Inspection on 30/10/06 for Mapleholme

This inspection was carried out on 30th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mapleholme 04/12/08

Mapleholme 17/12/07

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 Roth Key Unannounced Inspection 30 October and 2 November 2006 09:30 th nd Mapleholme DS0000035823.V307902.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.V307902.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.V307902.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.V307902.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 Birkett House is to be forwarded to the National Care Standards Commission. This information is to be provided by 30th March 2004. The matters detailed in the schedule of requirements must be completed in the stated timescales. 9th February 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 £342.65. 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 service user 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.V307902.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 10.5 hours and is based on two visits to the home. The inspection is also informed by information received about the service since the last inspection and by questionnaires completed by the manager and social workers. During the site visit to the home time was spent in the office 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 service users and staff. What the service does well: What has improved since the last inspection? What they could do better: The statement of purpose needs to fully reflect the homes procedure regarding emergency admissions to the home. Service users would benefit from the service user guide being put into a format that makes it more accessible to adults with a learning disability. Care plans and risk assessments must contain sufficient information in order to provide clear guidance to staff around how to appropriately support service users. Mapleholme DS0000035823.V307902.R01.S.doc Version 5.2 Page 6 The practices at the home in general provide service users with protection from abuse. The records of complaints do not provide evidence that service users are fully safeguarded. A record must be made of the action taken to investigate a complaint in order to demonstrate how a decision was made about the outcome. In order to ensure that service users are fully safeguarded improvements need to be made to the risk assessments around the use of bedrails at the home and to the way non-prescription medication is managed. The records held at the home need to provide evidence that service users are protected by the homes recruitment practices. Service users would benefit if 50 of staff had completed an NVQ in care or equivalent. 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. Mapleholme DS0000035823.V307902.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 Mapleholme DS0000035823.V307902.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 at least once during a 12 month period. 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 visiting the service. The assessment process ensures that the service is only offered to individuals whose needs can be met at home. Service users are able to make several visits to the home to make sure it is right for them. Improvements are needed to the statement of purpose in order to provide clear guidance about emergency placements. The service user guide should be made available in different formats so it is more accessible. EVIDENCE: A statement of purpose and a service user guide are available for prospective service users and their carers/representatives to refer to. Some further work is needed around making the service user guide accessible to all prospective service users as at present, the guide is in a written format, which may not be easily understood by all service users. Alternative methods of communicating the service users guide should be introduced. A copy of the most recent inspection report is available for service users and their families to refer to. Since the last inspection the statement of purpose has been amended to reflect the staff changes at the home. At the last inspection it was reported that emergency admissions are not accepted. At this inspection the statement of purpose reflects that emergency admissions are accepted in response to a crisis situation. The statement of purpose indicates that before a service user is accommodated at the home on an emergency basis a needs assessment is Mapleholme DS0000035823.V307902.R01.S.doc Version 5.2 Page 9 carried out to ensure that the service users needs can be met and that they are compatible with the other service users at the home. The manager reported that there have been several emergency admissions since the last inspection. The service users were all previously known to the service. The manager reported that only service users already known to the service would be accommodated on an emergency basis. This practice safeguards service users, however, this is not indicated in the statement of purpose. This needs to be addressed, as this is part of the procedure for emergency admissions to the home. The records seen for one service user who was provided a service on an emergency basis indicated that they were previously known to the service, a full assessment of their needs was available. A sample of written assessments of whether the home is suitable for prospective service users were seen and the assessment process was discussed with the manager and team co-ordinator. A thorough assessment is undertaken before a service user is offered a respite service. The records indicated that this assessment involves discussion with the service user, their families and any relevant professionals. A written assessment from the service users social worker is also obtained. The records showed that the service user and their carers are invited to view the home and the service user is able to make as many trial visits to the home as they wish, which include visits for tea and an overnight stay. The information gathered during the assessment forms the basis for developing the care plan. Mapleholme DS0000035823.V307902.