Inspection on 03/01/07 for Maybank House

This inspection was carried out on 3rd January 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

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Maybank House 588 Altrincham Road Brooklands Manchester M23 9JH Lead Inspector Nick Allen Unannounced Inspection 3rd January 2007 13:00 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 Maybank House DS0000066423.V326438.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. Maybank House DS0000066423.V326438.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Maybank House Address 588 Altrincham Road Brooklands Manchester M23 9JH 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) 0161 998 6566 Maybank House Limited Mrs Philomena Gibson Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Maybank House DS0000066423.V326438.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st May 2006 Brief Description of the Service: Maybank House is a care home providing personal care and accommodation for 25 residents who are 65 years and over. Mrs Gibson the owner of the home is also the registered manager. The home is located close to bus and train routes. It is also close to shops and local amenities. The home is a two-storey detached building comprising of 19 single bedrooms, 3 double bedrooms, and 3 lounges. There is a passenger lift available to the second floor. Parking space is available at the front and the side of the home. There are gardens to the sides and the back of the house. The fee range for the service is between £ 358.09 5.00 and £ 400.00 Maybank House DS0000066423.V326438.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day in January 2007. The inspection lasted for four hours during which time the inspector spoke to twelve service users and four members of staff as well as the responsible individual/ manger and the newly appointed manager. Information held by the Commission was also received, as part of the inspection process the Inspector looked at the files for three service users. This helped to see whether the National Minimum Standards were being met. What the service does well: What has improved since the last inspection? What they could do better: There is a need to continue to work towards maintaining good recording systems within the home. The responsible individual has decided to step down from the day-to-day management and has appointed a manger. The manager will need to apply to the Commission for Social Care Inspection to become the Registered Manger. In the meantime there is still a need for the Responsible Maybank House DS0000066423.V326438.R01.S.doc Version 5.2 Page 6 Individual to complete all necessary notifications and forward them to the Commission For Social Care Inspection. There needs to be a review of all the practices within the home to ensure that they are inline with the National Minimum Standards, this includes the accurate monitoring of the temperatures of all water outlets that Service Users have access to 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. Maybank House DS0000066423.V326438.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 Maybank House DS0000066423.V326438.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): 3,6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service Service users needs are assessed before admission. Information available for service users needed to be updated. EVIDENCE: During the case tracking process it was evident that service users have their needs assessed prior to admission. The Registered Provider/ Manager undertook these assessments at the time of the site visit. This will become the responsibility of the new manager. Following the assessment visit documentary evidence was seen that the home writes to the service user confirming that the home could meet the individuals needs. Maybank House DS0000066423.V326438.R01.S.doc Version 5.2 Page 9 The Registered Provider/ Manager said that the process worked well. When asked Service Users remembered having visited the home but could not remember any one visiting them prior to that. However of those spoken to all had lived at the home for some time. The Statement of Purpose and Service User Guide needed reviewing to give better information on the service and staffing arrangements for service users. The service does not provide intermediate care. Maybank House DS0000066423.V326438.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures for the planning of care and the administration of medication were thorough, relevant to presenting needs of residents and effectively promoted good health care. Service Users felt that they were respected. EVIDENCE: Of those files seen, all contained appropriate care plans. Plans covered all good practice topics. There was recorded evidence of monthly reviews. Maybank House DS0000066423.V326438.R01.S.doc Version 5.2 Page 11 The documents seen reflected the needs of the individual. Staff said the care plans were being used to guide daily practice. There was evidence of staff taking pride in the completion of the care plans and daily records. Comments made by residents when asked about their care were very positive. Collectively everyone said that they enjoyed living at the home. Health care needs were effectively met through the support of health care professionals including for example general practitioners, district nursing and chiropody services, with a record of visits maintained on individual files of service users. Continence management strategies were in place and free at the time of inspection. the home was odour Medication policies and procedures were in keeping with requirements. Medication administration records had been effectively completed and general storage facilities were suitable and secure. However it was observed that the district nursing staff were storing medication and dressings in one of the empty bedrooms. Neither the storage facility nor the bedroom was locked. This means that service users could access this room. There were no service users self-medicating. Maybank House DS0000066423.V326438.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were supported and enabled to exercise choice, participate in social activities and have a balanced and nutritious diet. EVIDENCE: Discussion with service users and direct observation confirmed that opportunities were made available for all service users to choose from a variety of activities. However there was not a dedicated individual activities coordinator, Staff shared this role. Records indicated that routines of the home remain flexible to meet the needs of service users; for example in relation to meal and bed times. There continues to be a limited amount of information in regard to advocacy. It was recommended that additional information about advocacy services be obtained and distributed to service users and their relatives to ensure Maybank House DS0000066423.V326438.R01.S.doc Version 5.2 Page 13 independence is maximised. The additional information, when available, should also be referred to in the Service User Guide. Menus examined indicated a balanced and nutritious diet was available. The special dietary needs and personal preferences of service users were known by catering staff. Maybank House DS0000066423.V326438.