Inspection on 23/01/08 for Maple Tree Lodge

This inspection was carried out on 23rd January 2008.

CSCI found this care home to be providing an Poor service.

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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Maple Tree Lodge 13/04/09

Maple Tree Lodge 14/04/08

Maple Tree Lodge 05/02/07

Maple Tree Lodge 08/11/05

Maple Tree Lodge 07/07/05

Maple Tree Lodge 22/02/05

Maple Tree Lodge 24/08/04

Maple Tree Lodge 28/02/04

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 Tree Lodge 87 Byron Street Loughborough Leicestershire LE11 5JN Lead Inspector Diane Butler Unannounced Inspection 23 January 2008 09:00 rd Maple Tree Lodge DS0000001759.V355065.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 Tree Lodge DS0000001759.V355065.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 Tree Lodge DS0000001759.V355065.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Maple Tree Lodge Address 87 Byron Street Loughborough Leicestershire LE11 5JN 01509 269637 01509 269637 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) Aspire Lifestyle Limited Julie Ward Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Maple Tree Lodge DS0000001759.V355065.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered provider may provide the following categories of service: Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning Disability - Code LD The maximum number of service users who can be accommodated is: 3 5th February 2007 2. Date of last inspection Brief Description of the Service: Maple Tree Cottage is a care home providing personal care and support for up to 3 residents with a learning disability. Two residents currently live at the home with the third room being used for storage. The home is a bungalow, located on a quiet residential road in Loughborough. Residents have their own bedrooms and there is a lounge/dining room, bathroom and kitchen. The home has a small garden to the rear with access via a portable ramp. Residents are supported to access a range of day care and leisure activities. The charges for living at the home vary depending on individuals assessed needs and level of support required. Current charges range from £950.00 per week to £1593.34 per week. Details of what is included in the charges can be found in the service user guide (a document which provides relevant information about the home), which is given to all residents on arrival at the home. A copy of the latest Inspection report is available at the home, or it can be accessed via the CSCI website: www.csci.org.uk. Further information about the home is available from the registered manager. Maple Tree Lodge DS0000001759.V355065.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use the service experience poor outcomes. This was an unannounced visit, which took place over a two day period in January 2008. The registered manager was on duty on the second day of the visit. When undertaking key inspections the Commission for Social Care Inspection (CSCI) focuses upon outcomes for residents and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved tracking the care that the two residents currently living at the home receive, through looking at their records, speaking with them where possible and discussion with support workers on duty at the time of the visit. Observation was also used where communication was difficult to evidence whether care and support needs were being met. Further planning for this visit included checking the service history of the home and the last Inspection report and looking through the AQAA document (Annual Quality Assurance Assessment), which was submitted to the Commission for Social Care Inspection prior to the visit. The AQAA document is the main way that providers inform us of how well their service is delivering good outcomes for the people using it. Surveys were also sent to a five support workers to gain their views of Maple Tree Lodge, one survey was returned. Comments received include: “We look after the wellbeing of the residents, i.e. day care, personal hygiene, college and day centre”. “It would be more convenient if the company had its own transport”. What the service does well: The registered manager ensures that the home is run in an open and inclusive manner, residents are able to make decisions on a daily basis and support workers treat them as individuals and encourage and enable them to be as independent as possible. One to one support is provided to both residents throughout the day and one waking night staff provides support during the night. Maple Tree Lodge DS0000001759.V355065.R01.S.doc Version 5.2 Page 6 The Care plans and life plans that are in place give the reader a clear understanding of the residents care and support needs. The registered manager and support workers have a good understanding of the resident’s current needs and support is offered in a respectful and sensitive way. Support workers feel supported by the registered manager and staff work well as a team. Throughout the visit the registered manager and support workers were seen interacting with the residents in a caring and relaxed manner. What has improved since the last inspection? What they could do better: Ensure that all staff complete a training course in safeguarding adults. This will ensure that the residents in their care are fully protected from any possible abuse. Ensure that all staff received formal induction on commencement of employment and have the necessary training there after to enable them to carry out their roles effectively. Residents need to know that they are being cared for by qualified and competent staff. Ensure that