Inspection on 17/12/07 for Mapleholme

This inspection was carried out on 17th December 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 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mapleholme 04/12/08

Mapleholme 30/10/06

Mapleholme 09/02/06

Mapleholme 27/01/05

Mapleholme 03/06/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Mapleholme Beckwith Street Birkenhead Wirral Cheshire CH41 3JP Lead Inspector Beate Field Key Unannounced Inspection 17 December 2007 and 3rd January 2008 10:30 th Mapleholme DS0000035823.V335634.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 Mapleholme DS0000035823.V335634.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. Mapleholme DS0000035823.V335634.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mapleholme Address Beckwith Street Birkenhead Wirral Cheshire CH41 3JP 0151 666 1250 0151 666 1298 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) Metropolitan Borough of Wirral Care Home 23 Category(ies) of Learning disability (22), Learning disability over registration, with number 65 years of age (1) of places Mapleholme DS0000035823.V335634.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service should at all times employ a suitably qualified and experienced manager who is registered with the National Care Standards Commission. Following the proposed review of the learning disability division, a written account of the service provided at Birket House is to be forwarded to the National Care Standards Commission. This information is to be provided by 30 March 2004. The matters detailed in the schedule of requirements must be completed in the stated timescales. 30th October 2006 3. Date of last inspection Brief Description of the Service: Mapleholme is one of several care homes managed by Wirral Metropolitan Borough Council. Mapleholme provides respite care to adults with learning disabilities who are in the age range of 18-65. All accommodation is provided in single bedrooms. The accommodation is situated on two floors. The upper floor is accessed by a passenger lift. The home is accessible to wheelchair users. The home is divided into three units. Each unit has bathing and toilet facilities, a dining area, kitchen facilities and a lounge. At the rear of the property is a large grassed area with a patio and flowerbeds. At the front of the building there is a paved parking area. The home is situated in the Birkenhead area of the Wirral. It is close to the town centre and easily accessible by public transport. At the time of the inspection, the weekly cost for the service was £66.85 per week. A copy of the statement of purpose, which describes the services offered at Mapleholme, is made available to relatives and social workers. The service users guide to the home is made available before a person comes to stay at the home and the content is discussed with them to ensure their understanding. Wirral Metropolitan Borough Council operates day service provision for adults with learning disabilities from the same premises. Both services are separately maintained but share a manager. Mapleholme DS0000035823.V335634.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection is based on two visits to the home, information received about the service since the last inspection, a pre-inspection questionnaire completed by the manager that gave information about the day-to-day running of the home and questionnaires completed by the people who use the service, their relatives and staff. During the visit to the home time was spent looking at a sample of records and policies and procedures and talking to the manager. A tour of the home was undertaken. The inspector spoke with some of the people who use the service and staff and observed the care provided to residents. A second visit was made to the home to view records that were not available at the home during the first visit. An expert by experience was present at the inspection for 2 hours. This person has experience of services for adult with a learning disability and was asked to visit the home to give their view on how the service is operating. The expert by experience toured the home with the inspector and spoke to staff and people who use the service. What the service does well: The assessment process ensures that the service is only offered to individuals whose needs can be met at the home. A full assessment takes place and people who would like to use the service and their carers are invited to the home for several visits to assess if the home is suitable. People who use the service are consulted with and encouraged to take part in life at the home. The daily routines and involvement in the local community ensure that the preferences of people who use the service are provided for. The food provided offers variety and caters for individual tastes and any special dietary needs. Staff training and policies and procedures are in place to ensure that the views of people who use the service are listened to. People who use the service are supported by the number of staff available and the training staff have received. Staff interact warmly and appropriately with the people who use the service. Staff are respectful towards them and promote their dignity. People who use the service benefit from the quality assurance systems in place at the home. People who use the service and their relatives said they were happy with the service provided. The expert by experience made a number of positive Mapleholme DS0000035823.V335634.R01.S.doc Version 5.2 Page 6 remarks about the service and said, “Overall I felt Mapleholme was a good place to come and stay for a few weeks.” What has improved since the last inspection? What they could do better: Further information is needed in some care plans in order to ensure that the staff have access to sufficient, up to date, written information around how to meet the needs of the people who use the service. The records held at the home need to provide evidence that the people who use the service are protected by the homes recruitment practices. The procedures for safeguarding vulnerable adults need to be correctly followed when an allegation of abuse is made in order to ensure that the welfare of the people who use the service is fully safeguarded. Risk assessments around the use of bed rails need to be available for any person who uses them during their stay at the home. These assessments need to be comprehensive in order to fully safeguard the people who use the service. Staff should receive supervision at least 6 times per year in order to ensure they have the support they need to carry out their roles effectively. Mapleholme DS0000035823.V335634.R01.S.doc Version 5.2 Page 7 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. Mapleholme DS0000035823.V335634.