Inspection on 05/12/05 for Maplewood House

This inspection was carried out on 5th December 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Maplewood House 04/04/07

Maplewood House 21/07/05

Maplewood House 07/12/04

Maplewood House 20/07/04

Similar services:

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

Insight - Eastchurch

Southfields

Thorndene

Magenta

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

CARE HOMES FOR OLDER PEOPLE Maplewood House Maplewood House Off Chatfield Court Caterham Surrey CR3 5YA Lead Inspector Cathy Clarke Announced Inspection 5th December 2005 10:00 X10015.doc Version 1.40 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 Maplewood House DS0000013712.V272913.R01.S.doc Version 5.0 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 Older People. 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. Maplewood House DS0000013712.V272913.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Maplewood House Address Maplewood House Off Chatfield Court Caterham Surrey CR3 5YA 01883 383807 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) Surrey Oaklands NHS Trust Mr Krishna Govinden Care Home 15 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (9) of places Maplewood House DS0000013712.V272913.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 45 AND ABOVE 21st July 2005 Date of last inspection Brief Description of the Service: Maplewood House is a detached property providing accommodation for 15 service users with mild to moderate learning disabilities. The home is located in Caterham and has easy access to the local shops, public transport and other local services. The home has its own transport and parking is available to the front of the property. The accommodation for service users is provided on the ground and first floors. All service users have their own bedroom. There is a large rear garden that is mainly laid to lawn. Maplewood House DS0000013712.V272913.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over a period of 4 ½ hrs and was the second inspection to be undertaken in the Commission for Social Care Inspection Year April 2005 to March 2006. Lead Inspector Cathy Clarke was assisted throughout the inspection by Mr. Krishna Govinden Registered Manager representing the establishment. A full tour of the premises was conducted. Five service users, and two staff members were consulted. Care plans, activity plans, medication administration records and storage, health care, complaints, and staff training were also inspected. The inspector would like to extend her thanks to the residents, staff and management at Maplewood House for their assistance and hospitality. What the service does well: What has improved since the last inspection? Garden Benches have been purchased and bedroom 9 has been redecorated. All of the net curtains have been renewed. The kitchen light fittings and electric insect repellent have been cleaned. The sealant around the sink in the kitchen has been replaced. A touch panel has been put on the side gate of the house to improve security. New policies and procedures have been introduced for Countering Fraud and Corruption, Organisational Change, Complaints, Acting up and Secondment, Maplewood House DS0000013712.V272913.R01.S.doc Version 5.0 Page 6 Serious Untoward Incidents and Protection arrangements. As each of the policies is received the service is removing the existing policy documents. What they could do better: 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. Maplewood House DS0000013712.V272913.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Maplewood House DS0000013712.V272913.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 Comprehensive information regarding the home is available for prospective service users and planned assessments are undertaken prior to moving into the home. EVIDENCE: The statement of purpose and service user guide have been reviewed and updated to include the new organisational name, changes to staff and the single room status of the home since the last inspection. There have been no new admissions to the home since the last inspection. Any prospective service user would be assessed prior to moving into the home and a trial period would be offered. A new admissions procedure has been developed with a comprehensive assessment tool. Special needs assessments have been conducted for 8 service users by the duty Care Manager. Maplewood House DS0000013712.V272913.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,9 Health action plans are being undertaken for all service users. There is a clear set of medication policies and procedures in place for the administration and storage of medicines. EVIDENCE: The registered manager informed the inspector that Health action plans are to be conducted for all service users. Two have been completed so far and are very comprehensive. There is a hospital communication book, which is in pictorial format and a protocol for service users going to hospital. A flu pandemic plan is being developed and all service users have received flu vaccinations. A winter plan has been completed. Six staff are trained to administer medication and their signatures were on file. The signatures of the staff trained to administer as required medications and rectal diazepam were also seen recorded. One of the service users spoken to self medicates. Her medication is prepared in a Dossett box every Tuesday. The service