Inspection on 05/12/07 for Maplin House

This inspection was carried out on 5th December 2007.

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 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

Maplin House 16/07/09

Maplin House 14/05/08

Maplin House 30/07/07

Maplin House 21/06/06

Maplin House 09/06/05

Maplin House 20/04/05

Maplin House 10/02/05

Maplin House 29/09/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Maplin House 117/119 Church Road Shoeburyness Essex SS3 9EY Lead Inspector Pauline Marshall Unannounced Inspection 5th December 2007 08:35 X10029.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 Maplin House DS0000015450.V355713.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 Older People and 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. Maplin House DS0000015450.V355713.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Maplin House Address 117/119 Church Road Shoeburyness Essex SS3 9EY 01702 297494 F/P 01702 297494 laycraftlimited@yahoo.co.uk 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) Mr Mohammud Yousouf Meeajun Mrs Oume Mahani Abdool Raheem Care Home 16 Category(ies) of Dementia - over 65 years of age (2), Learning registration, with number disability over 65 years of age (16) of places Maplin House DS0000015450.V355713.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may admit up to five persons (of the above 16) who are over 50 years of age. The home may admit two people (of the above 16) who have a diagnosis of Dementia and whose details are known to the CSCI. 30th July 2007 Date of last inspection Brief Description of the Service: Maplin House is a large detached care home set in a sought after residential area in Shoeburyness/Thorpe Bay. The home provides accommodation for up to sixteen older people with dementia and some degree of learning disabilities. Accommodation is provided on two floors, the home has eight single and four double bedrooms. There is a two bed roomed flat provided for staff living accommodation which is situated on the third floor of the building. The home has adequate communal areas on both floors and a shaft lift has been provided. There is limited outdoor space; the garden surrounds the property and has small areas that are suitable for seating. The home has its own mini-bus that is used for taking out residents that includes trips to the beach, shops and local parks. There is a bus route within a short walk of the home that goes to Southend town centre. There is a small car park at the rear to building. All prospective residents are provided with a Statement of Purpose and Service User Guide that supplies them with information on the home. The current range of fees is from £350 to £600 per week and there are additional charges for chiropody, magazines, newspapers, toiletries and day trips. Maplin House DS0000015450.V355713.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that took place over two separate visits, the first lasted for seven hours and forty-five minutes and the second was carried out on 7th December 2007 and lasted for twenty minutes. The process included a tour of the premises, a random selection of resident and staff files and discussions with residents the manager and staff. The manager submitted the homes annual quality assurance assessment (AQAA) which has been used throughout the report. Surveys were received from five residents, three relatives, two general practitioners, a district nurse and an advocate as a result of the previous inspection that took place on 30th July 2007. Twenty-four of the thirty-eight standards were inspected. What the service does well: What has improved since the last inspection? The manager has reviewed the homes Statement of Purpose and Service User Guide. Care plans now promote residents safety and include risk assessments and plans to minimise any identified risks. The menu and nutrition records have improved and now provide more detail. Maplin House DS0000015450.V355713.R01.S.doc Version 5.2 Page 6 The complaints system, including the whistle blowing procedure has been made more easily available to staff and t he manager has developed the quality assurance system to include the views of all interested parties and the system is now in use. The manager now allocates specific staff to carry out domestic and cooking tasks. 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. The summary of this inspection report can be made available in other formats on request. Maplin House DS0000015450.V355713.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Maplin House DS0000015450.V355713.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can be assured that the pre-admission process and the information provided by the manager will meet their needs. EVIDENCE: The homes Statement of Purpose and Service User guide were last reviewed in August 2007; both documents were undated but contained up to date information on the service. The manager said that she would be making further amendments to the homes documents to reflect the recent changes to Maplin House DS0000015450.V355713.R01.S.doc Version 5.2 Page 9 the CSCI office details and that she would ensure that future documents are dated. The three care files examined contained evidence of pre-admission assessments, however one of these was carried out by the Social Services. The manager states in her annual quality assurance assessment that the preadmission assessment ensures the suitability of new residents. There have been no admissions since the last inspection and the manager said that the homes assessment documentation would be used for all future admissions. The homes pre admission assessment document provides sufficient information on prospective residents’ health, social and emotional needs to enable the care plan to be devised. Residents spoken with confirmed that they had an assessment prior to their admission. Maplin House does not provide intermediate care. Maplin House DS0000015450.V355713.