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 Mapleholme DS0000035823.V335634.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 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The assessment process ensures that the service is only offered to individuals whose needs can be met at home. People are able to make several visits to the home to make sure it is right for them before using the service. EVIDENCE: A statement of purpose and a service user guide are available and provide information about the respite service to the people who may want to use the service, their relatives and any professionals working with them. Since the last inspection the service user guide has been put into an audio format that makes it more accessible to more of the people who may want to use the service. A copy of the most recent inspection report is available for people using the service and their families to refer to. A sample of written assessments of a person’s suitability to use the service was seen. This showed that a thorough assessment is undertaken before a person is offered a respite service. The records indicated that this assessment involves discussion with the individual, their families and any relevant professionals. A written assessment from a social worker is also obtained. Mapleholme DS0000035823.V335634.R01.S.doc Version 5.2 Page 10 The records showed that before a person begins to use the service they are invited to view the home and to make as many trial visits to the home as they wish, which includes visits for tea and an overnight stay. Relatives are also invited to visit the service. People spoken with during the visit said they had made trial visits before using the service and had been given enough information. 5 people who returned questionnaires said that they got enough information before deciding to use the service. Mapleholme DS0000035823.V335634.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 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although there has been some improvement to care planning, further information is needed in some care plans in order to ensure that the staff have access to sufficient, up to date, written information around how to meet the needs of the people who use the service. EVIDENCE: Six care plans were seen during the inspection. Some of the care plans contained greater information than others. Some of the care plans did not provide sufficient information around the personal care and social support needed by the people using the service. Some records showed that information provided by parents/carers had not been transferred into the care plan. Mapleholme DS0000035823.V335634.R01.S.doc Version 5.2 Page 12 The manager reported that prior to each visit to the home, the care plans are updated through discussion with the carer, person using the service and any relevant professionals. The care plans seen did not have any recorded evidence of this. The manager reported that this information is not held on the individual files. A sample of risk assessments were seen and in general indicated that the needs of the people who use the service are assessed and their need for independence is balanced with any risks to their wellbeing. There was no written evidence that risk assessments had been reviewed prior to each visit to the home. Evidence that care plans and risk assessments have been reviewed needs to be held on the file to ensure that staff have access to up to date information. The staff spoken, with were knowledgeable about the needs of the people who use the service and how to meet them. Some said that sometimes they do not have access to up to date information on how to support the people who use the service. A discussion with staff indicated that the people who use the service are assisted to make decisions about their lives in accordance with their abilities. The home has information on independent advocacy services, which the people who use the service or their representative could access. Records show that the people who use the service are asked their opinion about the day to day running of the home at weekly meetings. In addition the staff spoken to said that they frequently ask them for their views. People using the service at the time of the visit said that they are asked their opinion about the meals provided, any changes they would like and about the activities they would like to take part in during their stay. Some of the homes policies and procedures are suitable for the people who come to stay at the home. It would be good practice if more of the homes policies and procedures were made available in more suitable formats. People using the service at the time of the visit were asked about the service they are given at the home and gave positive comments. Comments made included “ I like coming here, I like all the staff and I can ask them for help at any time” “ I like it here and I like the staff.” “I get to meet new people and make friends – I love coming.” Staff were observed to interact warmly and appropriately with the people who use the service. Relatives who returned questionnaires said their relative always or usually has their needs met and get the support agreed. Some comments made were “The service provides a good environment for my relative and peace of mind during respite.” “We believe the home does a good job in looking after our relative. They enjoy going and are happy when there and regard it as a holiday.” “There is a nice atmosphere.” Mapleholme DS0000035823.V335634.R01.S.doc Version 5.2 Page 13 Mapleholme DS0000035823.V335634.R01.S.doc Version 5.2 Page 14 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, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The daily routines, activities and involvement in the local community ensure that the preferences of the people who use the service are provided for. The food provided offers variety and caters for individual tastes and any special dietary needs. EVIDENCE: The records show that the people who use this service take part in