Inspection on 09/02/06 for Mapleholme

This inspection was carried out on 9th February 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 no outstanding requirements from the previous inspection report, but made 9 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 30/10/06

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 Unannounced Inspection 9th February 2006 10:10 Mapleholme DS0000035823.V283268.R01.S.doc Version 5.1 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.V283268.R01.S.doc Version 5.1 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.V283268.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Mapleholme Address Beckwith Street Birkenhead Wirral Cheshire CH41 3JP 0151 6661250 0151 6661298 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.V283268.R01.S.doc Version 5.1 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 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. 2nd November 2005 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. Following the last inspection, the service moved to alternative premises. All accommodation is provided in single bedrooms. The accommodation is situated on two floors. The upper floor is accessed by a passenger lift. All parts of the home are accessible to wheelchair users. The home is divided into three units. Each unit has bathing and toilet facilities, a dining area with a small kitchen area 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. Wirral Metropolitan Borough Council operates day service provision for adults with learning disabilities from the same premises. Both services are separately maintained. Mapleholme DS0000035823.V283268.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 7 hours. During the inspection time was spent in the office examining records and policies and procedures. A team coordinator and the bursar were spoken with. A tour of the home took place. Several service users were spoken with. Staff were spoken with and were observed delivering care to service users. What the service does well: What has improved since the last inspection? What they could do better: The information provided to prospective service users and their families/representatives needs to be updated in order to fully reflect the service offered. In general, the management of medication meets the needs of service users. Improvements need to be made to the way non-prescription medication is managed. Some improvements need to be made to the Mapleholme DS0000035823.V283268.R01.S.doc Version 5.1 Page 6 appearance of the home. The flooring in a bathroom and tiles in a further bathroom need to be replaced. The records held at the home do not provide evidence that service users are protected by the homes recruitment practices. The safety of service users needs to be better promoted. Window restrictors need to be working effectively and steps must be taken to address the risks presented to service users by the first floor lounge window. Evidence that the gas and electrical wiring at the home is safe and that the passenger lift has been recently serviced needs to be made available to CSCI. Service users would benefit from 50 of staff having completed a National Vocational Qualification 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.V283268.R01.S.doc Version 5.1 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.V283268.R01.S.doc Version 5.1 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 The information provided to prospective service users and their families/representatives needs to be updated in order to fully reflect the service offered. A full assessment would take place to ensure that a service user’s needs could be met before they are offered a service. EVIDENCE: A statement of purpose and a service user guide are available for prospective service users and their carers/representatives to refer to. Both documents need to be amended to reflect the staff changes at the home and to reflect that emergency admissions are no longer accepted. A copy of these updated documents are to be forwarded to the Commission for Social Care Inspection. A copy of the most recent inspection report is available for service users and their families to refer to. 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 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 trial visits to the home, which includes a visit for tea and an overnight stay. The Mapleholme DS0000035823.V283268.R01.S.doc Version 5.1 Page 9 information gathered during the assessment forms the basis for developing the care plan. Mapleholme DS0000035823.V283268.R01.S.doc Version 5.1 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 Care planning reflects the assessed and changing needs of service users. Service users are consulted with and encouraged to take part in life at the home. Service users’ need for independence is balanced with any risks to their wellbeing. EVIDENCE: Three care plans were seen during the inspection. These provide sufficient information to enable staff to be able to meet the needs of service users during their stay. There was written information to indicate that the care plan is updated. Prior to each visit to the home, the care plan is updated through discussion with the carer, service user and any relevant professionals. The staff spoken, with were aware of the needs of the service users. A sample of risk assessments indicated that service users’ needs are assessed and their need for independence is balanced with any risks to their wellbeing. The records and a discussion with staff indicated that service users are assisted to make decisions about their lives in accordance with their abilities. Written information around the communication needs of service users, where appropriate, assists in this process. Records of service users likes and dislikes Mapleholme DS0000035823.V283268.R01.S.doc Version 5.1 Page 11 and preferences around daily living, such as what time they like to get up and the activities they enjoy also ensures service users choices are respected. The home has information on independent advocacy services, which the service users or their representative could access. Staff support service users to manage their finances. There was evidence that the service users and their carers had been consulted with on a regular basis around the move to the new premises. 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 at the home. It is recommended that more of the homes policies and procedures and the service user guide be made available in more suitable formats. Several service users were asked about the service they are given at the home, the comments made were all positive and included “ I like coming here,” “ I’m very happy,” “ I like the new home, it’s bigger, better, sunny and near to town.” Mapleholme DS0000035823.V283268.R01.S.doc Version 5.1 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 Service users take part in appropriate activities. The daily routines of service users and their involvement in the local community ensure that their preferences are provided for. The food provided offers variety and caters for service users tastes and any special dietary needs. EVIDENCE: Service users continue with educational, training or their employment activities whilst they are staying at the home. The care plans detail the support service users may need to undertake these activities. 