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Basic standards of care provision are acceptable but shortfalls in some areas could adversely affect outcomes for residents. EVIDENCE: Maplin House DS0000015450.V355713.R01.S.doc Version 5.2 Page 11 Three care files were examined and each contained a large amount of information. Two of the care files examined contained care plans and assessments that were carried out by the residents’ previous placement. The manager said that these were kept in the files to provide staff with information. The current care plan was found further on in the file. The possibility that staff would read the other homes version of the care plan and implement care that was no longer suitable was discussed and the manager said that she would move all older documentation to the back of the file to ensure there is no confusion as to which care plan is in use. The standard of information in the care plans has been improved upon, however there was property lists in each of the three care files examined that did not contain any details. The care plans examined did not provide sufficient information on the level of staff intervention; this was discussed and the manager said that as stated in her annual quality assurance assessment she plans to compile more in depth care plans in the next 12 months to ensure that staff have sufficient information. The daily significant events progress records examined provided sufficient details and a good record of the activities undertaken by the residents. Residents spoken with said they were happy with the care provided by the home. The care files examined had evidence that recent reviews had taken place and the manager said that reviews were now undertaken monthly. The three care files examined contained full details of all healthcare appointments, hospital letters, GP visits and reviews. There were details of optical, chiropody, audiology and dental appointments including their outcomes on each of the files. The manager states in her annual quality assurance assessment that “health professionals are contacted immediately when health problems arise”. Professionals’ surveys confirmed this. One of the care files examined contained details of a recent medication review where the GP requested that the home monitors their blood sugar; there was no evidence on the file that this had been monitored. The manager said that readings had been taken and that the paperwork had been removed for a recent review and had not yet been replaced. The manager has provided forms in each care plan to list the details of health appointments but these have not been used. A discussion took place about the benefits of these lists being completed; the manager said that the lists were devised to minimise the risk of health information being lost and that they would now be put to use. Maplin House DS0000015450.V355713.R01.S.doc Version 5.2 Page 12 Three medication administration record sheets (MARS) were examined and were fully completed using the appropriate coding where necessary. The medication cabinet was checked and the labels on medicines provided sufficient information from the prescriber. Random samples of the monitored dosage packs were checked against the medication administration sheets and were all found to be correct. The manager said that regular audits of the medication are undertaken. One of the medication administration sheets examined contained as and when (PRN) prescribed medication; there was no protocol in place to inform staff, when, how and why this was to be administered. The instructions on the packet stated as required; the manager said that these were offered to the resident for pain relief and that the resident requested them on a daily basis. The use of as and when medication was discussed and the manager said that she would be seeking a review of their use in this case. Residents spoken with throughout the day said that they felt respected by the staff and management and were well treated. Staff interaction was good and residents appeared relaxed and happy in staffs’ presence. The daily notes evidenced that residents were treated respectfully. Maplin House DS0000015450.V355713.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The level of activities offered to people has improved and provides people with a better quality of life. Whilst the menu offers a choice of healthy meals it is not always followed therefore residents cannot be assured of a balanced diet. Pauline – just highlighted to show you that I have altered this judgement a little. Maplin House DS0000015450.V355713.R01.S.doc Version 5.2 Page 14 EVIDENCE: The routines within the home are flexible to meet the individual needs of the residents. Activity records were completed on each of the three care files examined and included the details of a variety of activities including aromatherapy, board games, playing piano book, TV and films, rides out and shopping. Residents spoken with said that they were happy with the level of activities but would like to go out more often. The manager stated in her annual quality assurance assessment that residents go out in the minibus regularly and attend a friendship club weekly and that more variety of activities have been introduced in the last 12 months. The manager said that the home has its own mini-bus that can accommodate five residents and two staff at any one time; therefore trips have to be staggered. There is only two staff currently working at the home that has the skills to drive the mini-bus. Residents spoken with confirmed that they do have regular opportunities to access the local community. Records confirmed that trips to Leigh Community Centre take place every Monday and that residents regularly attend a selfadvocacy group at the local church. Weekly shopping trips where residents have lunch out also take place. The manager said that visitors are welcome at all times and residents spoken with confirmed this. Residents participate in monthly meetings and have the opportunity to air their views on a daily basis. The manager has recently devised a questionnaire for residents, which looks at how they want the home run. A relatives survey states that residents are able to personalise their own space and a tour of the home confirms this. The home operates a four-week rolling menu that offers residents a good range of healthy, balanced meals, however this menu was changed on the day