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including visiting the service. Staff are not provided with sufficient written information around how to meet the needs of service users. Service users have a voice in relation to how the home works, they are consulted with and encouraged to take part in life at the home. EVIDENCE: Four care plans were seen during the inspection. The care plans did not provide sufficient information around all aspects of personal and social support and healthcare needs as set out in standard 2 of the National Minimum Standards for Care Homes for Adults. For example, the exact support two of the service users need with washing and dressing and other aspects of personal care was not fully recorded. One care plan did not provide sufficient information around how to support a service user to ensure that they did not become sunburnt. The manager reported that prior to each visit to the home, the service users care plans are updated through discussion with the carer, service user and any relevant professionals. Some care plans did not have written evidence that the care plan had been reviewed. One care plan was dated over 12 months ago Mapleholme DS0000035823.V307902.R01.S.doc Version 5.2 Page 11 with no indication of a review since then. The staff spoken, with were knowledgeable about the needs of the needs of the service users and how to meet them. A questionnaire returned by a social worker indicates that staff demonstrate a clear understanding of the care needs of service users. A sample of risk assessments were seen and in general indicated that service users’ needs are assessed and their need for independence is balanced with any risks to their wellbeing. One care plan for a service user refers staff to a risk assessment for guidance on how to support a service user when being transported in the mini-bus and whilst out in the community. This risk assessment was not available. A risk assessment on another service users file covers areas of risk that do not relate to the service user. Risk assessments need to provide clear guidance to staff on how to support service users. A discussion with staff indicated that service users are assisted to make decisions about their lives in accordance with their abilities. Records of service users likes and dislikes and the activities they enjoy ensures service users choices are respected. The home has information on independent advocacy services, which the service users or their representative could access. Records show that service users 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 the service users for their views. Service users spoken with 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 service users who come to stay at the home. It would be good practice if more of the homes policies and procedures and the service user guide were made available in more suitable formats. Service users asked about the service they are given at the home, gave positive comments. Comments made included “ I like coming here,” “ The staff are nice and kind,” “I’m happy to come here.” Staff were observed to interact warmly and appropriately with service users. Mapleholme DS0000035823.V307902.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including visiting the service. The daily routines, activities and involvement in the local community ensure that the preferences of service users are provided for. The food provided offers variety and caters for service users tastes and any special dietary or cultural needs. EVIDENCE: The records show that service users take part in community life. Service users are supported to use local facilities such as shops and public transport. Service users spoken with said that they enjoy going to the local pub for bingo and into town. Service users and staff said that the location of the home is good for accessing the town and leisure services. This benefits service users. The family and friends of the service users are welcome at the home at any reasonable time. A telephone is available for service users and staff support service users to make telephone calls where appropriate. Discussion with the staff and service users showed that service users are supported and encouraged to participate in activities with others who do not have a disability. Mapleholme DS0000035823.V307902.R01.S.doc Version 5.2 Page 13 Discussions with the staff, records and observations confirmed that the home’s routines are flexible as much as possible. Service users continue with educational, training or their employment activities whilst they are staying at the home for respite. During the week service users 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 service users 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 the needs of the service users. The service users and staff reported that service users are involved in the planning of meals. The service user plans detail likes and dislikes and any dietary requirements. The service users reported that they enjoy the food provided. Some comments made were “the food is good” and “ we like it.” 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. Mapleholme DS0000035823.V307902.