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 Mapleholme DS0000035823.V283268.R01.S.doc Version 5.1 Page 13 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. Discussions with the team co-ordinator, records and observations confirmed that the home’s routines are flexible as much as possible. During the week service users are encouraged to get up in time to get ready for day services 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 indicated the support service users need in their daily lives in order to make choices and encourage independence. Service users are encouraged to keep their own bedrooms tidy. Staff were observed to interact warmly and appropriately with service users. Service users said they can choose when to be alone or in company and whether to take part in an activity. The service users and staff reported that service users are involved in the planning of meals. The service user plans detail likes and dislikes, any dietary requirements and any assistance service users need with eating. The service users reported that they enjoy the food provided. Some comments made were “the food is beautiful” and “ we get good puddings.” A menu is maintained. The menus indicated that a variety of different foods are provided. Mapleholme DS0000035823.V283268.R01.S.doc Version 5.1 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 The physical and emotional health needs of service users are met. In general, the management of medication meets the needs of service users. Improvements need to be made to the way non-prescription medication is managed. EVIDENCE: The care plans examined indicate the support service users require around their personal care. Individual preferences regarding personal and health care support are recorded in the service user plan. Service users are provided with support around their personal care by staff of the same gender. Observations indicated that staff promote the dignity of service users. 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. The medication procedure was seen and gives clear guidance to staff. All staff have received training in the home’s medication procedure and around the safe handling of medication. Medication is stored securely. A sample of medication administration records and corresponding medication were inspected and found to be correctly maintained. Paracetemol was available for one service user and was not prescribed by a GP. There was no record to indicate that the GP had Mapleholme DS0000035823.V283268.R01.S.doc Version 5.1 Page 15 been consulted prior to this medication being administered. The medication procedure indicates that this action is to be taken. Mapleholme DS0000035823.V283268.R01.S.doc Version 5.1 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 Staff training and policies and procedures are in place to ensure that service users views are listened to. The practices at the home provide service users with protection from abuse. EVIDENCE: There is a complaint procedure that is suited to the needs of service users with a learning disability. Staff reported that they elicit the views of service users. 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 the 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. No complaints have been made to the home since the last inspection. An adult protection and a whistle blowing procedure are available. The whistle blowing procedure contains the contact details of CSCI. All staff have had recent training around the protection of vulnerable adults. The home manages the personal allowances for most service users. The records of this were examined. 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. Mapleholme DS0000035823.V283268.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The home is accessible, clean and in general provides a homely, comfortable environment for service users. Some improvements are needed to the appearance of the home. Improvements need to be made to ensure the safety of service users. EVIDENCE: Since the last inspection, the service has moved to alternative premises that better meet the needs of the service users. Areas of the new premises have been refurbished making the home a brighter and more homely environment for service users. 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 kitchen facilities. The kitchen is 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 all service users including wheelchair users. 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 Mapleholme DS0000035823.V283268.R01.S.doc Version 5.1 Page 18 the home for security reasons. There are areas of the home that need some attention. The flooring in the bathroom in Elm Unit is heavily marked around the toilet area. This flooring needs to be replaced. Two tiles were missing at the base of the parker bath in the bathroom in Oak Unit. Some bathrooms did not contain blinds or curtains. The team co-ordinator reported that these have been ordered and that this will be followed up. 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. The team co-ordinator said that service users are escorted by a member of staff when using the lift due to the doors being heavy, this limits service users independence. It is recommended that a more domestic style lift be made available. The team co-ordinator reported that a service of the lift took place before the home re-opened. Evidence that the lift has been serviced recently was not available. This is to be provided to CSCI in order to demonstrate that the lift is safe for use. 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 number of these restrictors were not working. Steps were taken to attend to this during the inspection. Following the last visit to the service a risk assessment has been made available for the window to the first floor lounge/dining area which is over 5ft high. The barrier provided does not appear to be high enough to prevent a fall from this window. The risk assessment indicates that service users are to be accompanied when in this room and that staff are all aware of the risks presented. Although steps have been taken to reduce the risks presented, a more permanent solution is needed. The risk assessment indicates that a more permanent solution is to be identified by the health and safety officer. This needs to be attended to in order to fully ensure the safety of service users. The woodwork around the windows outside the home is showing signs of wear. This detracts from the appearance of the home. It is recommended that attention is given to the windows in order to enhance the appearance