of the inspection. The cook said that residents had requested chicken curry as an alternative to the corned beef hash or chicken pie that was detailed on the menu. The dessert was also changed from Jelly and ice cream to banana caramel. Residents spoken with said that they were happy with this change and liked chicken curry. The nutrition records have been improved upon to include details of each residents dietary intake, however the new format does not evidence that residents were offered a choice of meals. The nutrition records examined did not correspond with the menu being offered and were not always fully Maplin House DS0000015450.V355713.R01.S.doc Version 5.2 Page 15 completed. The home keeps a tea request book and residents are asked daily what they would like for tea; one of the entries in the tea request book did not correspond with that on the nutrition record. The importance of residents maintaining a healthy balanced diet and particularly the monitoring of the food intake of diabetic residents was discussed. Maplin House DS0000015450.V355713.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints and safeguarding systems that the home has in place provides people using the service with positive outcomes EVIDENCE: The home has a complaints and compliments book that is kept in the staff room; there have been no entries made in the complaints/compliments book since June 2006. The manager said that all complaints including minor ones are dealt with immediately; residents spoken with confirmed that their concerns are dealt with quickly. The need to record all complaints and their outcomes including minor concerns was discussed and the manger said that all future complaints, including minor ones would now be recorded in the complaints/compliments book. The home has a clear complaints procedure that is currently in the process of being reviewed to include up to date details of the CSCI office. Maplin House DS0000015450.V355713.R01.S.doc Version 5.2 Page 17 The homes safeguarding policy has been updated and includes details of the required actions of staff to any allegation of abuse and it is now in line with the Southend Borough Councils’ Adult Protection Committee procedures. The manager states in the annual quality assurance assessment that she intends to make staff and residents more aware of the whistle blowing policy. A copies of the policies and procedures are now kept in the staff room and all staff has been asked by the manager to sign and confirm that they have read and understood all the information. All staff including the most recently employed has had Safeguarding Adults (POVA) training. Maplin House DS0000015450.V355713.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean and comfortable and it meets the needs of the residents who live there. EVIDENCE: The home has two lounges and dining areas, one upstairs and one downstairs. They are both of a sufficient size to accommodate the current resident group. Maplin House DS0000015450.V355713.R01.S.doc Version 5.2 Page 19 The manager has recently replaced the dining tables and chairs and has purchased a new TV cabinet for the upstairs lounge. A range of repairs and renewals were identified in the homes annual development plan and many of the tasks have now been completed. The manager states in her annual quality assurance assessment that a daily checklist has been devised to help identify repairs and renewals and that more refurbishment is due to take place in the next 12 months. New kitchen and laundry equipment has been purchased and the manager said that they are in the process of moving the laundry to another area and intend to make the current laundry into a food storage area. The laundry chute in the upstairs hallway has been secured and was locked on inspection. The manager said that this is only opened when in use and kept locked at all other times. Staff have recently had infection control training and there were paper towels and liquid soaps in all of the communal areas. Staff spoken with was aware of infection control measures. Thel bedrooms contained many personal items and residents spoken with confirmed that they were encouraged to personalise their rooms. The home was clean, pleasant and hygienic. Maplin House DS0000015450.V355713.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst staff training is good, the shortfalls identified in the recruitment process do not protect residents fully. EVIDENCE: The rota identified the person responsible for cooking and cleaning but did not identify the designation of other staff with the exception of the manager. There were five staff on duty on the morning of the inspection including the manager; there was one senior carer, one carer, the cook and the cleaner. The cook was rotered to work from 10.00am to 13.00pm and as a carer from 14.00pm to 18.00pm in the afternoon. The manager said that the cook often works extra in the morning to assist residents that attend day centres to the Maplin House DS0000015450.V355713.R01.S.doc Version 5.2 Page 21 bus. There are two members of staff that live on the premises in a separate upstairs flat; both of these staff are written on the rota as the sleep-in on alternative nights. The home employs one waking night staff. The home employs eleven staff and five have achieved a minimum of NVQ level 2 in care and a further four are in the process of undertaking the award. The manager said that the home does not use agency staff and that permanent staff cover vacant shifts. Four staff files were examined and they all contained evidence of staff induction having taken place. Three of the staff files examined were for staff that had been employed within the last year; all three had shortfalls. Two files contained criminal records bureau (CRB) checks that had been carried out by a previous employer, the third file examined had a criminal record bureau check dated June 2007 and the employee had started work at the home in April 2007. The manager said that all three criminal record bureau checks had been applied for and that POVA 1st checks had been undertaken. There was evidence that criminal record bureau checks have been requested and that POVA 1st checks had been carried