Inspection on 07/02/06 for Maybank Residential Care Home

This inspection was carried out on 7th February 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Maybank Residential Care Home 06/12/07

Maybank Residential Care Home 11/12/06

Maybank Residential Care Home 12/09/05

Maybank Residential Care Home 09/03/05

Maybank Residential Care Home 08/09/04

Maybank Residential Care Home 20/01/04

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

CARE HOME ADULTS 18-65 Maybank Residential Care Home 43 Slough Road Iver Heath Bucks SL0 0DW Lead Inspector Mrs Maureen Richards Unannounced Inspection 7th February 2006 09:45 Maybank Residential Care Home DS0000059317.V280217.R01.S.doc Version 5.1 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 Residential Care Home DS0000059317.V280217.R01.S.doc Version 5.1 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Maybank Residential Care Home DS0000059317.V280217.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Maybank Residential Care Home Address 43 Slough Road Iver Heath Bucks SL0 0DW 01753 653636 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) The Regard Partnership Limited Lawrence Mudiwa Charamba Care Home 6 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (1) of places Maybank Residential Care Home DS0000059317.V280217.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Physical Disability Included in the six service users with learning disabilities, the home can accommodate one service user with a physical disability. 12th September 2005 Date of last inspection Brief Description of the Service: Maybank is a care home providing personal care and accommodation to five service users with a learning disability. The home is owned and managed by the Regard Partnership Ltd. The home is located in Iver heath, which is accessible to local shops including a post office and public house. Other facilities and interests are accessed by car. The home is a large chalet type bungalow, which has been extended on over the years. All of the bedrooms are single. The home has a secure large rear garden and a driveway at the front of the property. Maybank Residential Care Home DS0000059317.V280217.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection of Maybank took place over seven hours on the 7th February 2006. The inspection consisted of discussions with the manager, individual discussions with three staff, informal discussions with service users, a tour of the communal areas of the home and examining records. The outstanding key standards were assessed and the requirements made at the previous announced inspection were found to be complied with. This was a positive inspection with the majority of the standards assessed met. One service user commented, “He was very happy living at the home”. What the service does well: What has improved since the last inspection? What they could do better: Service user plans must include confirmation that having the front door locked to ensure the safety of one service user does not restrict other service users from leaving the home if they choose to. The manager must ensure that service users choices around the times they have a bath and go to bed are adhered to. Some improvements are required to medication practices. The organisation must ensure that the manager is clear of how complaints should be acknowledged and responded to. Maybank Residential Care Home DS0000059317.V280217.R01.S.doc Version 5.1 Page 6 The manager should check with the relevant governing body that the clinical waste is being disposed of appropriately The manager should ensure that systems are in place to maintain the cleanliness of the laundry room. The organisation must ensure that there is adequate staff on duty at all times, including on call to meet service user needs. Staff files must be further developed. Some improvements are required to health and safety practices and maintenance of health and safety records. 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. Maybank Residential Care Home DS0000059317.V280217.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Maybank Residential Care Home DS0000059317.V280217.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of the above standards were assessed. They key standard was assessed at the previous announced inspection and found to be complied with. Maybank Residential Care Home DS0000059317.V280217.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6&7 Service user plans are informative and detailed in plan of care, which ensures that service users needs are met in a safe and consistent way. Service users are supported to make decisions about their lives and encouraged to be involved in all aspects of life at the home. Service users plans must include any restrictions to ensure the protection of individuals. EVIDENCE: Three service users plans were viewed at this inspection. Service user plans include a photograph and a completed personal details information sheet. Service user plans outlined the level of support required by individuals in meeting their medical, healthcare, personal care and communication needs, support required at mealtimes, with getting out and about, with social life and daily living skills, leisure and daycentre activities and the support required with finances, religious and spiritual needs. Service users plans included guidelines on the management of specific behaviours and triggers for change in behaviours. A recommendation was made at the previous announced inspection that the manager should ensure that service user plans clearly outline behaviours and management of those behaviours. This has