Inspection on 09/10/07 for Maxey House

This inspection was carried out on 9th October 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 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

Maxey House 03/11/09

Maxey House 11/11/08

Maxey House 30/05/08

Maxey House 06/03/07

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 Unannounced Inspection 9th October 2007 11:00 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.V352815.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.V352815.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.V352815.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th March 2007 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. Residents have access to the gardens. The charges range from £395 to £405 per week Copies of CSCI reports are made available to residents and visitors on request. Maxey House DS0000015189.V352815.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 9th October 2007. The inspector met with the manager, provider, members of care staff and residents 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. The home has provided an Annual Quality Assurance Assessment (AQAA) and a number of surveys were received from relatives and residents. What the service does well: What has improved since the last inspection? What they could do better: Care plans must incorporate appropriate risk assessments to ensure residents safety. Staff must receive regular training to ensure they are competent to deliver care and support to the residents in the home. Staff must receive regular recorded supervision to ensure that their performance and development is monitored throughout the year. Maxey House DS0000015189.V352815.R01.S.doc Version 5.2 Page 6 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.V352815.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.V352815.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): 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 ensures that information is received to ensure that prospective residents needs can be met. EVIDENCE: Prospective residents and their family or relatives can make a number of visits to Maxey House as part of the assessment process to ‘test drive’ the home prior to admission to ensure as much as possible that the their assessed need’s can be met. The home continues to receive assessment information from the local authority including as a copy of the care plan. There were 30 residents in the. There have been no further changes to the assessment processes, Maxey House DS0000015189.V352815.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. Residents receive health and personal care to meet their assessed needs but improvements need to be made to risk assessing to ensure resident’s safety. EVIDENCE: Three resident 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 although reviews are recorded in the care plan “goal setting” sheet, more space is required so that any changes to care can be recorded in greater detail rather ‘no change’. The manager stated that she would implement a review sheet for each aspect of the care plan and discuss with the senior staff how changes to care are to be recorded. It was noted during discussion with the manager that one of the residents is experiencing increasing amounts of falls. A risk assessment needs to be in place to ensure that the resident’s needs are being adequately met. A requirement will be made regarding this issue. Maxey House DS0000015189.V352815.R01.S.doc Version 5.2 Page 10 The daily notes are recorded in a separate file which details appointments and visits from healthcare professionals i.e. GP, chiropodists and district nurses. District nurses also record visits of their visits to residents in a separate file. Medication administration records were inspected and they were accurately recorded. Maxey House DS0000015189.V352815.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 residents have access to appropriate activities to meet their needs. EVIDENCE: The manager stated that there is a range of activities provided in the home. These include exercise sessions, sport sessions, monthly music entertainment, coffee mornings, board games, bingo, and individual visits from ministers. There regular daily newspapers and access to television, video and DVD A hairdresser visits the home on a weekly basis. Day trips to the local area are offered throughout the year. Parties are arranged and the manager stated that the Christmas Party is being organised and Christmas cakes have been made. A senior carer continues to take the lead in arranging activities in the home. The ‘Sporting Chance’ activity providing a variety of games and exercises on a fortnightly basis has proved to be popular. Residents spoken to confirmed that they enjoyed this session and would like a weekly session rather than it being fortnightly. There also continues to be a fortnightly session of light exercises and for those who wish to participate. Maxey House DS0000015189.V352815.R01.S.doc Version 5.2 Page 12 Residents confirmed that they were encouraged to participate in arranged activities and that they also received regular visits from friends and relatives. Players. A number of residents also stated that they liked to spend time in their own room reading, listening to the radio or watching TV and joined in with some activities occasionally. Residents were complimentary about the quality and amount of food provided in the home. There continues to be a varied range of nutritious home cooked meals and residents have a choice of alternatives to the suggested menu choices when required. The manager stated that the cook consults with residents about particular preferences and whether the meals meet likes and dislikes. Snacks and drinks are also available at all times during the day. This was confirmed by a number of residents. Residents also confirmed that the manager and care staff are always friendly and caring. This was also observed throughout the day and staff were seen to interact with residents in a gentle, sensitive and caring manner. Maxey House DS0000015189.V352815.