Inspection on 14/02/06 for Maxey House

This inspection was carried out on 14th February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Maxey House 03/11/09

Maxey House 11/11/08

Maxey House 30/05/08

Maxey House 09/10/07

Maxey House 06/03/07

Maxey House 19/09/05

Maxey House 21/03/05

Maxey House 14/09/04

Maxey House 19/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Maxey House Lincoln Road Deeping Gate, Peterborough PE6 9BA Lead Inspector Andy Green Unannounced Inspection 14th February 2006 1:00 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 Maxey House DS0000015189.V270429.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. Maxey House DS0000015189.V270429.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Maxey House Address Lincoln Road Deeping Gate, Peterborough PE6 9BA 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) 01778 342244 01778 345850 Mrs Laura Louise Levin Mrs Jacqueline Watson Care Home 31 Category(ies) of Dementia (1), Old age, not falling within any registration, with number other category (31) of places Maxey House DS0000015189.V270429.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Maxey House is a large Georgian country residence standing in three acres of grounds. The home is within half a mile of the town of Market Deeping and approximately five miles from Peterborough city centre. The home consists of a main house with a modern single storey extension. Residential accommodation is provided in twenty-seven single and three double bedrooms. Twelve bedrooms have en-suite facilities. A lounge, dining room with quiet area, and conservatory form the communal areas of the home. Service users have access to the gardens. Maxey House DS0000015189.V270429.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Regulation Inspector, Andy Green undertook this unannounced inspection on 14th February 2006. The inspector met with the manager, members of care staff, service users and a visitor to gather views regarding the services offered in the home. A number of records were inspected including care plans, training records, medication records, fire records and staff files. A tour of the building and grounds was also undertaken. What the service does well: What has improved since the last inspection? What they could do better: The CSCI’s address needs to be added to The Statement of Purpose, Service Guide and Complaints Policy for service users and visitors information. Reviews of care need to be more frequent with any changes to care and support recorded in sufficient detail. It was agreed with the manager that the care plan files are in need of upgrading with each individual service ‘s file presented in a more accessible manner. One of the senior carers is focusing on increasing activity programmes in the home and she will be gathering information from service users to gauge their preferences and interests. The inspector was unable to see personnel files as the provider keeps these and she was not available during the inspection. The manager was reminded that staff files need to be accessible in the home and she stated that she would Maxey House DS0000015189.V270429.R01.S.doc Version 5.0 Page 6 ensure that personnel information would be kept in the lockable filing cabinet in the home’s office in future. Recorded supervision sessions are infrequent. The manager needs to ensure that all care staff receive regular recorded sessions to monitor their current practice and development needs. The frequency of supervision needs to be increased to ensure that care staff receive at least six sessions per year. 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. Maxey House DS0000015189.V270429.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 Maxey House DS0000015189.V270429.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): 1,3,5 The home produces a variety of information to ensure that prospective service users can decide if they wish to live in the home. Some amendments are needed to update these documents. EVIDENCE: Maxey House DS0000015189.V270429.R01.S.doc Version 5.0 Page 9 There have been no changes to the Statement of Purpose or Service User Guide since the last inspection. The manager stated that these documents would be reviewed during the year to ensure that they provide up to date information. It was noted however, that CSCI’s address needs to be added to these documents for service users information. The home receives assessment information from the local authority and a copy of the care plan. The manager and a senior carer make a visit to prospective service users to assess whether individual need can be met carry out a assessment as required. Prospective service users and their family/relatives can visit Maxey House as part of the assessment process, prior to admission. This ensures that the prospective service users need’s can be fully assessed and also gives the person a chance to experience life in the home. There are two vacancies in the home and prospective service users from the will be assessed in the forthcoming weeks. Maxey House DS0000015189.V270429.R01.S.doc Version 5.0 Page 10 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): 7,8,9,10 Service users receive appropriate health and personal care to meet their assessed needs. Medication administered in the home is recorded accurately. EVIDENCE: Four service user files were inspected and care plans showed sufficient details to ensure assessed needs are being met. Any changes in care are documented and daily notes are accurately kept. There was evidence that reviews are carried out with changes recorded in the “goal setting” sheet in the care plan. It was noted however, that reviews were infrequent and that changes to care and support were not always recorded in sufficient detail and only gave brief information. It was further agreed with the manager that the care plan files are in need of upgrading with each individual service user‘s file presented in a more accessible and thorough manner. The daily notes need to be recorded in a separate file. A variety of healthcare professionals continue to support service users in the home on a regular basis including district nurses, GPs and a chiropodist. Maxey House DS0000015189.V270429.R01.S.doc Version 5.0 Page 11 The home is committed to the prevention of pressure sores and there is a supply of appropriate mattresses and cushions. District nurses are available to attend to service user’s nursing needs as required. Medication records were inspected and they are accurately recorded. The manager stated that training staff who administer medication is being booked on an ongoing basis. Maxey House DS0000015189.V270429.R01.S.doc Version 5.0 Page 12 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): 12,13,15 Staff provide support to ensure that service users have access to appropriate activities to meet their needs. Some improvements are needed to offer a wider range of activities. EVIDENCE: The manager said that there is a range of activities in the home including monthly music entertainment, coffee mornings, bingo, and individual visits from ministers. A hairdresser continues to make regular visits to service users in the home. One of the senior carers is focusing on increasing activity programmes in the home and she will be gathering information from service users to gauge their preferences and interests. From this information she will be devising further activity sessions, which can be offered to service users. It was also suggested that she might contact specialists regarding the care of older people in the local area to gather information regarding further activities, eg. Age