been Maybank Residential Care Home DS0000059317.V280217.R01.S.doc Version 5.1 Page 10 addressed and the guidelines on the management of behaviours are more specific. Service user plans included service users signature and written evidence of being reviewed. A recommendation was made at the previous announced inspection that the manager should ensure that service users plans include an actual date of review and not that the review is on going, continuous or in three to six months. All of the service user plans included a specific review date. A requirement was made at the previous announced inspection that the manager must ensure that abbreviations used in service user plans are fully explained to ensure that all staff are clear on how situations should be managed. This has been complied with. A further requirement was made that the manager must ensure that the arrangements for visitors as requested by one service users next of kin is outlined clearly within the service users plans. The service users plan has been updated to reflect this. Service user plans were found to be well organised, easy to read and accessible. Service user plans makes reference to individuals communication needs and the level of support required by individuals in making decisions and choices in their every day life. One service user has advocacy involvement and this can be accessed if felt required for other individuals. Service user plans make reference to the support required with finances. The organisation act as an appointee for three service users and family members oversee others service users finances. At the end of the inspection it was noted that the front door was locked. This was to prevent one service user from wandering off. The manager confirmed that a risk assessment is in place to support this decision for this individual and that the other service users are able to unlock the door if they want to. The other service users plans and or risk assessment must indicate this to ensure that service users are not being restricted. The manager must ensure that care managers involved in service users care are aware of this. Maybank Residential Care Home DS0000059317.V280217.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 Family involvement and friendships are supported and encouraged to enable service users to develop and maintain family links and appropriate relationships. EVIDENCE: All of the service user plans seen make reference to family involvement. Family and friends are welcome at the home and the home has made progress in re establishing contact with one service user’s family. One service user goes on leave to his family. Service users can see visitors in their bedrooms or in communal areas of the home. The manager confirmed that staff would support a service user in not seeing a visitor if they did not want to. Service users are supported to use community facilities and are given the opportunity to make friends with people who do not have a disability. Service users would be able to develop and maintain a personal relationship within a risk assessment framework. Standard 16 was not assessed. However requirements were made at the previous announced inspection that service user plans must make reference to how individual service users post is managed and a lock was to be fitted to the Maybank Residential Care Home DS0000059317.V280217.R01.S.doc Version 5.1 Page 12 toilet door to ensure that service users privacy is maintained. These were found to be complied with. Maybank Residential Care Home DS0000059317.V280217.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 & 20 Service users are supported to meet their personal care needs whilst promoting their independence and privacy. Staff practices must be addressed to promote service user choice of bath and bedtime times. Medication administration records must include clear instructions on administration of medication to safeguard service users. EVIDENCE: All of the service user plans seen make reference to the support required in meeting individuals personal care needs and some make specific reference to supporting the service user to maintain their privacy and dignity. None of the service users require equipment to assist with moving and handling and two staff are available in the evening to support one individual with moving and handling when this individual is requiring assistance with personal care and they are suffering from the effects of night sedation. The manager confirmed that the times for getting up and going to bed are flexible although service users are supported to get and dressed for day centre attendance and can choose when they go to bed at night. At weekends service users can have a lie in if they choose to. During discussion with staff, staff confirmed that they have to rush in the evening to get all of the service users bathed, showered and ready for bed so that all of the laundry is done prior to the night staff coming on duty. This is unacceptable practice, which must be addressed. Maybank Residential Care Home DS0000059317.V280217.R01.S.doc Version 5.1 Page 14 All of the service users plans make reference to cultural needs although the home has no service user at present with any specific cultural needs. Service users have a choice of staff who support them with specific tasks and one service user chose a staff member to go on holiday with her which took place. One service user has specific aids to assist with his mobility. The manager confirmed that specialist services can be accessed through the GP and following review meetings with professionals involved in individuals care. Some