Inspection on 06/03/07 for Maxey House

This inspection was carried out on 6th March 2007.

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 14/02/06

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 Key Unannounced Inspection 10:00 6th March 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.V319736.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. 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.V319736.R01.S.doc Version 5.2 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.V319736.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th February 2006 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. The charges range from £357 - £395 per week Copies of CSCI reports are made available to service and visitors on request. Maxey House DS0000015189.V319736.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Regulation Inspector, Andy Green undertook this unannounced inspection on 6th March 2007. The inspector met with the manager, provider, members of care staff and service users to gather their 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: Service user plans must be reviewed appropriately to ensure that care and support needs are being met. This was a requirement from the last inspection; failure to comply with this requirement may result in legal action being taken against the service. Decoration in communal areas and hallways must be carried out The registered person must ensure that there is sufficient CRB checks made for all staff working in the home before commencing their employment Maxey House DS0000015189.V319736.R01.S.doc Version 5.2 Page 6 The registered person must ensure that records of all training undertaken by staff are accurately kept in the home. The registered person must ensure that staff receive regular recorded supervision throughout the year. It is recommended that the manager and senior staff meet formally on a regular basis to ensure that all care and management processes are adequately monitored. 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. Maxey House DS0000015189.V319736.R01.S.doc Version 5.2 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.V319736.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home produces a variety of information to ensure that prospective service users can decide if they wish to live in the home EVIDENCE: The Statement of Purpose has been reviewed and updated since the last inspection. CSCI’s address has been added to these documents for service users information and the provider’s details have also been amended. There were 27 service users in residence. The home continues to receive assessment information from the local authority and a copy of the care plan. Prospective service users and their family/relatives continue to visit Maxey House as part of the assessment process, prior to admission to ensure that the their need’s can be met and also gives the person a chance to experience life in the home. There have been no further changes to the assessment processes. Maxey House DS0000015189.V319736.R01.S.doc Version 5.2 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. 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. Service users receive appropriate health and personal care to meet their assessed needs. Medication administered in the home is recorded accurately. However improvements must be made to the care planning process. 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. It was noted that one of the service users care plan was in need of updating and a member of senior staff ensured that it was dealt with immediately. The manager has implemented a ‘Service Users History’ document which relatives of service users are asked to complete to give further background details. There was evidence that some reviews have occurred and these are recorded in the “goal setting” sheet in the care plan. However, reviews still remain infrequent and that any changes to care and support were not always written in sufficient detail with mostly ‘no change’ recorded. Maxey House DS0000015189.V319736.R01.S.doc Version 5.2 Page 10 A requirement regarding this issue was made at the last inspection of the home and action must be taken to improve the review process. Consequently a further requirement will be made regarding this issue. It was noted that the care plan files have been upgraded with each individual service user‘s file presented in a more accessible manner. The daily notes are recorded in a separate file. A variety of healthcare professionals support service users in the home on a regular basis including district nurses, GPs and a chiropodist. District nurses are available to attend to service user’s nursing needs as required. It was also recommended that the home contact the local ‘Falls Prevention’ officer for advice and staff awareness training. Contact details were given to the manager who agreed to follow this up. Medication records were inspected and they are accurately recorded. Medication is stored in a cabinet in a locked office. However it was noted that the medication cabinet lock was not working. Following discussion with the manager it was recommended that the cabinet should be adequately secured so that all medication is safely stored. The handy man was contacted who immediately installed a padlock to make the cabinet secure. Maxey House DS0000015189.V319736.R01.S.doc Version 5.2 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. 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. Staff provide support to ensure that service users have access to appropriate activities to meet their needs. EVIDENCE: The manager said that there are a range of activities provide in the home. These include monthly music entertainment, coffee mornings, bingo, and individual visits from ministers. A hairdresser continues to provide regular session for service users in the home. Day trips to the local area are offered throughout the year. A senior carer is co-ordinating an activity programme to improve the range of activities in the home. A successful contact has been made with an organisation called ‘A Sporting Chance’ who provides a variety of games and exercises on a fortnightly basis. There is also a fortnightly session of light exercises and aerobics for those who wish to participate. Service users confirmed that they were encouraged to participate in arranged activities and that they also received regular visits from friends and relatives. There is a varied range of home cooked meals and they have a choice of alternatives to the suggested menu choices when required. Snacks and drinks are also available at all times during the day. Service users were complimentary about the food provided in the home. Maxey House DS0000015189.V319736.R01.S.doc Version 5.2 Page 12 Service users also confirmed that staff that the management team and care staff are always friendly and caring. Maxey House DS0000015189.V319736.R01.S.doc Version 5.2 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. 