Inspection on 09/08/07 for Maple Lodge

This inspection was carried out on 9th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Maple Lodge 23/05/06

Maple Lodge 03/01/06

Maple Lodge 18/08/05

Maple Lodge 12/10/04

Maple Lodge 22/04/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

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Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Maple Lodge 10 Southborough Road Surbiton Surrey KT6 6JN Lead Inspector Adrian Gordon Key Unannounced Inspection 9th August 2007 10:30 Maple Lodge DS0000013393.V342756.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Maple Lodge DS0000013393.V342756.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Maple Lodge DS0000013393.V342756.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Maple Lodge Address 10 Southborough Road Surbiton Surrey KT6 6JN 020 8399 4356 020 8287 1950 richard@maplelodge.charitydays.co.uk 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) The Fircroft Trust Mr Richard Weir Care Home 13 Category(ies) of Learning disability (13) registration, with number of places Maple Lodge DS0000013393.V342756.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been agreed to allow one specified service user over the age of 65 to be accommodated. 23rd May 2006 Date of last inspection Brief Description of the Service: Maple Lodge is a care home which provides accommodation for thirteen adults with learning disabilities. It is located in a quiet residential street close to Surbiton. Local bus routes are accessible nearby. Trains, shops and facilities are available in Surbiton itself. The service is managed by The Fircroft Trust. Information about Maple Lodge is available in a detailed Statement of Purpose and easy to read Service User Guide. Fees are £592.27 per week. Maple Lodge DS0000013393.V342756.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out over the course of one day by one inspector. It consisted of a tour of the premises, examination of records and observation of care practice. The inspector met with five residents and four members of staff. No questionnaires were returned. What the service does well: What has improved since the last inspection? What they could do better: Residents bedroom doors are not lockable, which means that their privacy can be compromised. Residents must also be offered a key to their rooms where appropriate. Training must be provided on a more regular basis to ensure staff have all the core skills necessary to carry out their jobs. Records show that hot water is often at a temperature below that which is acceptable for washing or bathing. Action must be taken to ensure that this is put right. Maple Lodge DS0000013393.V342756.R01.S.doc Version 5.2 Page 6 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 DS0000013393.V342756.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Maple Lodge DS0000013393.V342756.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Easy to understand information is available for people who are thinking of using the service which helps them to decide if it is appropriate. EVIDENCE: Residents have a full assessment before being admitted to make sure the service can meet their needs. A detailed Statement of Purpose is available for people interested in the home. There is also a Service User Guide for residents which uses pictures and large print to explain about Maple Lodge and local facilities. Each resident has a contract which includes information about the fees for the service and terms and conditions. Service User Agreements are signed by residents and a copy kept in their files. Maple Lodge DS0000013393.V342756.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The support plans are person centred and clearly written and up to date, which enables staff to meet the individual needs of residents. EVIDENCE: Each resident has a detailed person centred Support Plan which includes photographs and symbols to make it easier to understand. These are clearly written and show how individual needs are best met by staff support. Areas covered include personal hygiene, health, social relationships and leisure. One plan had a life story with photos of the resident as a child with their family. This was an excellent document for the resident to have to remind them of their own history. Information is kept up to date and includes details such as the preferred name of each resident. Goals are identified and reviewed. Keyworkers write monthly reports which residents are encouraged to make comments about. Maple Lodge DS0000013393.V342756.R01.S.doc Version 5.2 Page 10 The Statement of Purpose states how each resident is treated as an indivudual and makes clear that dignity and choice are central to the serive provided. There is also information about the civil rights of people who live there. Minutes of monthly resident meetings show that there is good involvement. Recent discussion include holiday planning and a barbeque. Staff were observed to encourage residents to make decisions. For example a cinema outing was planned for the evening and each resident was able to say whether they wanted to go. Risk assessments are put in place to make sure that residents are kept as safe as possible whilst encouraging independence. For example one resident had a risk assessment for travelling in the community. These assessments are kept up to date and reviewed reguarly. Maple Lodge DS0000013393.V342756.