service users have psychiatric involvement and input. All of the service users have a key and co worker and keyworkers have become more involved in the development of service users plans. None of the service users are self-medicating. Staff are responsible for administration of medication. One staff member is responsible for ordering the medication and staff on duty sign medication in. The medication administration records seen showed some gaps in the administration of topical medications. The majority of medication administration records are pre printed by the pharmacy. One service user had recent changes to her medication and these were handwritten by staff and signed by two staff as outlined within the pharmaceutical guidelines. One service user was on as prescribed medication but there was no guidelines in place to indicate when this medication should be administered. One service user was on eardrops as directed but there was instructions as to what as directed meant. Guidelines must be obtained form the GP on the use of all as required medication and clear instructions must be given as to what as directed means on any prescribed medication. The home has a record of disposal of medication. A requirement was made at the previous announced inspection that a tamperproof medication disposal record must be put in place. This has been complied with. The home does not keep any homely remedies. A requirement was made at the previous announced inspection that the manager must consider how a request from a service user for pain relief out of hours will be addressed and a protocol must be put in place to support this. A protocol has been put in place, which indicates that the on call person would be contacted to go and buy pain relief if required and bring to the home. The home has one service user who goes on leave. At the previous inspection staff were decanting medication from the blister packs for the service user to take on leave. A requirement was made to address this and now the service user takes the complete blister pack on leave and brings it back on his return. The manager confirmed that new staff are inducted into the medication policy and procedures prior to administering medication. A completed induction for one staff member was signed to indicate that this person was safe and deemed competent to administer medication. The manager confirmed that all new staff attend the Boots safe administration of medication course within six months of employment. The medication cupboard was generally well organised with creams and lotions kept separate from oral medication. Maybank Residential Care Home DS0000059317.V280217.R01.S.doc Version 5.1 Page 15 The organisation has a medication policy in place, which is overdue for review since September 2004. Maybank Residential Care Home DS0000059317.V280217.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of the above standards were fully assessed at this inspection. The key standards were inspected and met at the previous announced inspection. The home has had one complaint since the previous announced inspection. The letter of response to the complainant did not outline the outcome of the investigation into each compliant raised. The manager advised that this was outlined in a second letter to be sent to the complainant and the complainant would have the opportunity to discuss it at a forthcoming review meeting. The manager advised that this second letter in response to the complaint would be sent to the complainant within the 28-day period. The first letter in response to the complaint acknowledged the complaint but also indicated that action had been taken. It did not indicate that the investigation into the complaint was continuing and that a second letter would be sent to advise the complainant of the outcome. The organisation should ensure that managers are clear of how complaints should be acknowledged and responded to. Maybank Residential Care Home DS0000059317.V280217.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 Systems are in place to ensure that the home is clean and that staff adhere to infection control legislation to benefit service users and staff. Further improvements are required to support this. EVIDENCE: Standard 24 was not assessed. Standard 24 was assessed at the previous announced inspection. Since the announced inspection new carpet has been fitted to the hallway, sitting room, stairs and landing. Non-slip flooring has been fitted to the bathrooms and one service user’s bedroom has been decorated. A ramp has been fitted between the conservatory and sitting room. The manager confirmed that blinds have now been ordered for the conservatory. At the previous inspection it was noted that the small toilet downstairs does not have a sink and a recommendation was made that the organisation should consider how good hygiene can be promoted where the toilet does not have a sink. The manger confirmed that service users who use this toilet are supported by staff and staff would support service users to wash their hands in the sink in the adjacent bathroom or in their bedrooms. The home has infection control polices in place which are overdue for review since December 2005. The home has small amounts of clinical waste which is Maybank Residential Care Home DS0000059317.V280217.R01.S.doc Version 5.1 Page 18 disposed of in yellow bags with the household waste. The manager confirms that the environmental health has agreed to this practice and the council takes it. The organisation’s policy supports this. The manager should request a letter from environmental health to support this practice. The home has a separate laundry room with entrance to the laundry from the outside. The washing machine has a sluicing facility. Staff are responsible for the cleaning and the home was found to be generally clean and tidy. The laundry room was untidy and disorganised and there was a build up of dust in this area. Some staff felt it was difficult to keep on top of the cleaning due to the current staffing levels and without impinging on time spent with service users. Maybank Residential Care Home DS0000059317.V280217.