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 home has a complaints process to make sure that service users have their complaints or concerns listened to and acted upon properly. 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. The home has a satisfactory policy regarding Adult Protection, which is in line with the Local Authority policies. Staff has received training in the protection of vulnerable adults in June 2006. 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.V319736.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,23,24,25,26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment of the home meets the service users needs. EVIDENCE: Maxey House DS0000015189.V319736.R01.S.doc Version 5.2 Page 15 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 manager stated that bedrooms are redecorated as part of an ongoing maintenance programme. The manager stated that the hallways and corridors would be redecorated by the end of April 2007. New dining chairs and tables have also been ordered. Service users continue to be encouraged to personalise their bedrooms and to bring furniture and other possessions to make their rooms more homely and comfortable as possible. This was confirmed by a service user who has made her bedroom homely and very comfortable. The grounds are 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.V319736.R01.S.doc Version 5.2 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. 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. Training is provided for care staff is so that they are competent to deliver care to the service users they support. Improvements to the home’s recruitment processes must be made to ensure that service users are protected from harm EVIDENCE: The home maintains a staff rota and on the day of inspection registered manager confirmed that 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 three carers and the manager during the morning and four carers in the afternoon/evening. There is also two waking night staff on duty during the evening/morning. There is also a full–time cook and a cleaner. Staff spoken to stated that they receive a variety of training including infection control, first aid, moving & handling and safe use of hoists with refreshers/updates to ensure safe practice throughout the year. Health & safety training and POVA training is also received. NVQ training is well established in the home at both level 2 & 3. However there were no individual records detailing training that has been undertaken. A separate form must be implemented to record each individual staff’s training achieved during the year with accompanying dates including dates for refreshers. The manager agreed to implement this, which will be incorporated in individual staff files. Consequently a requirement will be made regarding this issue. Maxey House DS0000015189.V319736.R01.S.doc Version 5.2 Page 17 Staff files are now located in a locked filing cabinet in the managers office. Four files were seen and they contained relevant information. However it was noted that insufficient CRB checks had been made on three files as previous CRB clearances had been used. The manager and provider were reminded that CRB’s are not transferable and that new CRB checks for these staff must be made. The provider agreed to action this issue immediately. Consequently a requirement will be made regarding this issue, which will be monitored during the next inspection of the home. Maxey House DS0000015189.V319736.R01.S.doc Version 5.2 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. 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. The manager provides guidance to staff to ensure that service users receive good quality care. Supervision of staff must be improved. EVIDENCE: Staff spoken to on the day of inspection confirmed that the management style of the home continues to be open and inclusive and service users confirmed that they are encouraged to approach the management team with any concerns. Staff confirmed that they were able to raise issues whenever they felt necessary. It is recommended that a manager/senior staff meeting be implemented to ensure that key tasks are co-ordinated and monitored. The manager agreed to consider implementing such a meeting. The registered provider is in regular contact with the home and staff and service users confirmed that they meet with her regularly. Maxey House DS0000015189.V319736.R01.S.doc Version 5.2 Page 19 Some improvements have been to 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 throughout the year. This issue was raised during the last inspection of the home and a further requirement has been made in this report. Fire records are kept and recorded regularly. Service contracts are in place for equipment in the home. Maxey House DS0000015189.V319736.R01.S.doc Version 5.2 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 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 2 X 3 Maxey House DS0000015189.V319736.R01.S.doc Version 5.2 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 OP7 Regulation 15(2) (b) Requirement Service user plans must be reviewed appropriately to ensure that care and support needs are being met. This was a requirement from the last inspection; failure to comply with this requirement may result in legal action being taken against the service. Decoration in communal areas and hallways must be carried out The registered person must ensure that there is sufficient CRB checks made for all staff working in the home before commencing their employment The registered person must ensure that records of all training undertaken by staff are accurately kept in the home. 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. DS0000015189.V319736.R01.S.doc Timescale for action 30/05/07 2 3 OP19 OP29 23 (2) (b) 19(i)(b) Schedule 2 17(2) Schedule 4 18 (2) 30/05/07 06/03/07 4 OP30 30/05/07 5 OP36 30/05/07 Maxey House Version 5.2 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. 1 Refer to Standard OP31 Good Practice Recommendations It is recommended that the manager and senior staff meet formally on a regular basis to ensure that all care and management processes are adequately monitored. Maxey House DS0000015189.V319736.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 Maxey House DS0000015189.V319736.R01.S.doc Version 5.2 Page 24 - 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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