community life. They are supported to use local facilities such as shops and public transport. People using the service at the time of the visit said that they enjoy going to the local pub for bingo and into town where they can go to the shops and use leisure services. Mapleholme DS0000035823.V335634.R01.S.doc Version 5.2 Page 15 The family and friends of the people who use the service are welcome at the home at any reasonable time. A telephone is available and staff support the people who use the service to make telephone calls where appropriate. Discussions with the staff, records and observations confirmed that the home’s routines are flexible as much as possible. The people using the service continue with educational, training or their employment activities whilst they are staying at the home for respite. During the week the people using the service are encouraged to get up in time to get ready for these activities and to go to bed at a reasonable time. At the weekends times for getting up and going to bed are more flexible. The records inspected did not consistently indicate the support the people using the service need in their daily lives in order to make choices and encourage independence. As already indicated, care plans need to provide clear guidance to staff on how to meet these personal care and social support needs. People using the service at the time of the visit reported that they are involved in the planning of meals. They said that they like the food and that there is a good choice. Some comments were “ the food is always nice.” “I like the meals.” The care plans detail likes and dislikes and any dietary requirements. A menu is maintained. The menus indicated that a variety of different foods are provided. There is a choice of meals available and a cooked breakfast is available on request. Fresh fruit was observed to be available in each of the units. The home employs two cooks. The manager reported that both have had up to date food hygiene training. During the visit the inspector had Christmas lunch with some of the people who use the service. The lunch was well presented and nicely cooked. The expert by experience said “ I felt that Mapleholme was a nice place to come and stay; it was clean and had a friendly atmosphere, the staff that I spoke to were friendly. The two people who use the service that I spoke to seemed happy and said they could make their own decisions about what they wanted to do. The manager and staff try to do as much as they can when people come to stay.” Mapleholme DS0000035823.V335634.R01.S.doc Version 5.2 Page 16 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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service receive the support they need with their health care. EVIDENCE: Staff reported and records showed that people who use the service are supported to access healthcare services during their stay if this is required. Records showed that they have access to a GP as needed and that the home involves other health and social care professionals where appropriate. Mapleholme DS0000035823.V335634.R01.S.doc Version 5.2 Page 17 The people who use the service are provided with support around their personal care by staff of the same gender. Observations indicated that staff are respectful towards the people who use the service and promote their dignity. Staff interviewed were very aware of the support needs of the people who use the service. The medication procedure was seen and gives clear guidance to staff. All staff who administer medication have received training in the home’s medication procedure and around the safe handling of medication. A number of staff have recently attended a 2 day training course in the safe handling of medication to update their knowledge in this area. The competence of staff to administer medication is assessed through supervision. Medication is stored securely. A sample of medication administration records and corresponding medication were inspected and found to be correctly maintained. 2 staff are now signing all medication records to reduce the risk of errors occurring. Mapleholme DS0000035823.V335634.R01.S.doc Version 5.2 Page 18 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 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The practices at the home in general provide the people who use the service with protection from abuse. EVIDENCE: There is a complaint procedure that is suited to the needs of the people who use the service. Relatives, advocates and health and social care professionals have access to a suitable complaints procedure, which gives them a clear picture of how to raise a concern or complaint on behalf of someone who uses the service. Staff reported that they regularly find out the views of the people who use the service to ensure they are happy being at the home and are getting the support they need. People who use the service and relatives who returned questionnaires knew how to make a complaint. CSCI has not received any complaints about this service since the last inspection. 2 complaints have been made to the home since January 2007. Records showed whether the complaint was founded, how the complaint was investigated in order to reach this decision and any action taken. An adult protection and a whistle blowing procedure are available. The whistle blowing procedure contains the contact details of the CSCI. All staff have Mapleholme DS0000035823.V335634.R01.S.doc Version 5.2 Page 19 received training around the protection of vulnerable adults. Notifications regarding adult protection matters have been referred to the appropriate agencies since the last inspection and in general appropriate action taken by the home to safeguard the people who use the service. One allegation had been investigated by the home prior to a referral being made to the social services safeguarding team. This is not the correct procedure to follow. The involvement of the police and the safeguarding team in this matter was not documented. The home manages the personal allowances for most of the people who use the service. The records of personal allowances for 6 people were seen and were in order. From discussion with members of staff and from an examination of the financial records, the home’s policies and practices with regards to money and financial affairs safeguard the people who use the service. The people who use the service sign financial