Inspection on 21/11/05 for Maple House

This inspection was carried out on 21st November 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 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Maple House 11/04/08

Maple House 17/05/07

Maple House 22/05/06

Maple House 18/05/05

Maple House 18/11/04

Maple House 14/06/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Maple House 51 Peveril Road Tibshelf Alfreton Derbyshire DE55 5LR Lead Inspector Jenny Thornton Unannounced Inspection 21 November 2005 12:45 DS0000020051.V265625.R01.S.doc Version 5.0 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 DS0000020051.V265625.R01.S.doc Version 5.0 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. DS0000020051.V265625.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Maple House Address 51 Peveril Road Tibshelf Alfreton Derbyshire DE55 5LR (01773) 872720 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Peter South Mr Peter South Care Home 3 Category(ies) of Learning disability (3) registration, with number of places DS0000020051.V265625.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th May 2005 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 extending the facilities. 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. DS0000020051.V265625.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was un-announced and took place over four hours. The inspector met the manager/provider and spent time with the two residents. The inspector looked around the home and examined various records. The home has made progress towards meeting the requirements and recommendations from the last inspection report dated 18th May 2005. What the service does well: What has improved since the last inspection? What they could do better: The manager/provider needs to attend all essential training to update his knowledge and skills, and undertake an approved management qualification. The building work and refurbishment of all areas needs to be duly completed. The rear garden needs to be made safe for residents to use. DS0000020051.V265625.R01.S.doc Version 5.0 Page 6 The manager needs to put in place a system for monitoring the quality of care and services provided at the home. The home’s recruitment policy and procedure and staff application form requires updating to cover all the required information and documents so as to ensure that staff are suitable to work with vulnerable adults. The manager needs to put in place an induction training programme that complies with the Learning Disability Award framework. 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. DS0000020051.V265625.R01.S.doc Version 5.0 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 DS0000020051.V265625.R01.S.doc Version 5.0 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): EVIDENCE: The above standards were not reviewed on this inspection. DS0000020051.V265625.R01.S.doc Version 5.0 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 the following standard(s): EVIDENCE: The above standards were not reviewed on this inspection. DS0000020051.V265625.R01.S.doc Version 5.0 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 the following standard(s): 11,13,16 and 17 Residents receive a varied and healthy diet and enjoy their meals at the home. Residents receive a good level of personal support and access a range of activities, which met their preferred lifestyles. EVIDENCE: New menus had been introduced, which had been drawn up with involvement of residents. The menus included a variety of foods based on healthy eating. Residents said that the meals included home cooked foods, which they enjoyed, and that their dietary needs and preferences were met. Relationships observed between residents and the manager were open and good-humoured. Residents received a good level of support, which enabled them to learn and develop social and daily living skills. Residents helped with some housekeeping duties around the home such as setting the table, washing the pots, making a snack and drink and tidying their room. It was obvious from discussions with residents and the manager that residents are encouraged to make choices and decisions about their lives, and are involved DS0000020051.V265625.R01.S.doc Version 5.0 Page 11 in all aspects of life in the home. Residents felt able to express their views. Residents are part of the local community and enjoyed going out to local pubs and attended clubs for people with a learning disability. Approved locks had been fitted to residents’ doors and residents had been offered a key to their room. One resident chose to lock his bedroom door when he went out. One resident had no family links, but the other resident was in regular contact with his family being visited regularly at the day service near to the family home. DS0000020051.V265625.R01.S.doc Version 5.0 Page 12 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): 20 Procedures in place for the safekeeping and handling of medicines safeguard residents’ welfare. EVIDENCE: Policies and procedures were in place relating to the safekeeping and handling of medicines. The manager is a registered nurse and has received training to administer medicines. Both residents were healthy and neither resident was taking medication at the time of the inspection. The manager kept a small supply of non-prescription medicines such as paracetamol, which were kept in a secure area. The manager said that the residents hardly ever required these. The home’s medicine policies did not include the administration of ‘homely remedies’. On completion of the home’s extension the manager planned to