user asks staff to check it with her and then staff sign the medication administration record. Maplewood House DS0000013712.V272913.R01.S.doc Version 5.0 Page 10 Two members of staff transfer medication for this service user from a blister pack into the dossett container and a medication transfer record is signed and dated. A procedure document and risk assessment is in place for this activity. The local pharmacy inspects medication procedures every quarter. Medication profiles are available for all medications. A care plan for those with epilepsy is in place. Current photographs of service users are on file. There is a checklist for any updates to medication. When service users go on home leave or holiday the pharmacy supplies medications in bottled containers. A weekly audit of medications is undertaken to check the stock, medication records and contents of the drugs cabinet. A tracer sheet is put into the medication folder when the MAR chart had been taken out at times of home leave, hospital admission or holidays. The home has a list of homely remedies approved by the General Practitioner for the home. Guidelines for the administration and ordering of medicines in place. Medication profiles identify service users medication, dose, contra indications, and side effects and are reviewed by the GP every 6 months. A controlled drugs register is in place however there are no controlled drugs within the home. Blood and urine test results are kept in a register and any other health related investigations. Maplewood House DS0000013712.V272913.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,14,15 Service users take part in various activities in the home and in the local community. Regular meetings are held with service users to assist them with making choices. The service provides a varied diet, which is planned with the service users input, and alternative choices are always available. EVIDENCE: One of the service users showed the inspector her figures made out of sugar icing. She informed the inspector that she goes to her mother’s house every Saturday and attends various advocacy groups. The service user is also part of the Caterham Integration group. Service users enjoy taking part in activities in the local community. A local advocacy service provides a bus service, which service users have been using. This is paid for out of the homes transport budget. There are five members of staff who are drivers. Nine service users have been on holidays this year to Tunisia, Bognor Regis and Italy. Day trips have been organised for those who do not wish to go on holiday. Staff went with some of the service users to see the Christmas lights being turned on in Coulsdon. Service users will be going to see the local Pantomime. Maplewood House DS0000013712.V272913.R01.S.doc Version 5.0 Page 12 Service user meetings are held every month and the minutes are in pictorial format. In the latest minutes it was observed that service users take an active part in running the home. One of the service users has voiced an interest in becoming involved in a recycling project. Service users spoken to during the inspection confirmed that they enjoy their meals and can have an alternative choice if they do not like what is on the menu. Service users were having tomatoe soup, bread and yogurt for lunch. The kitchen was clean and tidy and fridge and freezer temperatures were within the required limits. Cupboards were well stocked and food that has been opened had been labelled and dated. The air vent, lighting and electric insect repellent and insect screen had all been recently cleaned. The environmental health inspector following inspection in May 2005 recommended that the sealant on the work surface behind the sink be replaced and this work had been completed. Maplewood House DS0000013712.V272913.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Policies are in place to protect service users from abuse and neglect and the registered manager and staff have been appropriately trained. EVIDENCE: There have been no vulnerable adult issues or complaints in the home since the last inspection. There is a procedure in place and a complaints log book. Maplewood House DS0000013712.V272913.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22,26 The layout of the home is suitable for it’s stated purpose. It is accessible, safe and well maintained. The home was found to meet service users’ individual and collective needs in a comfortable and homely way. EVIDENCE: Since the last inspection new benches have been purchased for the garden and room 8 has been redecorated. New dining room chairs have been purchased. The home has been decorated for Christmas. With decorations on the ceiling in the lounge and dining room and a Christmas tree and wreath outside the front door of the property. Bedroom 3 and 13 must be redecorated. The bathroom upstairs opposite room 11 must have the floor stains eradicated and new sealant applied around the toilet. Maplewood House DS0000013712.V272913.R01.S.doc Version 5.0 Page 15 The downstairs bathroom must be repainted and flooring replaced. There are holes in the flooring where the bath has been moved. The shower pole must be moved to a more appropriate place to enable the shower curtain to be easily pulled around the bath. Equipment within the home includes: wheelchairs, a hoist, slings, grab rails, a rotating cushion for use in transport vehicles, a transfer belt, sliding sheets, and a one-way glide. The Parker bath was inspected on the 13th May 2005 and found to be in good working order. The hoist was inspected on 19th August 2005. There is an electric bed within the home used as a normal divan. A bathing aid is on trial for one of the service users. Staff are experiencing difficulties using the hoist over the carpet in one of the service users rooms and the inspector has advised the service to contact the manual handling advisor for the trust for his or her advice. The home is very clean and tidy with no mal odorous smells. Please see requirements and recommendations section of this report. Maplewood House DS0000013712.V272913.