out but they were dated 29th November 2007. A discussion took place regarding the importance of having robust recruitment policies and practice and the manager said that it has sometimes been difficult to recruit and that she already knew one of the staff she had recruited. The manager said that these staff had all been working under the supervision of more experienced staff. The manager has provided staff with good training opportunities including, moving and handling, abuse, health and safety, first aid, medication and infection control. Staff spoken with confirmed that the infection control training undertaken recently had helped them to identify and eliminate the possible risk of infection. In the annual quality assurance assessment the manager states that the training schedules and mandatory training have improved in the last 12 months. The manager said that due to shortage of staff the homes training schedule had suffered delays during the past year; five full-time and two part-time staff have left in the past twelve months. The training schedule devised by the manager now includes service specific training such as dementia, diabetes, nutrition, pressure area care and Parkinson’s’ disease. The schedule commences in January 2008 and will offer all staff basic training and updates that includes moving and handling, infection control, fire safety, first aid, health and safety, abuse, food hygiene and administration of medication. Maplin House DS0000015450.V355713.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst there have been improvements in health and safety issues since the last inspection the shortfalls identified in the recruitment process, the care planning Maplin House DS0000015450.V355713.R01.S.doc Version 5.2 Page 23 system and the supervision of staff do not provide people living in the home with good outcomes. EVIDENCE: The manager has completed the Registered Managers Award and the NVQ level 4 in Care but is awaiting certification; she has worked at the home for 17 years in various roles. The manager has trained as a trainer for moving and handling and intends to regularly offer this training to the staff team. The manager regularly updates her practice and has recently had infection control, the monitoring of blood sugar and Safeguarding Adults (Abuse) training. Shortfalls in the management of the home do not provide residents with the outcomes they should have in all areas of their care and protection. The manager has recently developed the homes quality assurance system and has consulted residents, their relatives, the local General Practitioner, a district nurse and the visiting chiropodist on all aspects of living at Maplin House. The homes annual quality assurance assessment (AQAA) was fully completed and returned to the CSCI by the due date. The manager is appointee for all but one of the homes residents. Three residents cash transaction records, receipts and cash were checked and all found to be correct. The manager has been providing staff with supervision infrequently; there was evidence that supervision takes place but one of the staff files examined did not contain any record of supervision taking place and the employee had worked at the home since June 2007. Staff spoken with confirmed that supervision does take place but is infrequent. The manager identified supervision as needing improvement in the homes annual quality assurance assessment and plans to carry out regular supervision for all staff within the next 12 months. Regular staff meetings are held and topics discussed include handover, communication, accident recording, activity charts and the diversity of the staff team. Staff is asked to sign the office copy of the minutes of the meeting to confirm that they have received a copy. The home has a range of health and safety policies that staff signs to confirm they have read and understood. There was an up to date record of recent fire drills and the fire equipment has been tested regularly. Water temperature regulators have been fitted to all water outlets in the bedrooms and communal Maplin House DS0000015450.V355713.R01.S.doc Version 5.2 Page 24 bathrooms. All safety certificates were in place and up to date. The home has assessments for the control of hazardous substances harmful to health (COSHH) in place but the cupboard storing the hazardous chemicals did not have a lock on it and the laundry door where the COSHH cupboard is sited was also unlocked. The manager arranged for a lock to be fitted and the work was carried out the next day. Maplin House DS0000015450.V355713.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 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 3 2 X 3 2 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 2 32 X 33 3 34 X 35 3 36 2 37 X 38 3 Maplin House DS0000015450.V355713.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation 12 and 15 Requirement The care plans must contain sufficient detail to clearly demonstrate the level of staff intervention that is required for each individual resident. Timescale for action 31/03/08 2. OP8 13 All instructions from health care 31/01/08 professionals must be carried out and documented in the individual’s care file. There must be clear instructions to staff with regard to as and when prescribed (PRN) medication and PRN medication should be reviewed if it is required on a daily basis. The manager must ensure that all recruitment checks have been carried out and are satisfactory before an employee starts work at the home. The manager must ensure that all staff working in the home receives appropriate supervision. 31/01/08 3. OP9 13 4. OP29 19 31/01/08 5. OP36 18 31/03/08 Maplin House DS0000015450.V355713.R01.S.doc Version 5.2 Page 27 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 OP15 Good Practice Recommendations Changes to the planned menu should be recorded so that the home can ensure that residents receive a balanced healthy diet. Maplin House DS0000015450.V355713.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. Maplin House DS0000015450.V355713.R01.S.doc Version 5.2 Page 29 - 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. 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