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including visiting the service. Service users have access to health and social care professionals as their needs require. The care plans need to contain further information around how staff are to meet service users personal care needs. In general, the management of medication meets the needs of service users. Improvements need to be made to the way nonprescription medication is managed. EVIDENCE: Staff reported that service users are supported to access healthcare services during their stay if this is required. There is a system in place for ensuring that CSCI is informed of any incidents affecting the welfare of service users. Records showed that the service users have access to a GP as needed and that the home involves other health and social care professionals where appropriate. Mapleholme DS0000035823.V307902.R01.S.doc Version 5.2 Page 15 As already indicated the care plans examined did not give sufficient information around how staff are to meet the personal care needs of service users. Individual preferences regarding personal and health care support were not consistently recorded in the service user plans. Service users are provided with support around their personal care by staff of the same gender. Observations indicated that staff are respectful towards service users and promote their dignity. 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. The competence of staff to administer medication is assessed through supervision. A new way of assessing this has been introduced since the last inspection and this will further safeguard service users. Medication is stored securely. Two of the cupboards that are used to store medication were difficult to open and the manager had to ask another member of staff to assist with the opening of one cupboard. It is recommended that this storage facility be assessed with a view to changing the lock or providing an alternative means of secure storage. A sample of medication administration records and corresponding medication were inspected and found to be correctly maintained. At the last inspection paracetemol was available for one service user and was not prescribed by a GP. There was no record to indicate that the GP had been consulted prior to this medication being administered. The medication procedure indicated that this action should be taken. At this inspection parents have been asked to complete a form indicating that they have consulted their son/daughters GP to ensure that a homely remedy is safe to administer. The responsibility to ensure that it is safe to administer medication that is not prescribed by a GP rests with the home. This was brought to the attention of the manager to be addressed without delay. Mapleholme DS0000035823.V307902.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including visiting the service. Staff training and policies and procedures are in place to ensure that service users views are listened to. The practices at the home in general provide service users with protection from abuse. The records of complaints do not provide evidence that service users are fully safeguarded. EVIDENCE: There is a complaint procedure that is suited to the needs of service users with a learning disability. Staff reported that they regularly elicit the views of service users to ensure they are happy with the service. Information is available to enable a complaint to be made on behalf of a service user by an advocate. The complaint procedure describes the stages of making a complaint and that the complainant will get an answer to their complaint within a maximum of 21 days. The staff were aware of the content of the complaint procedure and how to respond to complaints. CSCI has not received any complaints about this service since the last inspection. 3 complaints have been made to the home from January 2006. Records showed whether the complaint was substantiated or not but did not indicate how the complaint was investigated in order to reach this decision. An adult protection and a whistle blowing procedure are available. The whistle blowing procedure contains the contact details of CSCI. The majority of staff have recently updated their training around the protection of vulnerable adults. The remaining staff have been given a date to attend this training. Notifications regarding adult protection matters have been referred to the appropriate agencies since the last inspection and appropriate action taken by the home to safeguard the service users. Mapleholme DS0000035823.V307902.R01.S.doc Version 5.2 Page 17 The home manages the personal allowances for most service users who visit the service. The records of 5 service users personal allowances 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 service users’ money and financial affairs safeguard service users. However, records showed that service users do not always sign financial records to indicate they have received their personal allowance. Service users should be encouraged to do so where appropriate. Carers sign records of personal allowances. Mapleholme DS0000035823.V307902.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including visiting the service. The home is clean and in general provides a safe and comfortable environment for service users. Mapleholme DS0000035823.V307902.R01.S.doc Version 5.2 Page 19 EVIDENCE: The home is divided into three units, which are accessible to each other. Each unit is individually staffed. All service users have their own bedrooms. Each unit has a lounge and a dining area with basic kitchen facilities. The kitchen facilities are accessible to all service users and a risk assessment has been developed in order to safeguard service users where this is needed. The home is accessible to service users who use wheelchairs. Furnishings in the home are domestic in character and reflect the needs of the service users. The home is easily accessible to local community facilities by use of public transport. In addition the home has its own mini bus, which enables service users to engage in activities outside of the home. CCTV cameras are used at entry points of the home for security reasons. In general the home is suitably decorated and furnished. 