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to enjoy a good range of activities of their choosing. EVIDENCE: Residents are able to take part in a good range of activities and interests. These include day centre and college, outings to shops, bars and cafes, and events in the home such as barbeques. All residents are able to go on a holiday which they help to choose. A notice board in the dining area has information about events and activities locally. A minibus is available to take people out if required, however this is not accessible to all residents. The manager said they are looking into getting a more suitable vehicle. Visitors are made welcome and residents talked about their friends and family that either come and visit or who they go out to see. There is little information about sexuality in care plans, however staff talked about how they are Maple Lodge DS0000013393.V342756.R01.S.doc Version 5.2 Page 12 supporting one resident to have a relationship. This has raised a number of issues around consent which are being handled with sensitivity. Residents are given a Service User Agreement which outlines responsibilities while living there, for example domestic chores and looking after their rooms. A chart was seen in one residents room which uses pictures to help them understand what they are doing during the week and anything they are responsible for. Menus for the week ahead are agreed at weekends with residents who said they enjoyed the food they have. Some residents get involved in cooking or help out in preparing. An alternative to the menu is offered if requested. Fresh food was seen in the fridge and fruit was available from a bowl in the kitchen. Maple Lodge DS0000013393.V342756.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good support is in place from staff and specialists to ensure that health care needs are met. EVIDENCE: Information on health needs is detailed in Support Plans. These show that residents have access to specialist support and routine checks, such as hearing test, optician and breast screening. Specialist support is available from the Community Learning Disability Team if needed. Medication records are checked by management on a weekly basis. Medication Administration Record (MAR) sheets were seen to be accurate and clearly written. No gaps were evident. Each resident has a medication profile which is kept up to date. A new document has been introduced called ‘When I Die’ which gives information about each residents preferences in the event of death. This is an Maple Lodge DS0000013393.V342756.R01.S.doc Version 5.2 Page 14 excellent piece of information giving the views of residents about arrangements, including what they would like if they were dying, funeral music and what type of burial they want. Maple Lodge DS0000013393.V342756.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are given good information about how to complain and their views are listened to. EVIDENCE: There is a detailed complaints procedure which has been made easier to read with pictures so that residents understand it. Residents confirmed that they knew how to complain and that the procedure had been given to them. It was also seen on the notice board in the dining room. There have been no recent complaints. There are good systems for monitoring and recording each resident’s money. Records are clearly written and entries are signed. Receipts of purchases are kept and numbered. One entry showed that a member of staff had lunch paid by a resident while supporting them in the community. The manager agreed to reimburse this money as it is not normal practice. Although this appears to have been a misunderstanding, all staff must be made aware of how residents money can be used. The service has a copy of the local adult abuse procedures for the Royal Borough of Kingston. Staff were aware of the action to take in the event of any concerns. Not all staff have received training in the Protection of vulnerable Adults over the past year. This must be provided. Maple Lodge DS0000013393.V342756.R01.S.doc Version 5.2 Page 16 Maple Lodge DS0000013393.V342756.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in the clean, homely and spacious environment. EVIDENCE: Maple Lodge is a large house with rooms set out over three floors. On the ground floor is a large lounge and separate dining area which both lead out into the rear garden. A permanent ramp makes it easier for residents with mobility problems to get outside. The lounge is comfortably furnished and there were pictures of residents on the walls which made it homely. There is a spacious, well equipped kitchen with low surfaces for residents to make use of if preferred. All communal areas were clean, bright and pleasantly decorated. There are bedrooms are on all three floors. Two of these were seen which were of a good size, clean and personalised with pictures and photographs. Residents to not have keys to their rooms and bedroom doors are not lockable Maple Lodge DS0000013393.V342756.R01.S.doc Version 5.2 Page 18 from the inside. Although staff knock before entering, it does not promote independence or privacy. There are a sufficient number of baths and showers for the people who live their. The shower on the ground floor is easy to use and there are handrails to support residents. The bath on the first floor is not easy for all the residents to make use of and an accessible bath should be considered. Records of hot water temperatures show that it is often around 30°C. This is not warm enough for a bath or shower. The person in charge said that there was an old boiler which they are looking at replacing. Maple Lodge DS0000013393.V342756.