the maintenance issues identified at both this inspection and the previous inspections are dealt with. Residents need to be provided with safe and comfortable surroundings. Ensure that the registered manager has appropriate time in which to carry out her managerial responsibilities effectively. Maple Tree Lodge DS0000001759.V355065.R01.S.doc Version 5.2 Page 7 Ensure that regular audits of the systems currently used to record resident’s money held for safekeeping are carried out. This will protect the residents from possible financial abuse. Ensure that views of others involved with the home including residents families, advocates and/or professionals are sought with regard to the service currently being offered. Ensure that recommendations made within the fire risk assessment are carried out. This will ensure the on going safety of the residents in their care. 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 Tree Lodge DS0000001759.V355065.R01.S.doc Version 5.2 Page 8 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 Tree Lodge DS0000001759.V355065.R01.S.doc Version 5.2 Page 9 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. Resident’s needs are appropriately assessed before moving into the home and they are given relevant information about the home to enable them to make a choice as to whether they wish to live there. EVIDENCE: A service user guide is in place. This document, which is provided in an easy read format, is given to all residents living at Maple Tree Cottage. Information within the service user guide includes what accommodation and support will be provided and how much things cost. An easy read contract and complaints procedure, which have both been developed since the last inspection, are also included. The registered manager confirmed that both residents had received a copy of this document, which they keep in their room. There have been no new admissions to the home since the last key inspection in February 2007. The registered manager explained that should a room become available she would firstly obtain a needs assessment from any prospective residents social worker to see what care and support they may need. Maple Tree Lodge DS0000001759.V355065.R01.S.doc Version 5.2 Page 10 She would then complete her own assessment and would invite the prospective resident to look around the home and meet the residents already living there. A number of over night stays would also be arranged to ensure that it was the right place for them. On checking the files for both residents currently living at the home it was noted that both had an initial assessment in place. Maple Tree Lodge DS0000001759.V355065.R01.S.doc Version 5.2 Page 11 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 good This judgement has been made using available evidence including a visit to this service. Care plans provide support workers with the information they need to meet the needs of the residents in their care. EVIDENCE: Care plans and life plans are in place for both residents and it was evident that the residents were involved in developing and reviewing these documents. The Life plans give the reader a good picture of the residents social care and support needs, what their likes and dislikes are, what they like to do during the day and evening and what they need support with. Details of family, friends and other people that are important to them are also included. The care plans give a clear picture of the resident’s health care needs and include actions the support workers need to take to meet those needs. Maple Tree Lodge DS0000001759.V355065.R01.S.doc Version 5.2 Page 12 The care plans cover a range of needs including personal care, mobility, communication, eating and drinking and behaviour. Within the behaviour care plan there are examples of the behaviour the resident may display and examples of the actions staff can take to try to alleviate the behaviour. This is good practice. Care plans are reviewed on a monthly basis and if any changes are evident the care plans are amended to reflect this. Residents living at Maple Tree Cottage are able to make decisions on a daily basis, these include when to get up and when to go to bed, when to shower, what to wear and what to eat and what activities they wish to complete. Support workers encourage the residents to be involved in life in the home as much as possible and issues that arise are discussed on a daily basis. Support workers enable the residents to take responsible risks on a daily basis and risk assessments are in place for activities undertaken both in house and whilst out in the community. Those seen were up to date and included all the risks associated with the activity being undertaken. It was noted that the kitchen door was locked when support workers were not around, we were informed that a risk had been identified when residents access the kitchen area alone therefore the door is currently kept locked when support workers are busy. A risk assessment for this was in place. Maple Tree Lodge DS0000001759.V355065.R01.S.doc Version 5.2 Page 13 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): 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 supported to be part of the local community. EVIDENCE: Both residents are supported to attend college on a part time basis and the team leader on duty during the visit explained that the support workers provide a range of activities throughout the week including completing puzzles, baking cakes, trips out and visits to the shops. The team leader explained, “we try to take the residents out every day if at all possible, they love to go out”. On checking the resident’s personal