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. At the last inspection some decorative works were identified which have in general been attended to. The flooring in the bathroom in Elm Unit has not been addressed. This is heavily marked around the toilet area. This flooring needs to be replaced. Some bathrooms continue to have no blinds or curtains. Some have had blinds fitted but have no pull cord to enable them to be used. The manager reported that this is in the process of being addressed. At the time of the inspection the company supplying the blinds were taking measurements of the windows. The windows at the home have been fitted with restrictors in accordance with a requirement made at a previous inspection of the home. At this inspection a sample of windows were seen and the restrictors were functioning adequately. Following the last visit to the service a further wooden barrier has been put in place across the window to the first floor lounge/dining area. This is in accordance with a risk assessment for the window, which is over 5ft high. 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 service users. It was recommended at the last inspection that attention is given to the windows in order to enhance the appearance of the home for service users. The window frames have been re-painted since the last inspection. The Mapleholme DS0000035823.V307902.R01.S.doc Version 5.2 Page 20 gardens at the back of the home have received further attention since the last visit to the home. More bushes and flowers have been planted and a further seating area has been made available making this a more attractive area for service users. There are plans to develop the garden area further. 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 service users to open and close. At the last inspection, the team co-ordinator said that service users are escorted by a member of staff when using the lift. This was because the doors are heavy. This may limit service users independence. It is therefore recommended that a more domestic style lift be made available. The manager reported that a service of the lift took place before the home re-opened. Evidence that there is a contract for the servicing of the lift was available. The manager reported that the service certificate is held at social services head quarters and that the department responsible will not provide a copy to the home. This information is to be provided to CSCI in order to demonstrate that the lift is safe for use. Bed rails are used for some service users who visit the service. Risk assessments around the use of bed rails are available. These do not provide sufficient information. These risk assessments must indicate any possible risks and how they are to be guarded against. One bed rails risk assessment seen was dated October 2004, with no evidence of this having been reviewed since then. It is suggested that an occupational therapist be consulted and that the NHS guidelines available on risk assessing bed rails 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.V307902.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including visiting the service. Service users are supported by sufficient numbers of staff although service users would benefit further if more than the 50 of staff had completed an NVQ in care or equivalent. The records held at the home do not provide adequate evidence that service users are sufficiently protected by the homes recruitment practices. EVIDENCE: An examination of records and a discussion with staff indicated that there are a sufficient number of staff and that staff are appropriately deployed to meet the needs of the current service users. The staffing levels were discussed with the manager, who reported that staffing levels are determined by an individual assessment of the needs of each service user prior to admission to the home for respite. There is a clear staff structure in operation and staff were aware of the lines of accountability at the home. Since the last inspection staff have been recruited to vacant positions and interviews for further staff were being arranged at the time of the inspection. 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 service users and how the Mapleholme DS0000035823.V307902.R01.S.doc Version 5.2 Page 22 home works are deployed. Records and a discussion with staff showed a team meeting had been held recently. Staff training records and staff spoken with indicated that training is provided to ensure service users 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. 30 of staff hold an NVQ qualification. Steps are being taken to ensure 50 of staff hold this qualification. The records relating to the recruitment of two members of who have been employed since the last inspection were seen. A second reference was not available for one of the staff. The Care Homes Regulations 2001 indicate that 2 references must be available. Evidence that staff are physically and mentally fit to work at the care home was also not available. The manager reported that health references are maintained at social services headquarters. As indicated at the last inspection, in accordance with policy and guidance published by CSCI in November 2005, with the agreement of 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 CCSI as to the criteria for accessing the records held at the human resources department. This arrangement has not been agreed with CSCI. Mapleholme DS0000035823.V307902.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 at least once during a 12 month period. 