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff are competent and experienced which ensures that residents are well supported. EVIDENCE: During the inspection staff were able to show a good understanding of individuals who lived there. They got on well with the residents and the atmosphere in the home was light hearted and relaxed. A large board in the kitchen showed photos of staff so that residents knew in advance who was going to be on duty. Staffing levels were appropriate to meet the needs of people living there. Records for bank staff were looked at. These contained recruitment monitoring sheets which showed that all staff had the necessary checks before working. These include references, photograph, proof of identification and a Criminal Records Bureau check. When new staff are interviewed residents sit in and are able to ask questions. Maple Lodge DS0000013393.V342756.R01.S.doc Version 5.2 Page 20 Recent training completed by staff includes ‘Understanding behaviour that challenges’ and ‘Empowering Learning’. Some staff have completed NVQ3 in Care. However not everyone has had the training they need over the past year. The registered manager has written a training plan identifies future training needs for 2007. These includes core skills training such as moving and handling, food hygiene and health and safety. During the inspection it was suggested that Makaton training would be useful to improve communication with some residents. Maple Lodge DS0000013393.V342756.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good management and monitoring systems in place which ensures that the service runs effectively. EVIDENCE: The registered manager was not available at this inspection. There are good management systems to ensure that the home is run effectively in his absence. A house leader takes responsibility for the day to day running of the service. Staff confirmed that they get the support they need from the manager. An annual development plan is in place for Maple Lodge which includes aims and objectives for 2007. In addition, Fircroft sends out quality assurance Maple Lodge DS0000013393.V342756.R01.S.doc Version 5.2 Page 22 questionnaires to residents and relatives every six months. Some of these were seen, however it is unclear what action is taken about some of the comments and suggestions made. These should feed in to the development plan. Health and safety checks are mostly up to date and a monthly audit is carried out to ensure that the home is safe for residents. Checks on portable appliances and fire extinguishers were last done in June 2006. These are overdue and must be carried out. The fire system was checked in February 2007 and fire points are tested weekly. There are regular fire drills. Hot water temperatures are checked every week. Maple Lodge DS0000013393.V342756.R01.S.doc Version 5.2 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 Standard No Score 1 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 2 27 2 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 4 3 X 3 X X 2 X Maple Lodge DS0000013393.V342756.R01.S.doc Version 5.2 Page 24 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. 1 Standard YA23 Regulation 13(6) Requirement To further protect residents all staff must have refresher training in the Protection of Vulnerable Adults. To make sure residents financial interests are protected all staff must be informed of the appropriste use of resident money. To promote privacy all residents must be able to lock their doors and be offered a key where appropriate. So that residents are able to wash and bathe in comfort the hot water must be maintained at around 43°C So that staff have the necessary skills to carry out their jobs, core skills training must be provided. To make sure there are no unnecessary risks to the health and safety of residents, portable appliances and fire extinguishers must be tested. Timescale for action 01/12/07 2 YA23 13(6) 15/09/07 3 YA26 12(4)(a) 01/12/07 4 YA27 23(2)(j) 01/11/07 5 6 YA35 YA42 18(1)(c) 13(4)(c) 01/12/07 01/10/07 Maple Lodge DS0000013393.V342756.R01.S.doc Version 5.2 Page 25 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 Refer to Standard YA14 YA15 YA35 YA39 Good Practice Recommendations So that all residents can make use of the transport a fully accessible vehicle should be purchased. Sexual identity should be included in support plans to better enable staff to support and understand residents. To enable staff to better communicate with residents Makaton training should be offered. To show that the views of residents and relatives are taken into account, comments and suggestions in questionnaires should be included in the Annual Development Plan. Maple Lodge DS0000013393.V342756.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 DS0000013393.V342756.R01.S.doc Version 5.2 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. 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