timetable of opportunities it was noted that swimming sessions, visiting the snoozlem and foot spa treatment were included though we were informed that these were not being carried out at the present time. Maple Tree Lodge DS0000001759.V355065.R01.S.doc Version 5.2 Page 14 One timetable also stated that the resident attended college on a Tuesday, though the team leader on duty stated that college is currently on a Monday and Wednesday. The registered manager stated that the time tables would be updated straight the way. A number of outings have been arranged since the last inspection in February last year and both residents enjoyed a holiday at Butlins during the summer. The registered manager explained that due to the increased ages of the residents it was getting more difficult to find suitable college places and leisure activities that the residents wished to attend, particularly in the evenings, therefore support workers ensure that the residents have suitable opportunities during the day to be part of and participate in, the local community. Throughout the visit the residents were supported on a one to one basis to take part in appropriate activities including completing puzzles, going out for walks, visits to the shops and going go out for lunch. One resident was supported to buy some new shoes whilst the second resident was supported to attend the local barbers for a haircut. Residents are able to choose what to eat on a daily basis and mealtimes are relaxed, flexible and unrushed. On checking the menu it showed that a varied choice is offered, including jacket potatoes, shepherds pie and roast pork, the week prior to the visit also showed that the residents had enjoyed fish and chips on two occasions, a particular favourite with one of the residents. Visiting is encouraged and visitors can call at any time. Maple Tree Lodge DS0000001759.V355065.R01.S.doc Version 5.2 Page 15 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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are looked after well in respect of their health and personal care. EVIDENCE: Residents are encouraged to be as independent as possible and care and support is offered in a sensitive and respectful way. Care plans and life plans are in place to show support workers how the residents prefer to be supported and inform them of the residents individual likes and dislikes around daily living. Throughout the visit support workers were seen interacting with the residents in a caring and relaxed manner. Daily records show that residents are supported to attend appointments at their local GP surgery, the opticians and the dentist and chiropody appointments and visits to their consultant are also arranged on their behalf. Maple Tree Lodge DS0000001759.V355065.R01.S.doc Version 5.2 Page 16 Resident’s medication records were checked. Medication had been appropriately signed into the home and medication had been signed for when given. On checking the blister packs for one resident it was noted that for one tablet which is prescribed morning and night, the last tablet for the month was missing, on speaking with the registered manager we were informed that this was because the medication had previously been commenced during the month and not enough tablets had been provided. The registered manager stated that it was her intention to make the resident an appointment to see their GP in order to address this issue. On the day of the visit the resident’s medication was being stored in a lockable filing cabinet, however, a medicine cabinet has recently been purchased and installed and will replace the filing cabinet in the near future. All team leaders have had training in the safe handling of medicines. Maple Tree Lodge DS0000001759.V355065.R01.S.doc Version 5.2 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service. Residents are on the whole protected from harm. EVIDENCE: A complaints procedure is in place. A copy of this, which is provided in easy read format is included in the service user guide, which has been given to both residents and a copy is available in the lounge area of the home. The registered manager is also in the process of displaying a copy in the hall way so that visitors to the home are aware of what to do if they have a concern or complaint. The registered manager explained that as well as having a printed copy of the complaints procedure residents are also reminded on a regular basis of what to do if they are not happy about something. The AQAA (Annual Quality Assurance Assessment) document received prior to this visit stated that no complaints had been received since the last inspection in February 2007. This was confirmed on checking the complaints book and whilst speaking with the registered manager. Training in adult protection has been provided since the last inspection however, the most recent support workers to be employed, one of which has worked at the home for just over one year have yet to receive this training. Maple Tree Lodge DS0000001759.V355065.R01.S.doc Version 5.2 Page 18 Both support workers spoken with on the day of the visit were aware of actions to take should abuse be suspected and the registered manager is aware of the procedures to follow to ensure that the residents in her care are protected. On checking the money kept on behalf of one of the residents it was noted that there were some minor shortfalls in the recording with the recorded balance not corresponding with the money actually held. The record sheet showed a balance of £31.48, an entry showed that £4.00 had been spent, the balance was then recorded as £26.49. On checking the money held it was noted that there was £27.79 in their wallet. It is recommended that a regular audit be carried out to ensure that support workers are completing these records appropriately; this would further protect the residents in their care. Maple Tree Lodge DS0000001759.V355065.R01.S.doc Version 5.2 Page 19 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): 24,25,26,27,30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Though the home is clean and comfortable, the decoration and floor coverings in some areas of the home are in need of attention. EVIDENCE: Maple tree Cottage is a three bedroom bungalow situated in a residential area of Loughborough. Accommodation is currently provided to two residents as the third bedroom is used for storage. The home’s tumble dryer is also situated in this room. Communal accommodation is provided on the ground floor and consists of a lounge/dining room, kitchen, shower room and toilet. Overall the home provides a comfortable and homely atmosphere however, it was noted that a number of areas within the home are in need of redecoration Maple Tree Lodge DS0000001759.V355065.R01.S.doc Version 5.2 Page 20 including the lounge/dining room, residents bedrooms and the kitchen. The kitchen floor is also in need of attention. The team leader on duty on the first day of the visit did state that they were in the process of arranging for the redecoration of a number of rooms in the home. The registered manager explained that a verbal agreement had also been received from the owners of the home with regard to the refurbishment of the kitchen. Both residents have their own bedroom and these were personalised and included their own belongings. It was noted that whilst both were in need of some decoration, one was in more need than the other. It was also noted that problems with one resident’s wardrobe meant that this was currently being kept in the third bedroom. The team leader spoken with explained that new beds had recently been purchased for the residents and they were awaiting a delivery date for these. A new shower room has been installed since the last inspection and new electrical appliances have been purchased including a new cooker, washing machine and tumble dryer. A small enclosed garden can be found to the rear of the property, which is accessible by a number of stone steps. A portable ramp has been purchased since the last inspection to enable the resident’s access to this area. Maple Tree Lodge DS0000001759.V355065.R01.S.doc Version 5.2 Page 21 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): 32,33,34,35,36 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Residents are supported and protected by the homes recruitment practices, however, lack of appropriate staff training could affect the care and support that residents receive. EVIDENCE: Residents are provided with one to one support throughout the day from 8.00am in the morning until 10.00pm at night and one waking night staff provides support during the night. As well as supporting the residents, support workers are also responsible for the cooking of their meals, the cleaning of the home and the residents washing and ironing. Maple Tree Lodge DS0000001759.V355065.R01.S.doc Version 5.2 Page 22 An appropriate recruitment procedure is in place, application forms are completed, references are collected and a CRB (Criminal Records Bureau) and POVA 1st (Protection of Vulnerable Adults) check are obtained. On checking the files belonging to the two support workers on duty during the visit all the necessary checks were found to be in place. The registered manager explained that all new staff complete an in house induction and shadow an experienced member of staff for the first two weeks of their employment to give them a feel of the home and allow them to get to know the residents. This was confirmed on checking the recruitment files of the two most recent staff members to be employed. It was noted that formal induction is not currently provided. On checking the training record it was noted that although some training had been provided in the last 12 months, including protection of vulnerable adults and for one support worker, infection control, not all staff had been provided with training related to the specific disabilities and conditions of the residents in their care. On speaking with one support worker who had worked at the home for just over a year we were informed that the only training they had received had been fire safety training. Not all staff have been provided with first aid training, including the registered manager and support workers have yet to be provided with moving and handling training even though the mobility of one resident has deteriorated. Support workers who have received training in areas such as first aid, infection control and health and safety these courses had been completed between four and eight years ago and no refresher training had been provided to bring the support workers up to date with best practices in these areas. Staff meetings and supervision sessions are provided on a regular basis and both support workers spoken with during the visit stated that they felt supported by the registered manager. On the day of the inspection a relaxed atmosphere was evident with support workers going about their work in a relaxed, unhurried and professional manner. Maple Tree Lodge DS0000001759.V355065.R01.S.doc Version 5.2 Page 23 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): 37,38,39,42 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Resident’s benefit from the overall ethos of the home, which the registered manager provides however, shortfalls within safe working practices could put