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,30 Staff rotas were adequate and there was sufficient staff available for each shift. Staff training was comprehensive, providing service users with staff that had a good command of the core skills required. EVIDENCE: Two members of staff were interviewed during the inspection. Both are key workers and have worked for the home for a considerable length of time. One of the staff is undertaking level 3 NVQ and the other is to be registered for Level 2. Staff have undertaken regular training courses and updates and were aware of where the policies and procedures of the service are kept. Staff have confirmed that they receive supervision and annual appraisal interviews. Relatives have commented that staff make them feel very welcome when visiting the home and staff do very well considering all that they do. They are also very happy with key workers. Seven of the fourteen staff employed are undertaking NVQ level 2 or 3 training and the registered manager is an NVQ assessor. Staff have attended the following training programmes: disability awareness, dealing with difficult situations, diversity and equality, eating and drinking awareness, and a one day course on health action plans. Maplewood House DS0000013712.V272913.R01.S.doc Version 5.0 Page 17 Statutory courses on manual handling, fire safety and health and safety have been provided. Staff have confirmed that they have received training on the protection of vulnerable adults. Maplewood House DS0000013712.V272913.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,35,38 Service users and staff benefit from the management approach at the home providing an open, positive and inclusive atmosphere. Procedures are in place to safeguard service users money. Health and safety policies and procedures are in place and enforced. EVIDENCE: The registered manager has an open and inclusive style of management and staff were seen to respond favourably to this and were very knowledgeable about the care provided to service users. Staff supervisions and meetings are conducted monthly. The registered manager holds the NVQ Level 4 Registered Managers Award and is an NVQ Assessor. At present he is undertaking an open learning research study at Surrey University into the Care of the Elderly in particular those with Dementia. Maplewood House DS0000013712.V272913.R01.S.doc Version 5.0 Page 19 The Finance Director is the appointee for service users and the Manager and two others are signatories. All service users have individual bank accounts. There is a petty cash float with a small amount of money per week for each service user to use for activities and shopping for personal items. Any withdrawals over £50 have to be sanctioned by the Finance Director and over £150 has to be approved by the Service Manager. Service users money is kept in individual envelopes in a petty cash tin. Monies were counted during the inspection and all found to be correct. The registered manager keeps a calibration file, which contains all of the necessary reports and receipts for checks made on equipment and services within the home. The fire extinguishers were all checked in April 2005 and call bells checked in October 2005. The fire exit door to the home is alarmed, as is the front door. The side gate has been fitted with a touch panel to improve the security of the premises. The registered manager undertakes a monthly health and safety audit of the home. Maplewood House DS0000013712.V272913.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 3 X X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 3 Maplewood House DS0000013712.V272913.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP24 Regulation 23 (2) (b) Requirement The upstairs bathroom floor must be cleaned to eradicate marks and new sealant fixed around the toilet. The paintwork is to be renewed in the downstairs bathroom and flooring replaced. The shower pole is to be moved to a more suitable place to enable the curtain to be freely pulled. Room 3 and 13 require redecoration. Timescale for action 31/01/06 2 OP24 23 (2) (d) 31/03/06 3 OP24 23 (2) (d) 31/03/06 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 Refer to Standard OP9 Good Practice Recommendations It is recommended that the registered manager contact the Trusts Pharmacist to ascertain when the next pharmacy inspection is to be undertaken in the home. Maplewood House DS0000013712.V272913.R01.S.doc Version 5.0 Page 22 2 OP22 It is recommended that the service contact the manual handling advisor for the trust for his or her advice. Maplewood House DS0000013712.V272913.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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. 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