of the home for service users. Consideration could be given to further enhancing the appearance of the front of the home. The gardens at the back of the home have received some attention since the last visit to the home. Bushes and flowers have been planted and a seating area has been made available making this a more attractive area for service users. There are plans to develop the garden area further. Mapleholme DS0000035823.V283268.R01.S.doc Version 5.1 Page 19 The visitor’s policy and procedure does not reflect the current practices around receiving visitors to the home. It is recommended that this is updated to address this. A tour of the building showed that it was bright, well ventilated and free from malodours. Mapleholme DS0000035823.V283268.R01.S.doc Version 5.1 Page 20 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 Service users are supported by the number of staff available and the training staff have received, however, service users would benefit further if 50 of staff had completed an NVQ in care or equivalent. The records held at the home do not provide evidence that service users are protected by the homes recruitment practices. EVIDENCE: An examination of the rota for the week of the inspection 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 team co-ordinator, 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. There are currently five vacancies for care assistants and a vacancy for a team co-ordinator. Relief staff and the current staff team cover 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 home works are deployed. Records and a discussion with staff showed a team meeting had been held recently. Mapleholme DS0000035823.V283268.R01.S.doc Version 5.1 Page 21 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. Steps are being taken to ensure that 50 of staff hold an NVQ qualification. At present, there are 12 support workers, 1 has an NVQ and 4 support workers are working towards this qualification. 5 out of 13 care assistants have an NVQ and 4 are completing this qualification. Both team co-ordinators hold an NVQ qualification. Three new members of staff have been employed since the last inspection. The references and CRB/POVA check records were not available. The team coordinator reported that the records of staff recruitment are generally held at the head quarters of Wirral Metropolitan Borough Council. 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.V283268.R01.S.doc Version 5.1 Page 22 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 Service users benefit from the quality assurance systems in place at the home. It was not possible to fully assess the safety of the premises as not all of the safety certificates were available. EVIDENCE: There is currently an acting manager in post. The acting manager has experience of managing a residential care service and has experience of working with adults with learning disabilities. The acting manager has undertaken management training and has applied to undertake the NVQ Level 4 in Care. An application to register the acting manager is to be made to CSCI. There are a number of quality assurance systems in operation. An annual development plan is produced each year. The most recent plan was not looked at, at this inspection. 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 inspection. A client and parent/carer consultation questionnaire is available and is due to be re-issued. Mapleholme DS0000035823.V283268.R01.S.doc Version 5.1 Page 23 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 bimonthly 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. The records of fire safety training showed that all staff had received recent training around this. The records of fire drills, fire alarm tests and emergency lighting tests were seen and were in order. Care should be taken to ensure that the names of the staff who take part in the fire drill is recorded. Records of fire safety maintenance checks were also available. The gas safety check certificate and electrical wiring safety check certificate were not available. This information is held at Metropolitan Borough of Wirral head quarters. A copy of the gas and electrical wiring certificates must be forwarded to CSCI in order to demonstrate that the home is safe. Mapleholme DS0000035823.V283268.R01.S.doc Version 5.1 Page 24 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 3 23 3 ENVIRONMENT Standard No Score 24 1 25 X 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 3 3 3 3 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 2 X 2 X 3 X X 2 X Mapleholme DS0000035823.V283268.R01.S.doc Version 5.1 Page 25 No 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 person must review the statement of purpose and the service users guide to reflect the changes to the staff and that emergency admissions are no longer accepted. A copy of these updated documents are to be forwarded to the Commission for Social Care Inspection. The registered person must ensure that the medication procedure is followed when managing non-prescription medication. The registered person must ensure that the window restrictors are working effectively at all times in accordance with the home’s risk assessment. The registered person must provide evidence to CSCI that the lift has been serviced and is safe for use. The registered person must replace the flooring in the bathroom in Elm Unit and the missing tiles at the base of the parker bath in the bathroom in DS0000035823.V283268.R01.S.doc Timescale for action 09/03/06 2 YA20 13 09/02/06 3 YA24 13 09/02/06 4 YA24 23 09/03/06 5 YA24 23 09/03/06 Mapleholme Version 5.1 Page 26 Oak Unit. 6 YA24 13 The registered person must take steps to permanently address the risks presented to service users by the first floor lounge window. The registered person 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. The registered person must ensure that an application to register the acting manager is made to CSCI. The registered person must ensure that a copy of the gas and electrical wiring certificates are forwarded to CSCI in order to demonstrate that the home is safe. 09/03/06 7 YA34 17 09/02/06 8 YA37 8 09/03/06 9 YA42 23 09/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard YA24 YA24 YA24 YA32 Good Practice Recommendations It is recommended that attention be given to the window frames in order to enhance the appearance of the home for service users. It is recommended that a more domestic style lift be made available. The visitors policy and procedure should be amended to reflect the current practices around receiving visitors to the home. 50 of care staff are to hold an NVQ qualification or equivalent. Mapleholme DS0000035823.V283268.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Liverpool Local 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.V283268.R01.S.doc Version 5.1 Page 28 - 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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