the residents at risk. EVIDENCE: The registered manager has worked at the home for five years and has completed her NVQ level 4, and registered managers award. It was evident during the inspection that the residents and support workers benefit from the management and leadership that the registered manager provides and there was a relaxed and friendly atmosphere throughout the visit. Maple Tree Lodge DS0000001759.V355065.R01.S.doc Version 5.2 Page 24 The home has investors in people and a number of monitoring systems are in place to check on the service being provided, this includes regular staff meetings, daily meetings with the residents and monthly monitoring visits by representivies of the organisation which owns Maple Tree Cottage. Views of others involved with the home including residents families, advocates and/or professionals involved in their care are not currently obtained. It was noted that the registered manager continues to work on shift as part of the one to one support team and is only provided with 3 hours each week for managerial duties. This is acknowledged as insufficient time to enable her to carry out her managerial responsibilities effectively. On checking the training file it was evident that not all staff have been provided with the relevant training to ensure the health, welfare and safety of the residents currently living in the home. This includes training in Health and Safety and Food Hygiene. Not all staff have been provided with first aid training, including the registered manager which means that some shifts have no member of staff with a first aid qualification on duty. Support workers have yet to be provided with Moving and Handling training even though the mobility of one resident has deteriorated to the point where the registered manager feels moving and handling training is needed. The registered manager has contacted the local fire officer with regard to the homes fire system as required at the last inspection and a risk assessment was carried out by an outside company in August 2007 to assess the suitability of the current system that is in place. The risk assessment recommended a number of improvements some of which have been actioned locally, some of which are still awaiting action from the owners of the home. Actions taken locally include the installation of smoke detectors with light sensors in resident’s bedrooms and luminous exit signs. The owners have yet to arrange for the testing of the hard wiring system as required at the last inspection in February 2007. Maple Tree Lodge DS0000001759.V355065.R01.S.doc Version 5.2 Page 25 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 2 25 3 26 2 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 1 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 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 X 2 3 2 X X 1 X Maple Tree Lodge DS0000001759.V355065.R01.S.doc Version 5.2 Page 26 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(6) Timescale for action The registered person shall make 30/06/08 arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. The registered person must ensure that all staff are appropriately trained in safeguarding adults procedures. Staff need to know the procedures to follow in order to for them to protect the residents in their care. The registered person shall 30/06/08 having regard to the number and needs of the service users ensure that – the premises to be used as a care home are of sound construction and kept in a good stated of repair externally and internally. all parts of the care home are kept clean and reasonably decorated. Maple Tree Lodge DS0000001759.V355065.R01.S.doc Version 5.2 Page 27 Requirement 2. YA24 23(b) (d) The registered person must ensure that the maintenance issues identified at both this inspection and previous inspections are dealt with. Residents need to be provided with safe and comfortable surroundings. 3 YA35 18 (1) (c) (i) The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of the service users – ensure that the persons employed by the registered person to work at the care home receive - training appropriate to the work they are to perform. The registered person must ensure that all staff receive the required training including health and safety. Residents need to know that they are being cared for by qualified and competent staff. 4 YA37 12(a) The registered person shall ensure that the care home is conducted so as – To promote and make proper provision for the health and welfare of service users. The registered provider must ensure that the registered manager has appropriate time in which to carry out her managerial responsibilities effectively. 30/06/08 30/06/08 Maple Tree Lodge DS0000001759.V355065.R01.S.doc Version 5.2 Page 28 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 Refer to Standard YA23 YA35 YA39 Good Practice Recommendations The registered person should carry out regular audits of the systems currently used to record residents money held for safekeeping. The registered person should provide all new support workers with LDQ (Learning disability qualification) induction training. The registered person should look at ways of obtaining views of others involved with the home including residents families, advocates and/or professionals with regard to the service offered. The registered person should ensure that recommendations made within the fire risk assessment carried out in August 2007 are carried out. 4 YA42 Maple Tree Lodge DS0000001759.V355065.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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. 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