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33 & 34 Staff have specialist training to meet service users needs. Staff indicate that sufficient staffing levels are not being provided to ensure that service users needs are met and to enable them to carry out other tasks and responsibilities. Some further information is required on staff files to ensure that safe recruitment practices are in place to protect service users. EVIDENCE: Staff were observed communicating with service users. They appear to have a good understanding of service users needs and in understanding individual’s communication needs. The manager confirmed that staff are committed and motivated and their involvement in keyworking has further developed this. The majority of the staff team have attended specialist training on epilepsy and dementia. Staff have crisis prevention training as outlined as required in the management of some behaviours. The home has two care staff with an NVQ and four care staff are currently undertaking NVQ’s. The home has no staff under 18 years of age. The rota indicated that there are two staff on the morning shift up until the service users go out to the day centres and there are two staff on shift in the afternoon as service users return from day centres. There are two staff on shift Maybank Residential Care Home DS0000059317.V280217.R01.S.doc Version 5.1 Page 20 at each daytime shift at the weekend and there is always one member of staff on duty to support individuals on their day off from day centres. There is a one waking night staff member. The manager confirmed that extra staff are provided for specific activities. Staff commented that at times the staffing levels were insufficient to meet service users needs, to cover appointments and to enable them to do the cooking and cleaning. This results in staff being expected to work extra hours, which they sometimes get paid for or get time back, which they cannot always take. The manager confirmed that only one staff member was owed time owing of three hours. The manager confirmed that he works Monday to Friday and is available to cover the home as required. The manager advised that the fees are not enough to meet currant costs. The manager confirmed that he has requested an increase in the staffing budget to address this and he hoped to have an increase in staffing from April. The home has one service user vacancy and the staffing levels will need to be increased to reflect the increase in service user numbers and address the issues identified by staff The manager and deputy manager provide back up on call. On one occasion the deputy manager was on shift whilst on call and therefore was unable to get the back up support she required to meet a service users needs. The organisation has senior managers on call who were not contacted on this occasion. The manager must review the current arrangements of staff on shift being expected to provide on call support. The home has two weekly staff meetings and staff are expected to attend a staff meeting at least once a month. Records are maintained of meetings to support this. Three staff files were viewed at this inspection. One staff files contained an application form, health questionnaire, copy of contract, two references, CRB clearance, copy of driving licence, copy of passport and a copy of visa permit. The other two files were for bank staff at the home. Those files contained an application form, one contained a photograph and the other contained a copy of passport, one file contained two references and the other file contained two references one which was addressed to “whom it may concern “and was not specific to that role. Both files contained CRB clearance, but one of those CRB’s on file was carried out by an agency and not the Regard Partnership. The manager confirmed that this individual was already employed by the Regard Partnership in another home and he had a CRB carried out. Record of this must be maintained on the staff file kept at Maybank. In one of the staff files seen the visa had expired on the 31st January 2006. The manager confirmed that the staff member had written to the home office to address this but there was no record on file to support this. Maybank Residential Care Home DS0000059317.V280217.