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 residents 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 residents and visitors. 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 have received training in the protection of vulnerable adults and the manager is organising updates via the local authority trainer. Maxey House DS0000015189.V352815.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 good. This judgement has been made using available evidence including a visit to this service. The environment of the home meets the resident’s needs. EVIDENCE: Maxey House DS0000015189.V352815.R01.S.doc Version 5.2 Page 15 The home is suitable to meet the requirements of the residents and it is presented in a clean and tidy manner and free from odours. Maintained required for the renewal of the premises and decoration is undertaken on an ongoing basis. The manager stated that bedrooms continue to be redecorated as part of an ongoing maintenance programme throughout the year. Since the last inspection of the home the hallways and corridors have been redecorated and new dining chairs and tables have been installed in the dining area. Residents can personalise their bedrooms with furniture and other possessions including television and, music systems to make their rooms more homely and comfortable as possible. This was evidence in the rooms that were seen during the day and confirmed by residents who had made their bedrooms homely and very comfortable. The grounds continue to be well-presented and accessible to residents. A new driveway, paths and patio area has recently been completed. An audit of bedroom curtains has been undertaken and new curtains are being ordered where required. There have been no further changes to the environment since the last inspection. Maxey House DS0000015189.V352815.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 for care staff must be improved to ensure they are competent to deliver care to the residents they support. EVIDENCE: The home maintains a staff rota and the manager confirmed that the home is fully staffed at present. There were three carers and the manager during the morning and four carers in the afternoon and evening. Two waking night staff are on duty during the evening into morning. There is also a full–time cook, kitchen assistant and a cleaner. Staff spoken to stated that they had received a variety of training including first aid, fire safety, food hygiene and safe use of hoists. NVQ training for staff continues in the home at both level 2 & 3. Since the last inspection the manager has implemented individual recording sheet to detail each individual staff’s training achieved during the year with accompanying dates. On inspection it was noted that training has been infrequent during this year and the manager was reminded that staff need to be up to date to ensure safe practice. A requirement will be made regarding this issue. Maxey House DS0000015189.V352815.R01.S.doc Version 5.2 Page 17 The manager stated that she is negotiating a contract with a training organisation to implement a thorough training package for staff. The manager agreed to forward a copy of the training programme to CSCI to evidence planned training for staff. Three staff files were inspected and they contained appropriate documents including application form, references and evidence of CRB checks. Maxey House DS0000015189.V352815.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 but recorded supervision of staff must be improved. EVIDENCE: Staff spoken to confirmed that the management style of the home continues to be open and residents confirmed that they could raise concerns with the manager and the provider whenever they wished to. Staff also confirmed that they were able to raise issues whenever they felt necessary. However it was noted that recorded supervision has been infrequent and this must be improved to ensure that staff’s performance and development needs are monitored throughout the year. A requirement will be made regarding this issue. Maxey House DS0000015189.V352815.R01.S.doc Version 5.2 Page 19 The provider is in regular contact with the home and staff and residents confirmed this to be the case. A number of residents stated that they would like to see monthly meetings in place with the provider to discuss issues or ideas regarding services provided in the home. This comment was fed back to the manager for further discussion/action with the provider. Fire alarm and emergency lighting tests are recorded regularly. Service contracts are also in place for equipment used in the home. Maxey House DS0000015189.V352815.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 X X 3 X 3 N/A 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 3 3 X X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 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.V352815.R01.S.doc Version 5.2 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 2 Standard OP7 OP30 Regulation 13 (4) (b) (c) 18 (1) (c) Requirement Care plans must incorporate appropriate risk assessments to ensure residents safety. Staff must receive regular training to ensure they are competent to deliver care and support to the residents in the home. Staff must receive regular recorded supervision to ensure that their performance and development is monitored throughout the year. Timescale for action 30/11/07 30/11/07 3 OP36 18(2) 30/11/07 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.V352815.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Team 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.V352815.R01.S.doc Version 5.2 Page 23 - 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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