Inspection on 29/08/07 for Maple Lodge

This inspection was carried out on 29th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 Lodge 15/07/09

Maple Lodge 20/12/06

Maple Lodge 30/01/06

Maple Lodge 01/08/05

Maple Lodge 14/01/05

Maple Lodge 25/05/04

Maple Lodge 16/03/04

Similar services:

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Maple Lodge Rotherwood Drive Rowley Park Stafford Staffordshire ST17 9AF Lead Inspector Mrs Joanna Wooller KEY Unannounced Inspection 29th August 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Maple Lodge DS0000005120.V347655.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Maple Lodge DS0000005120.V347655.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Maple Lodge Address Rotherwood Drive Rowley Park Stafford Staffordshire ST17 9AF 01785 255259 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) www.schealthcare.co.uk Southern Cross Healthcare Services Ltd Mrs Julie Ann Anderson Care Home 40 Category(ies) of Dementia - over 65 years of age (40), Old age, registration, with number not falling within any other category (40), of places Physical disability over 65 years of age (20) Maple Lodge DS0000005120.V347655.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th December 2006 Brief Description of the Service: Maple Lodge was opened in October 1999. The home was purpose built and is a detached care home, which stands in its own grounds. The home is registered to admit 40 residents over the age of 65 in the above category, who require personal care only. There are 40 single bedrooms all with en suite facilities and a passenger lift is available. Two bright and spacious lounges are available with two lounge/dining areas. There is a hobbies room which doubles up as a hairdressing salon on the first floor. In Lilly suite there is easy access, through French doors, for residents to enjoy the attractive, enclosed grounds with established trees; seating has been provided, some with pergola cover. In the reception area there is a hospitality, quiet lounge for all to use. A bus service runs from the end of the road half a mile from where the home is situated into the centre of Stafford, where all local services and shops are to be found. There are ample car parking facilities. Weekly fees are from £374 up to £550 Maple Lodge DS0000005120.V347655.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in one day by the lead inspector. Jane Anderson, Care Manager was in the home and she assisted the inspector throughout the visit. The inspection included the following elements; a tour of the building, observation and inspection of records relating to provision of care, discussions with several residents, discussions with the staff members on duty, and an inspection of the managerial aspects such as staffing issues, quality assurance and health & safety. Since the last inspection there had been no changes to the management of the home, no complaints had been received and no additional visits had been necessitated. There was strong evidence that all aspects of care were being well addressed, with residents being able to choose the home following a preadmission assessment. Residents’ plans had been well written; some were based on the community care plans completed by social workers. Health, personal and social care needs had been met and well documented. Privacy, dignity and choice aspects for residents were being upheld. No complaints, incidents or reports of abuse of any kind had been received since the last inspection, and policies and procedures seen covered these issues. The home was evidenced as fit for its purpose and was seen to provide a safe environment for the residents and staff. A homely atmosphere had been created in lounges and bedrooms, and the premises were very clean and tidy. Adequate spacious areas for residents were provided including; communal space, dining/activity space, bathing/toilet facilities, and bedrooms. Health and safety aspects had been given a high priority and no shortfalls were noted. Staffing levels and skill mix had been adequate to meet the assessed needs of the existing residents. Recruitment and retention of staff aspects were good with little staff turnover. Staff training had been given a high priority, with induction training being followed by NVQ training, and staff had received regular supervision. The manager monitors the training requirements on a matrix to ensure no shortfalls are made. What the service does well: Maple Lodge DS0000005120.V347655.R01.S.doc Version 5.2 Page 6 The home offers very personalised care to a group of residents in a warm and caring environment. The home appeared to be well managed by Ms Anderson who is a registered care manager. General management aspects were good with quality assurance taking place. Records had been correctly filed and stored. Assurances were given regarding the positive financial viability of the home, and that suitable accounting and business procedures are followed. 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. The summary of this inspection report can be made available in other formats on request. Maple Lodge DS0000005120.V347655.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Maple Lodge DS0000005120.V347655.