provide a specific locked cupboard for storing medicines. DS0000020051.V265625.R01.S.doc Version 5.0 Page 13 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): 23 Systems have been put in place to safeguard resident’s welfare, although the manager needs to attend training on adult protection procedures to safeguard residents interests. EVIDENCE: There has been no allegations of abuse at the home in the last year. The home’s policy relating to prevention of abuse stated that other Agencies such as the police and Social Services may be involved in an allegation of abuse. The manager did not have an up-to-date copy of the Local Authority’s vulnerable adults policy and procedure. The home did not employ any staff; the manager had not received training on protection of vulnerable adults. This matter is outstanding from the previous two inspection reports. Neither resident was able to manage their own finances or allowances, and Derbyshire County Council was appointee for their finances. The manager received the resident’s allowances on their behalf and had put clear records in place relating to this. Resident’s allowances were transferred into there own bank account and their bank statements were kept in their care plan. Both residents kept a small amount of money in safe keeping at the home and money was kept securely. A clear balance sheet had been put in place to show all money received, kept and withdrawn on a resident’s behalf, which safeguarded resident’s interests. All entries and withdrawals of money contained the manager’s signature; the manager said that resident’s were unable to meaningfully witness and counter sign transactions of their money and therefore did not sign the records. Individual balance sheets were not kept in a bound book containing consecutively numbered pages. DS0000020051.V265625.R01.S.doc Version 5.0 Page 14 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): 24 and 25 The environment is clean and comfortable, although further work is required to ensure that all areas of the home are suitably decorated and safe to live in. EVIDENCE: As the previous three inspections the home was being extended with a view to accommodating up to five residents. For the duration of the extension the home has been able to accommodate only two residents rather than the registered number of three beds, as suitable accommodation was not provided for a third resident. The work to extend the home was being completed by the manager/provider during times when service users were attending day services. The extension and internal work was nearing completion, and the provider intended that all work would be completed by the end of April 2006. Work had been carried out to clean and decorate the existing accommodation, and the manager intended to decorate and replace the corridor carpet and day areas once all building work was finished. Since the last inspection the main bathroom had been refurbished and three bedrooms had been redecorated. New furniture and carpets had been fitted in two bedrooms and were due to be fitted in a third room. Approved door locks and new fire doors had been fitted throughout the house; the manager said DS0000020051.V265625.R01.S.doc Version 5.0 Page 15 that certain fire doors required intermittent strips and a self-closing device fitting. This did not apply to rooms currently occupied by residents. The rear garden was in an unsafe condition as this contained builder’s equipment and rubble. This issue was highlighted on the previous inspection report dated May 2005. It was acknowledged that residents did not currently use the garden during the winter months. DS0000020051.V265625.R01.S.doc Version 5.0 Page 16 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): 34 and 35 The manager has not attended appropriate training to update his knowledge and skills to enable him to fully meet resident’s needs. EVIDENCE: The registered provider/manager lives at the home and provides all care and support to the residents. Both residents continue to attend day centres five days a week and clubs several evenings a week. The manager confirmed that the member of staff previously employed to work at the home had left. The registered provider/manager was getting married at the end of November, and the inspector was shown evidence that an enhanced criminal record disclosure was being processed to enable his future wife to provide support to residents. The manager intends to employ staff once the home’s registration and occupancy increases. The home’s policy and procedure relating to the recruitment of staff and application form required updating to include all the required information and documents in regards to a person applying to work in the care home. The home did not have a written induction programme for new staff to ensure they have received the required training to carry out their job. The manager acknowledged that he had not undertaken either mandatory or any other training in the last year, such as first aid, food hygiene, adult protection and fire and health and safety. An immediate requirement was DS0000020051.V265625.R01.S.doc Version 5.0 Page 17 made on the inspection for the manager to attend the mandatory training. The above matter was highlighted on the previous inspection report. The manager said that Derbyshire Fire and Rescue service had advised him that in view of the size of the home and the residents’ abilities, the manager was not required to attend formal fire training, but could update his knowledge on fire safety by watching one of the approved fire safety videos. The manager agreed to obtain