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 &42 The organisation has systems in place to monitor the quality of care and to ensure that standards are being maintained. Some improvements are required to health and safety practices to safeguard service users. EVIDENCE: The organisation carry out monthly monitoring visits and a copy of the outcome of the visit is kept at the home and one sent to the Commission. This is a detailed and thorough report. The organisation carry out six monthly quality audits surveys of all of the care services and feedback is obtained from service users, relatives and professionals. The results of the quality monitoring is made available but they are not specific to Maybank. The manager confirmed that the home carries out an annual internal audit, which is specific to the home and includes feedback from staff. Maybank Residential Care Home DS0000059317.V280217.R01.S.doc Version 5.1 Page 22 The manager confirmed that staff have the required mandatory training and other staff are scheduled to go on updates. The home has COSHH data sheets in place and a second copy of COSHH data sheets are kept in the laundry room where the cleaning materials are stored. The home has records in place to indicate that a fixed lighting check was carried out in September 2005. The report indicates that some areas need action but there is no indication if action was taken to address the shortfalls. This must be clarified. The home has a letter on file to advise that the portable appliance testing was scheduled to take place on the 20th December 2005 but there are no records to indicate if this was carried out. The home has records in place to confirm that a legionella test was carried out. The home has British Gas safety records in place. The home has a series of generic risk assessments in place, which were reviewed and updated in January 2006. The home has a fire risk assessment, which is overdue for review. The manager confirmed that this had been reviewed but he was waiting to be signed off by the health and safety department. The home has accident and incident records in place and the manager is proactive in reporting under regulation 37. The home has fire records in place and the records indicate that a weekly fire point check, emergency lighting monthly check and monthly fire drills take place. The fire drill records do not include the time of the drill and do not indicate the names of staff on duty and service users at home at the time of the drill. The fire drill records should be updated to include this to ensure that the times of fire drills are alternated and that all staff and service users get the opportunity to be present for drills on a regular basis. The home has records in place to confirm that the fire equipment is serviced. The organisation carry out an annual health and safety audit and a report is produced to support this. All work identified from that audit was found to have been completed. Staff at the home carry out a visual health and safety check of all areas of the home and records are maintained to support this. This record indicated some gaps in the recording of water temperatures. The home keeps a record of food, fridge and freezer temperatures. The fridge and freezer temperature records have been updated to include action to be taken if the temperature is above or below safe levels. There were some gaps in the recording of this information. Maybank Residential Care Home DS0000059317.V280217.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 x 2 x 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 x 23 x ENVIRONMENT Standard No Score 24 x 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 2 34 2 35 x 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 x x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 3 16 x 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 x 2 x x x 3 x x 2 x Maybank Residential Care Home DS0000059317.V280217.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA7 Regulation 12 Requirement The manager must ensure that service user plans include confirmation that having the front door locked to ensure the safety of one service user does not restrict other individuals from leaving the home if they choose to. The manager must investigate if service users are being rushed to get bathed, showered and ready for bed and action taken to address such practice. Guidelines must be obtained form the GP on the use of all as required medication and clear instructions must be given as to what as directed means on any prescribed medication. The organisation must ensure that there is sufficient staff on duty at all times to meet service users needs, including back up on call. Staff files must contain evidence of request to home office to renew out of date visas, confirmation of CRB by the Regard Partnership and references specific to the post DS0000059317.V280217.R01.S.doc Timescale for action 31/03/06 2. YA18 12 10/03/06 3. YA20 13 31/03/06 4. YA33 18 10/03/06 5. YA34 19 28/02/06 Maybank Residential Care Home Version 5.1 Page 25 applied for. 6. 7. YA42 YA42 23 23 The manager must ensure that the action required on the fixed lighting report is carried out. A copy of the portable appliance testing report must be kept at the home to confirm that portable appliance tests are up to date. 28/02/06 28/02/06 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. 2. 3. 4. 5. Refer to Standard YA22 YA30 YA30 YA42 YA42 Good Practice Recommendations The organisation should ensure that the manager is clear of how complaints should be acknowledged and responded to. The manager should request a letter from environmental health to support the practice of disposing clinical waste with household waste. The laundry room should be kept clean. The fire drill records should be updated to indicate the time of the drill, the staff on duty and service users in the home at the time of the drill. The manager should ensure that all water temperatures, fridge, freezer and food temperature records are completed. Maybank Residential Care Home DS0000059317.V280217.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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. Extracts may not be used or reproduced without the express permission of CSCI Maybank Residential Care Home DS0000059317.V280217.R01.S.doc Version 5.1 Page 27 - 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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