records to indicate they have received their personal allowance in accordance with their abilities. Mapleholme DS0000035823.V335634.R01.S.doc Version 5.2 Page 20 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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is clean and in general provides a safe and comfortable environment for the people who use the service. The practices around the use of bed rails do not fully safeguard the people who use the service. EVIDENCE: The home is divided into three units, which are accessible to each other. Each unit is individually staffed. All bedrooms are single. Each unit has a lounge and a dining area with basic kitchen facilities. The kitchen facilities are accessible to the people who use the service and a risk assessment has been developed in order to safeguard them where this is needed. Furnishings in Mapleholme DS0000035823.V335634.R01.S.doc Version 5.2 Page 21 the home are domestic in character. The home is easily accessible to local community facilities by use of public transport. In addition the home has its own mini-bus. CCTV cameras are used at entry points of the home for security reasons. In general the home is suitably decorated and furnished. Since the last inspection there have been further improvements to the appearance of the home. Some areas have been redecorated, the garden and patio have been made to look more welcoming and some furniture and fittings have been replaced. Some areas of the home are showing signs of wear and tear and some furnishings appeared worn. The manager reported that there is no maintenance and renewal programme for the fabric and decoration of the premises. It is recommended that this be put in place as this would ensure that a good standard of decoration and furnishings are maintained throughout the home at all times. The decorative works identified at the last inspection have been attended to. Some of the bathrooms at the home do not appear homely and domestic. It is recommended that ways of addressing this be looked at in order to enhance the home for the people who use the service. The expert by experience said, “ the kitchen areas and lounges are done in nice bright colours and the lounges have nice, comfortable seats to sit in. The bedrooms are done in pastel colours, which make the bedrooms look nice and bright and cosy. The bathrooms, shower areas and toilets could do with a bit more work, they seem a bit dull and could do with a lick of paint to brighten them up.” The water and radiators are regulated to ensure they are maintained at a safe temperature. The windows at the home have been fitted with restrictors. A sample of windows were seen and the restrictors were functioning adequately. A lift is available. This is a service lift and does not look domestic in appearance. The doors to the lift are heavy and could be difficult for some people who use the service to open and close. It continues to be recommended that a more domestic style lift be made available. Evidence that there is a contract for the servicing of the lift and evidence of a recent inspection was available. Bed rails are used for some people who visit the service. Since the last visit staff have received training around the safe use of bed rails. Risk assessments around the use of bed rails and consent for their use are generally available. A risk assessment and evidence of consent was not available for one individual. One risk assessment referred to a person not having a protective bumper when they come to stay as they pull it off. The risk assessment provided no information as to how staff are to keep this person safe from possible entrapment. The risk assessments are not reviewed prior to each stay. The Mapleholme DS0000035823.V335634.R01.S.doc Version 5.2 Page 22 action taken to ensure that the bedrail is fitted correctly and prevents no hazards is not fully recorded. The NHS guidelines on risk assessing bed rails are available and should be used in order to produce a comprehensive risk assessment. A tour of the building showed that it was bright, well ventilated and free from malodours. Mapleholme DS0000035823.V335634.R01.S.doc Version 5.2 Page 23 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 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The records held at the home do not provide enough evidence to show that the people who use the service are protected by the homes recruitment practices. EVIDENCE: The staffing levels were discussed with the manager, who reported that staffing levels are determined by an individual assessment of the needs of each person prior to admission to the home for respite. There has been high sickness levels at the home and the manager explained the action taken to address this. Relief staff and the current staff team cover any staff vacancies and absences. The same relief staff who are employed by Metropolitan Borough of Wirral and who know the people who use the service and how the home works are deployed. There is a clear staff structure in operation and staff were aware of the lines of accountability at the home. Records and a discussion with staff showed a Mapleholme DS0000035823.V335634.R01.S.doc Version 5.2 Page 24 team meeting had not been held recently but that one was planned by the end of the year. Some staff said they had not received supervision on a regular basis. Records showed that staff were not receiving supervision at the recommended frequencies of at least 6 times per year. Staff spoken with said they enjoy working at the service. Some concern was expressed about sickness levels and the impact of this on the rest of the staff team. The staff said that in general the people who use the service have a positive experience. Some comments made were “The staff give 100 .” “People who visit make choices and decisions. They get involved in the local community.” “People get a good service here.” Staff training records and staff spoken with indicated that training is provided to ensure the people who use the service are being cared for properly and that their needs are being met in accordance with current good practice. The induction and foundation training programmes have been developed in accordance with the National Training Organisation training targets. Training around equal opportunities is provided to staff. 