written confirmation from the home’s fire officer as to what training was required. DS0000020051.V265625.R01.S.doc Version 5.0 Page 18 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): 39, 41 and 42 Good progress has been made to ensure that health and safety systems are in place and required records are kept to safeguard residents. EVIDENCE: The provider/manager is a first level nurse trained in learning disability who in the past had undertaken an introductory NEBBSM management course but had not undertaken the registered manager’s qualification (NVQ4). The manager had made enquires about the registered manager’s course. As previously stated the manager had not attended recent updates in first aid, food hygiene, fire and health and safety. Since the last inspection the manager had completed a written risk assessment of the radiators, which identified no risk of scalding to residents. The manager confirmed that a standard mixer valve had been fitted to the main bath/shower to maintain safe hot water temperatures, and that this would be fitted in the new bathroom on completion. The manager agreed to update the safe bathing risk assessments to clearly show this. Records showed that the fire alarm DS0000020051.V265625.R01.S.doc Version 5.0 Page 19 system was checked weekly and that two fire drills had been held in the last year. The manager confirmed that a new gas boiler had been fitted and that the home had no other gas appliances. The electrical appliances were checked in March 2005, and that an electrical installation certificate would be obtained once the building work was completed. The manager had taken steps to ensure that the required information and records were maintained in the home as listed in the Care Homes Regulations. The manager had obtained additional safety data sheets for products used in the home, which are classified as a hazardous substance. Although the manager had been unable to obtain safety data sheets for certain products purchased locally. It was apparent from discussions with the residents that the home is run in their best interests and that their views are sought about the services provided. However the home had no systems in place for measuring the quality of care and services provided. This had been highlighted at previous inspections. DS0000020051.V265625.R01.S.doc Version 5.0 Page 20 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 X X X X Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 X X X X X LIFESTYLES Standard No Score 11 3 12 X 13 3 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X N/A 1 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 X Standard No 37 38 39 40 41 42 43 Score X X 1 X 3 2 X DS0000020051.V265625.R01.S.doc Version 5.0 Page 21 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA23 Regulation 13 Requirement The registered manager must undertake training in adult protection. This requirement is outstanding from previous inspections. Timescale for action 30/03/06 2. YA24 23 The registered manager 30/04/06 must produce a clear plan for the completion of all outstanding building work and refurbishment of the home. This requirement is outstanding from previous inspections. The rear garden must be suitable and safe for residents to use.. This requirement is outstanding from previous inspections. The registered manager must undertake appropriate training to ensure he has the necessary skills for managing the home. DS0000020051.V265625.R01.S.doc 3. YA24 23 30/04/06 4. YA35 10 30/04/06 Version 5.0 Page 22 5. YA37 10 This requirement is outstanding from previous inspections. The registered manager 30/04/06 must enrol on N.V.Q. Level 4 in management or equivalent. This requirement is outstanding from previous inspections. The registered manager and staff must undertake training on fire safety, first aid, food hygiene and health and safety. This requirement is outstanding from previous inspections. 30/06/06 6. YA42 13 7. YA42 23 The home must obtain a 31/07/05 certificate which shows that the electrical installations have been checked to the required standard. The registered manager must ensure that safety data sheets are available on all substances used in the home, which are classified as hazardous. The registered manager must identify and put systems in place for monitoring the quality of care provided at the home. This requirement is outstanding from previous inspections. 30/04/06 8. YA42 13 9. YA39 24 30/04/06 DS0000020051.V265625.R01.S.doc Version 5.0 Page 23 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 YA20 Good Practice Recommendations The home’s medicine policies should clearly state what ‘homely remedies’ can be administered, including the strength and frequency of doses. The manager should obtain an up-to-date copy of Derbyshire’s vulnerable adults policy and procedure. Balance sheets of money kept and withdrawn on resident’s behalf should be held in a bound book containing consecutively numbered pages. The home’s recruitment policy and procedure and staff application form should be updating to cover all the required information and documents, which applies to a person working in the home. The manager should have in place an induction training programme that complies with the Learning Disability Award framework. 2 3. YA23 YA23 4. YA34 5. YA35 DS0000020051.V265625.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Derbyshire Area Office 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 DS0000020051.V265625.R01.S.doc Version 5.0 Page 25 - 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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