Concern and The Alzheimer’s Society. Maxey House DS0000015189.V270429.R01.S.doc Version 5.0 Page 13 There is a varied range of meals offered to service users and they have a choice of alternatives to the suggested menu choices. Snacks and drinks are also available at all times during the day. Service users were complimentary about the food provided in the home. Service users and a visitor to the home stated that the management team and care staff are friendly and caring. Maxey House DS0000015189.V270429.R01.S.doc Version 5.0 Page 14 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 The home has a complaints process to make sure that service users have their complaints or concerns listened to and acted upon properly. Some amendments to the policy are required. EVIDENCE: The home has a clear complaints procedure, which is also displayed near the front entrance for service users and visitors. It includes agreed timescales to make sure that all complaints are investigated and actioned appropriately. The home has not received any complaints since the last inspection. CSCI has also not received any complaints regarding the home. Although the policy contains the CSCI phone number the address also needs to be added. The manager stated that this would be actioned immediately. The home has a satisfactory policy regarding Adult Protection, which is in line with the Local Authority policies. Staff need to receive training in the protection of vulnerable adults to ensure that service users are protected from abuse. The manager was given contact details for the Local authority Adult Protection Trainer and she stated that she would book dates for all staff. It was observed during the inspection that care staff spoke to service users in a friendly, social and respectful manner. Service users spoken to also confirmed that staff were caring and provided friendly support. Maxey House DS0000015189.V270429.R01.S.doc Version 5.0 Page 15 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): 19,20,22,24,25,26 The environment of the home provides service users with a safe, comfortable, clean and a well-maintained place in which to live. Service user bedrooms are presented in a style to meet individual preferences and wishes. EVIDENCE: Maxey House DS0000015189.V270429.R01.S.doc Version 5.0 Page 16 Maintenance is actioned as required for the renewal of the premises and decoration is undertaken on an ongoing basis. The home was clean and free from odours. The registered manager stated that renovation and decoration of the upstairs corridor and ceiling have been completed. Service users are encouraged to personalise their bedrooms and to bring furniture and other possessions to make their rooms more homely and comfortable if they so wish. The manager stated that five bedrooms have been redecorated to meet individual preferences as part of an ongoing maintenance programme. The grounds remain well-presented and accessible to service users and they are often used during the warmer months of the year. There have been no further changes to the environment since the last inspection. Maxey House DS0000015189.V270429.R01.S.doc Version 5.0 Page 17 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 The home’s recruitment policy and processes makes sure that service users are protected from harm. Training is provided to make sure that care staff are competent to deliver care to the service users they support. Availability of personnel files needs to be improved. EVIDENCE: The home maintains a staff rota and on the day of inspection registered manager confirmed that all staff are over 18 years of age and that the member of staff in charge of the home at any time is always over the age of 21. The home is fully staffed at present. The home was well staffed on the day of inspection to meet the needs of service users. There were four carers during the morning and four carers in the afternoon/evening. There are also two waking night staff on duty during the evening/morning. Staff members spoken to stated that they receive a variety of training including infection control, first aid, moving & handling and use of hoists with refreshers/updates to ensure safe practice throughout the year. Health & safety training and POVA training is being booked for the forthcoming months. Maxey House DS0000015189.V270429.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): 31,32,36,38 The manager provides supportive leadership and guidance to staff to ensure that service users receive good quality care. Supervision of staff and some record keeping needs to be improved. EVIDENCE: Staff spoken to on the day of inspection confirmed that the management style of the home is open and inclusive and service users confirmed that they are encouraged to approach the management team with any concerns. Staff meetings are held and staff confirmed that they were able to raise issues whenever they felt necessary. The registered provider is in regular contact with the home and staff confirmed that they meet with her regularly. Care staff have received some recorded supervision sessions but they have been infrequent. The manager must ensure that all members of staff receive regular recorded sessions to monitor their practice and development needs on at least six sessions per year. This issue was raised during the last inspection of the home and a further requirement has been made in this report. Maxey House DS0000015189.V270429.R01.S.doc Version 5.0 Page 19 The inspector was unable to see staff files as the provider keeps these in her office and she was not available during the inspection. The manager was reminded that these documents need to be accessible in the home and she stated that she would ensure that personnel information would be kept in the lockable filing cabinet in the home’s office in future. The manager also stated that she is enrolled on an NVQ level 4 in Management and Care but that she is waiting for a commencement date. Fire records are kept and recorded regularly. Service contracts are in place for equipment in the home. Maxey House DS0000015189.V270429.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 2 X 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 X 3 X 3 3 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 3 X X X 2 2 3 Maxey House DS0000015189.V270429.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes 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 OP36 Regulation 18 (2) Requirement The registered person must ensure that staff receive regular recorded supervision throughout the year This was a requirement from the last inspection; failure to comply with this requirement may result in legal action being taken against the service. The address of the Commission for Social Care Inspection must be included in the Statement of Purpose and Service Users Guide Service users plans need to be reviewed appropriately and stored in an accessible manner A programme of activities needs to be in place to give more choice for service users Care staff must receive training regarding Adult Protection to ensure that service users are safeguarded from abuse. Staff personnel files need to be available in the home for inspection at all times Timescale for action 31/03/06 2 OP1 5 (f) 31/03/06 3 4 5 OP7 OP12 OP18 15 (2) (b) 16(2) (m) 18 ( c) (i) 30/04/06 30/04/06 30/04/06 6 OP37 17 (3) (b) 31/03/06 Maxey House DS0000015189.V270429.R01.S.doc Version 5.0 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Maxey House DS0000015189.V270429.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE 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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