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Prospective Service Users have all the information they need to make an informed choice about whether to move into the home. Information included in the Statement of Purpose and Service User Guide is carried out as described. EVIDENCE: Staff confirmed that each Service Users with the support of their relatives or social worker had been included in a pre admission assessment process prior to moving into the home. Documentation available to the inspector evidenced that the care plans are based on the information gained in this important process. The care plans were very informative and personalised. Information was kept on notice boards in the foyer, which was useful to family members and visitors. Maple Lodge DS0000005120.V347655.R01.S.doc Version 5.2 Page 9 The care manager completes all assessments and discussions take place with the team of staff prior to admission. No changes have been made to the documentation since the last visit and the inspector raised no issues. Maple Lodge DS0000005120.V347655.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The assessed health and personal care needs of individual residents had been well documented and were being met, with good standards of care being delivered. There was a safe system for the receipt, storage, administration and disposal of medicines. Residents were treated with respect, privacy and dignity, during the caring and dying process. EVIDENCE: Many residents spoken to all commented positively about the care being provided, the friendly staff and management. The residents’ individual plans and associated documentation were all very well written, meaningful and reflected the current condition of residents. The documentation seen and a discussion with both residents and staff members evidenced that health and personal care needs were being well met. Maple Lodge DS0000005120.V347655.R01.S.doc Version 5.2 Page 11 During the inspection it was observed that privacy and dignity were being afforded to residents, and there was very good interaction between residents and staff. Care staff were seen knocking on doors before entering. When asked residents told the inspector that they were treated with respect, and that the staff were very good. NHS facilities and professionals including community nurses, medical consultants and clinical nurse specialists had all been accessed when required, and these events were seen recorded. The local GPs and a local pharmacist offer a service to the residents in the home, and there is a good working relationship with them. Records of their visits and outcomes were seen documented. The medicines within the home were administered with a safe system following medicines policy documentation. No resident was ‘self medicating’, but locked facilities were available. The pharmacist had completed audits and the systems were found in order. The manager completes monthly audits with regard to administration and documentation of medication. Maple Lodge DS0000005120.V347655.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The full social programme was made available; resident’s views were sought and acted upon. There was a relaxed atmosphere with residents continuing with their daily routine. Qualified cooks, offering choice and a balanced diet, prepared the meals at the home. A new system called Nutmeg had been introduced into the home to ensure the meals are balanced and appropriate. EVIDENCE: The activity co-ordinator was on annual leave, despite this the residents were having planned sessions of activities which were planned in each day. The hairdresser was in the home during the inspection and many residents were taking the opportunity to have there hair done. Residents were made aware of the full social programme from the displayed notices in the entrance hall. Maple Lodge DS0000005120.V347655.R01.S.doc Version 5.2 Page 13 Visitors were made welcome by the staff and management; no restrictions were made for the times of visiting. Links with the community are good. Residents were aware of the daily menu and told the inspector their choice. The inspector was impressed with the commitment by the management. Since the previous inspection the company had introduced ‘Nutmeg’ which is a balanced programme of nutritionally suitable meals to meet the residents needs. Menus did appear well balanced and offered a lot of choice. Maple Lodge DS0000005120.V347655.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The home follows a robust complaints procedure and this was followed at all times. Residents’ rights were protected and staff were trained to ensure that residents were protected form abuse. EVIDENCE: An examination of the complaints book, the relevant policy and procedure documentation, and a discussion with staff, evidenced that complaints were listened to and dealt with in the correct manner. Since the last inspection no complaints had been recorded or brought to the attention of this commission. Thank you cards were seen from appreciative relatives. No incidents of neglect or abuse of any kind has been reported. The policy documentation seen, and a discussion with staff confirmed that residents are protected from all forms of abuse. Documentation seen evidenced that the above issues had been discussed at length during staff induction, training and on-going supervision. Maple Lodge DS0000005120.V347655.R01.S.doc Version 5.2 Page 15 Maple Lodge DS0000005120.V347655.