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure of the home enabled service users and their relatives to feel confident that any complaints would be listened to and acted upon. EVIDENCE: The complaints policy and procedures of the home met the requirements of the standard. When spoken to members of staff demonstrated an understanding of the process. Of those Service Users spoken to all knew who they should talk to if they were unhappy with the care they received. All also made positive comments and one said “what is there to complain about” A suitable record for complaints was available. The Responsible Individual/ Manager said that no complaints had been received by the service. Maybank House DS0000066423.V326438.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The premises were homely, clean and well maintained. This enabled service users to live in pleasant surroundings appropriate to their needs EVIDENCE: Public areas were well furnished and decorated appropriately. Bedrooms were personalised and the décor reflected the personality and preferences of the individual. On a previous inspection there had been issues identified around bedroom door locks and missing window restrictors. These issues had now been addressed, Maybank House DS0000066423.V326438.R01.S.doc Version 5.2 Page 16 however it was noted that one of the first floor toilets did not have a privacy lock. A number of empty bedrooms were being used for storage. These rooms were not locked and could pose a Health and safety risk to service users. It was found that the temperature of the hot water in some bedrooms was too high. This was despite the fact that the handy person completed a weekly check of the water temperatures. A requirement to address this was made. Routine maintenance tasks maintenance records held. had been completed as evidenced from Control of infection policies and procedures were in place. Laundry facilities were suitably sited and clothing was washed at required temperatures. Maybank House DS0000066423.V326438.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Effective recruitment and training processes ensured that skilled and competent staff members were employed at the care home. EVIDENCE: Examination of staffing rotas together with direct observation and discussion with staff confirmed that the numbers and skills mix of staff met the presenting needs of those people living at the home. The home was staffed, as a minimum, in accordance with previous regulatory guidelines taking into account the changing dependency needs of service users. There was a commitment to training evidenced from training plans and records. Staff members spoken to were undertaking health and safety training. Over 50 of care staff hold NVQ level 2 in Care. Details of additional training was available. Recruitment policies and procedures were in place as were details of induction training. There had been one new member of staff recruited since the last Maybank House DS0000066423.V326438.R01.S.doc Version 5.2 Page 18 inspection. Details of that process were appropriate. Criminal Records Bureau disclosures for existing staff will need to be updated soon. Maybank House DS0000066423.V326438.R01.S.doc Version 5.2 Page 19 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): 31,33,35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Policies and procedures of the home promoted a quality service and positive health and safety practices promoted positive outcomes for service users. Some daily records still contained minimal information. Maybank House DS0000066423.V326438.R01.S.doc Version 5.2 Page 20 EVIDENCE: The Responsible Individual/ manager has had suitable experience in the management of care services for older people, had undertaken relevant professional training. However they have not undertaken a relevant qualification in either care or management. As a result the Responsible Individual/ Manager has appointed a qualified person to manage the home on a day-to-day basis. This person has yet to register with the Commission For Social Care Inspection. The views of service users and other stakeholders had been sought via a questionnaire; the findings had been analysed and any necessary follow up action undertaken. Policies and procedures had been kept under review. Supervision and appraisal processes had been established. These processes were thorough and supported general supervision and guidance that were provided for staff on a routine daily basis. Records were maintained in good order and stored in accordance with data protection requirements. There was an understanding of the importance of confidentiality and data protection requirements. Training in safe working practices was provided for staff members. Refresher training in these topics plus moving and handling training for staff was available. Health and safety policies and procedures were in place with safety notices posted appropriately throughout the building. A fire risk assessment and fire records were provided for inspection. Gas, central heating and electrical checks had been carried out. The measures taken had improved the safety of the environment for the benefit of residents. Maybank House DS0000066423.V326438.R01.S.doc Version 5.2 Page 21 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 X x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 x x x x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Maybank House DS0000066423.V326438.R01.S.doc Version 5.2 Page 22 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 OP19 Regulation 12 Requirement The Responsible Individual must ensure that all hot water outlets accessed by service users are maintained at an appropriate temperature. That these temperatures are recorded. Previous Time scale of 01/06/06 was not met All medication storage facilities must be secure and locked at all times. Timescale for action 31/01/07 2. OP9 13(2) 20/01/07 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 Maybank House DS0000066423.V326438.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 Maybank House DS0000066423.V326438.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. 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