all accommodation including carpets and soft furnishing is subject to deep cleaning. 19,Schedu The registered manager must le 2 ensure that records required within Schedule 2, evidencing the fitness of workers are held in the home. 18(1)(c ) The registered manager must ensure that staff employed in the home receive training appropriate to the work they are to perform. 24(1) The registered manager must (2)&(3) identify and put into operation quality assurance and quality monitoring systems. this requirment is outstanding from previous inspections. 9(b) The registered manager must enroll on a training course for NVQ4 in management 17 The registered manager must (1)(2)&(3 ensure that all statutory records ) are maintained and available for inspection. 13(3)(4)& The registered manager and staff (5), member must undertake training 10(2)&(3) on moving and handling,first aid,infection control and food , hygiene. This requirement is outstanding from previous inspections. 16(2)(j) The registered manager must complete the work required to comply with the requirements of the Environmental Health C52 C02 S20051 Maple House V225890 180505 Stage 4.doc 31 july 2005 31 August 2005 31 August 2005 30 September 2005 30 September 2005 31 December 2005 31 August 2005 31 August 2005 31 August 2005 Maple House Version 1.30 Page 21 16. 42 13(4)(a)& (c) 17. 18. 19. 42 42 42 13(3) 23(2)(b) 23(4)(d)& (e) 20. 24 23(2)(b) Officer. This requirement is outstanding from previous inspections.31 July 2005 The registered manager must complete written risk assessment for radiators which are not low surface temperature or guarded. The registered manager must ensure that data is available on all substances used in the home. The registered manager must provide a certificate of safety for electrical installation. The registered manager must ensure that arrangements are in place to ensure fire training twice per year and drills, practices and alarm checks are completed and recorded. The manager must ensure that the front bedroom is redecorated with a replacement carpet and furniture that is maintained to a suitable standard of repair and cleanliness. Immediate Requireme nt. 31 July 2005 31 July 2005 Immediate requirment . 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. Refer to Standard 35 36 Good Practice Recommendations The manager should have in place an induction and foundation training programme that complies with the Learning Disability Award framework. The manager should establish a system of staff supervision, undertaking any appropriate training to assist him in developing such a programme. Maple House C52 C02 S20051 Maple House V225890 180505 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection South Point Cardinal Square Nottingham Road Derby. DE1 3QT 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 C52 C02 S20051 Maple House V225890 180505 Stage 4.doc Version 1.30 Page 23 - 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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