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 visiting the service. Service users benefit from the quality assurance systems in place at the home. Improvements around the home’s fire safety procedures are needed in order to demonstrate that service users are fully safeguarded. EVIDENCE: There is currently an acting manager in post. The acting manager has experience of managing a residential care service and has 11 years experience of working with adults with learning disabilities. The acting manager has undertaken a supervisory management qualification and is currently undertaking the NVQ Level 4 in Care and Management. An application to register the acting manager has been made to CSCI. There are a number of quality assurance systems in operation. An annual development plan is produced each year. Feedback is sought from service users at service user meetings and through individual discussion with staff. The service users were encouraged to meet with the inspector at this Mapleholme DS0000035823.V307902.R01.S.doc Version 5.2 Page 24 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 a senior manager is available to speak to parents/carers about the operation of the service on an informal basis. 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. Staff meetings are held on a regular basis. 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. A questionnaire returned by a social worker indicates that the home communicates well and that they are satisfied with the overall care provided to service users. Certificates relating to the electrical and gas safety of the home were seen and were in order. Records showed that the 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. The manager reported that further training has been provided since then and that the frequencies for fire safety training that are recommended by the fire service are followed. Care must be taken to record all fire safety training provided to staff. The manager reported that this training covers fire prevention and what to do in the event of a fire. Records showed that the door to the manager’s office does not close fully and that this matter was reported in July 2006. This is a fire door and must close fully in order to be effective. A fire risk assessment was made available during the inspection. The manager is taking steps to address the issues for attention that are highlighted in this assessment. Both staff and training records indicated that staff receive appropriate training in safe working practices. Mapleholme DS0000035823.V307902.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 2 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 2 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 2 33 3 34 2 35 3 36 x 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 2 3 2 X 3 X 3 X X 2 X Mapleholme DS0000035823.V307902.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 YA1 Regulation 6 Requirement The registered persons must ensure that the statement of purpose and the service users guide fully reflect the procedures to be followed around the provision of a service on an emergency basis. The registered persons must ensure that care plans contain sufficient information around all aspects of personal and social support and healthcare needs as set out in standard 2 of the National Minimum Standards for Care Homes for Adults. The registered persons must ensure that risk assessments contain clear information as to the action staff are to take to appropriately support service users. The registered persons must ensure that the medication procedure is followed when managing non-prescription medication (Previous timescale of 09/02/06 not met). DS0000035823.V307902.R01.S.doc Timescale for action 02/12/06 2. YA6 YA18 15 02/11/06 3. YA9 13 02/11/06 4. YA20 13 02/11/06 Mapleholme Version 5.2 Page 27 5. YA22 22 The registered persons must ensure that a record is made of the action taken to investigate a complaint in order to demonstrate how a decision was made about the outcome. The registered persons must provide evidence to CSCI that the lift has been serviced and is safe for use (Previous timescale of 09/03/06 not met). The registered persons must replace the flooring in the bathroom in Elm Unit. (Previous timescale of 09/03/06 not met). 02/11/06 6. YA24 23 02/12/06 7. YA24 23 02/02/07 8. YA24 13 The registered persons must 02/11/06 ensure that a comprehensive risk assessment is available for the use of bed rails. A review of these risk assessments must take place. 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). The registered persons must ensure that a record is made of any fire prevention training provided to staff. The registered persons must ensure that the fire door to the manager’s office closes fully so as to be effective in the event of a fire. 02/11/06 9. YA34 17 10 YA42 23 02/11/06 11 YA42 23 02/12/06 Mapleholme DS0000035823.V307902.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. Refer to Standard YA1 Good Practice Recommendations The service user guide should be made available in formats that make it more accessible to adults with a learning disability. Alternative methods of communicating the guide, other than a written format should be introduced. It is recommended that the medication storage facilities be assessed regarding ease of opening with a view to changing the locks or providing an alternative means of secure storage. Service users should sign records to indicate they have received their personal allowance where appropriate. 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. 50 of care staff are to hold an NVQ qualification or equivalent. 2. YA20 3. 4. YA23 YA24 5. 6. YA24 YA24 7. YA32 Mapleholme DS0000035823.V307902.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mapleholme DS0000035823.V307902.R01.S.doc Version 5.2 Page 30 - 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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