50 of staff hold an NVQ qualification. The records relating to the recruitment of three members of staff were seen. 2 references were not available for one member of staff. A second reference was not available for another of the staff. Evidence of a criminal records bureau check was not available for one staff member. Evidence that staff are physically and mentally fit to work at the care home was also not available. Other information relating to the employment of staff such as disciplinary action was also not available at the service. The manager reported that some records relating to employment of staff are maintained at social services headquarters. As indicated at the last inspection, in accordance with policy and guidance published by the CSCI in November 2005, with the agreement of the CSCI, providers who have a centralised human resources department can hold some recruitment information within this department as long as there is sufficient documented evidence at the home that all the required checks and references have been undertaken and there is an agreement with the CCSI as to the criteria for accessing the records held at the human resources department. This arrangement has not been agreed with the CSCI. Mapleholme DS0000035823.V335634.R01.S.doc Version 5.2 Page 25 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 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service benefit from the quality assurance systems in place at the home. EVIDENCE: A new manager has been appointed since the last inspection. The manager has experience of managing a residential care service for older people and has experience of working with adults with learning disabilities. The manager has undertaken relevant care and management training. An application to register the manager is in the process of being made to the CSCI. Mapleholme DS0000035823.V335634.R01.S.doc Version 5.2 Page 26 There is a clear management structure at the home. There are 2 deputy managers, which ensures that there is generally a manager available during the day. There are also senior carers available on each shift. There are a number of quality assurance systems in operation. An annual development plan is produced each year. Feedback is sought from the people who use the service at meetings and through individual discussion with staff. The people who use the service were encouraged to meet with the inspector and the expert by experience at this inspection. A client and parent/carer consultation questionnaire is available and is due to be re-issued. The manager reported that there are plans to set up a service users committee, which, looks specifically at how the respite service operates, what works well and what can be improved upon. Every Friday evening efforts are made to ensure that a member of the management team is available to discuss developments and encourage an exchange of views with parents/carers about the operation of the service. There are also meetings held with parents to discuss their views. Newsletters provide updates to parents/carers about any new developments and changes to the service. The representative of the registered provider makes visits to the home on a monthly basis in accordance with Regulation 26 of the Care Homes Regulations 2001. A copy of these reports are forwarded to the CSCI. There is evidence that a review takes place of policies and procedures and that these are updated accordingly. Records showed that the electrical wiring and gas supply are safe and fire prevention systems are serviced on a regular basis. Tests of the fire systems and fire drills take place. The records of fire safety training showed that all staff had last received fire safety training in January 2006. Steps have been taken to ensure that staff have regular access to fire safety training. Mapleholme DS0000035823.V335634.R01.S.doc Version 5.2 Page 27 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 3 5 X 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 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Mapleholme DS0000035823.V335634.R01.S.doc Version 5.2 Page 28 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 YA6 Regulation 15 Requirement The registered persons must ensure that care plans contain sufficient information around all aspects of personal and social support as set out in standard 2 of the National Minimum Standards for Care Homes for Adults. (Previous timescale of 2/11/06 not met.) The registered persons must ensure that there is a clear record to indicate that care plans and risk assessments have been reviewed and the information in these documents has been updated. The registered persons must ensure that the procedures for safeguarding vulnerable adults are followed when an allegation of abuse is made. Timescale for action 03/02/08 2. YA6 YA9 15 03/02/08 3. YA23 13 03/01/08 4. YA24 13 The registered persons must 03/01/08 ensure that a comprehensive risk assessment is available for each person who uses bed rails. A review of these risk assessments DS0000035823.V335634.R01.S.doc Version 5.2 Page 29 Mapleholme must take place prior to each visit to the service. (Previous timescale of 2/11/06 not met.) 5. YA34 17 The registered persons must demonstrate that the required information in Schedule 4 of the Care Homes Regulations 2001 has been obtained in respect of staff to ensure their suitability to work with vulnerable adults (Previous timescale of 09/02/06 not met). 03/01/08 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 YA24 Good Practice Recommendations A planned maintenance and renewal programme for the fabric and decoration of the premises should be put in place in order to ensure that a good standard of decoration and furnishings are maintained at all times. It is recommended that a more domestic style lift be made available. It is recommended that attention is given to the bathrooms to make them appear more domestic and homely in appearance. The NHS guidelines on risk assessing bed rails should be used in order to produce a comprehensive risk assessment for each person who uses bed rails. Staff should receive supervision at least 6 times per year. 2. 3. YA24 YA24 4. YA24 5. YA36 Mapleholme DS0000035823.V335634.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Burlington House Crosby Road North Waterloo Liverpool L22 0LG 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 Mapleholme DS0000035823.V335634.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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