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. A routine sample of the home identified a well-maintained environment providing the residents with a homely place to live. Residents had the opportunity to personalise their personal space. The management recognised that certain carpets need replacing. This will be part of the general refurbishment. EVIDENCE: The home was evidenced as being well maintained and suited for its intended purpose. Future plans to upgrade the home will include changing the carpets identified at the visit in need of replacement in the dining areas. Maple Lodge DS0000005120.V347655.R01.S.doc Version 5.2 Page 17 A random sample of the bedrooms evidenced that they were personalised to suit individuals taste. Many residents like to stay in their rooms for quiet times but they were encouraged to go to the dining room for meals and activities. Bathing and toilet facilities were well sited throughout the home. These were found to be clean and tidy. COSHH systems in place were satisfactory and the domestic staff were seen to be vigilant with their trolleys and equipment to avoid accidents in the home. Maple Lodge DS0000005120.V347655.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The assessed needs of service users had been met by an adequate number of suitably trained staff. Recruitment followed the company procedures and had been correctly addressed which had contributed to the protection of service users. Staff training had been given a high priority. EVIDENCE: The duty rosters seen, and a discussion with the care manager and the staff, evidenced that adequate numbers of staff had been on duty to meet the needs of the existing service users. Staffing levels are maintained to meet the individual residents needs. Staffing rosters were checked and were in order. Six carers were on duty during the day hours and four carers were on duty for each night shift. Adequate ancillary staff had been provided each week – one kitchen assistant was in the home and two domestics were on duty. One maintenance person was in the home too. Maple Lodge DS0000005120.V347655.R01.S.doc Version 5.2 Page 19 The homes recruitment policy, procedures and documentation were examined and recruitment issues had been handled correctly. Staff had been subject to POVA/CRB comprehensive checks, and these were seen recorded. Training had been given a high priority and the training records of individuals were seen. The records evidenced that care assistants had benefited from ‘in house’ and external training, which had covered the needs of the registered client group. Staff told the inspector that they were encouraged to study. Training had been provided for staff in the awareness and management of dementia related conditions, and staff outlined this to the inspector. Maple Lodge DS0000005120.V347655.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The home appeared to be well managed and quality assurance was in place. Financial aspects were correctly addressed and recorded with safeguards to residents. Health and safety issues had been given a high priority and managed well. EVIDENCE: From observations made and discussions with the manager and staff, it was evident that the home was being run in the interests of service users. Maple Lodge DS0000005120.V347655.R01.S.doc Version 5.2 Page 21 Quality Assurance including feedback from residents and their representatives, was seen documented. Documentation seen evidenced that the views of visiting professionals had also been established, and included in the review process. A check on the records and a discussion with both residents and representatives evidenced that all service users had the opportunity to handle their own finances and all residents and families had chosen to do so. Day to day monies of residents were checked and money held reconciled with the ledger. A company check was being made on the day of the visit. Inventories of valuables and belongings brought into the home were seen recorded. No health and safety issues were noted during this inspection, including a tour of the home. The documentation seen for checks and examination of plant and equipment was all correct and up to date. The manager and staff spoken to confirmed that health and safety issues are given a high priority. The manager holds a wealth of experience and knowledge, which was evident at the visit. She is fully aware of the individual residents needs and the residents know her well as she works with the staff on regular occasions. Her supernumerary time is spent well ensuring the home is well run and the staff are supported. The manager has yet to complete the Managers Award as part of her ongoing development and this must be completed in the next 12 months. Maple Lodge DS0000005120.V347655.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 4 X X X X X X 4 STAFFING Standard No Score 27 4 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 4 X X 4 Maple Lodge DS0000005120.V347655.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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 OP31 Good Practice Recommendations The manager must complete the Managers Award within the next 12 months. Maple Lodge DS0000005120.V347655.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Birmingham Local Office Commission for Social Care Inspection 1st Floor, Ladywood House 45-56 Stephenson Street Birmingham West Midlands B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Maple Lodge DS0000005120.V347655.R01.S.doc Version 5.2 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. 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