Inspection on 23/08/07 for Maycroft

This inspection was carried out on 23rd August 2007.

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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Maycroft 25/05/06

Maycroft 25/10/05

Maycroft 26/04/05

Maycroft 03/12/04

Maycroft 04/06/04

Maycroft 11/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Maycroft 791 Alcester Road South Kings Heath Birmingham West Midlands B14 5HG Lead Inspector Kerry Coulter Key Unannounced Inspection 23rd August 2007 09:30 Maycroft DS0000016730.V342629.R01.S.doc Version 5.2 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 Maycroft DS0000016730.V342629.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 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. Maycroft DS0000016730.V342629.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Maycroft Address 791 Alcester Road South Kings Heath Birmingham West Midlands B14 5HG 0121474 5394 0121 474 5394 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) suehullin@tracscare.co.uk Tracscare Group Ltd Elaine Powell Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Maycroft DS0000016730.V342629.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Residents must be aged under 65 years That one named service user over 65 may be accommodated in the home for reasons of old age. That details regarding how the specific care and social needs, of the named person over 65 will be met, must be included in the service users plan. Future admissions and the Statement of Purpose are amended to reflect the age of service users accommodated. 25th May 2006 (Key) Date of last inspection Brief Description of the Service: Maycroft is a dormer style bungalow, located on the main Alcester Road in South Birmingham. The service users accommodation is all located on the ground floor, and comprises of eight single bedrooms, and a communal lounge, dining room, kitchen, assisted bathroom, shower room, and two wcs. A staff office and sleep in room is provided on the first floor. The home has gardens at the front and rear of the premises. Maycroft is well located for local amenities, and transport links. The home has a vehicle to facilitate access into the community. Maycroft accommodates both males and females, who have a learning disability. The service caters for people who display some behaviours that challenge. Previous inspection reports are available in the home’s office for visitors who wish to read them. Maycroft DS0000016730.V342629.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit was carried out over one day; the home did not know the inspector was going to visit. This was the homes key inspection for the inspection year 2007 to 2008. A random short visit also took place in January 2007 to see how the home was progressing towards meeting requirements made at the last key inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home and a questionnaire about the home – Annual Quality Assurance Assessment (AQAA). Two people who live in the home were case tracked this involves establishing individuals experience of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking people’s care helps us understand the experiences of people who use the service. The people who live at the home were spoken to. Due to their learning disability and communication needs it was not always possible to get their views on the home. Three survey forms were received from relatives of people who live at the home, some of their comments are included in this report. What the service does well: The staff are very good at helping people stay in touch with their family. This includes making phone-calls, writing letters and in person. Lots of different activities are offered to people who live at the home. People have lots of fruit and vegetables and get the food they like. The home has a satisfactory complaints procedure that ensures complaints are appropriately investigated. Each person has their own bedroom that is decorated in the way they have chosen. Maycroft DS0000016730.V342629.R01.S.doc Version 5.2 Page 6 Support to people is given in a warm and friendly manner, and staff were seen to be polite, considerate and patient. What has improved since the last inspection? What they could do better: People’s care plans need to be updated when their health needs change and more information on their cultural and religious needs to ensure they get the right support from staff. Try to reduce the number of cancelled activities so that people who live at the home are not disappointed when a planned activity does not take place. Minor improvement is needed to the medication system to ensure people get the medication they need. Staff need to ensure they follow the guidelines from the Speech and Language Therapist and do not give food to people that could cause a high risk of choking. Maycroft DS0000016730.V342629.R01.S.doc Version 5.2 Page 7 The bedroom carpet that is stained should be replaced as soon as possible so that this room is a pleasant place for the person to spend time in. Staff need to have regular training in manual handling so that they know how to safely move people. Some areas of health and safety need to get better so that people who live at the home, staff and visitors are not put at risk of injury. 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. Maycroft DS0000016730.V342629.R01.S.doc Version 5.2 Page 8 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 Maycroft DS0000016730.V342629.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An assessment is undertaken prior to moving in, to ensure the home is able to meet the needs of the individual. EVIDENCE: The home currently has one vacancy but no new people have moved in since the last key inspection. Assessments had been completed on two potential new people and these were seen to be comprehensive. Discussion with staff indicated that one potential person had visited the home last month but that they had decided not to move there. Two files were sampled to check that people living at the home had a copy of their terms and conditions. Both had agreements in place that included details on the fees and these had been signed by the person’s representative. Maycroft DS0000016730.V342629.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning systems are generally satisfactory and provide staff with most of the information they need to effectively meet people’s individual needs. EVIDENCE: The records of two of the people living at the home were looked at. These included an individual care plan that stated how staff are to support the individual with their daily routine, sleeping, diet and nutrition, exercise, their communication needs, the things they like and dislike including activities and leisure interests, the things they need help with and the things they can do on their own. Care plans were generally detailed and had been regularly reviewed but they had not been updated to reflect changing health needs, this is further detailed within the health section of this report. Care plans had a section for people’s religious and cultural needs but these had not been appropriately completed. For one person ‘none known’ had been recorded, this area needs to be Maycroft DS0000016730.V342629.R01.S.doc Version 5.2 Page 11 explored with the person or with the involvement of relatives or people who know the person well. Each person has new individual ‘social dictionaries’ that have been produced to help staff know how the person communicates and how staff can help the individual to communicate their needs and wants. People are consulted about their care and included in their reviews. Staff were observed to consult with people during the visit, for example before the Inspector went into people’s bedrooms staff first checked with the individual for their permission. It is good that regular peoples meetings are held. Issues discussed included activities, holidays and college courses. Tracs also holds an annual ‘focus day’ where people from across all the homes in the area have the opportunity to attend. One person said she goes to these and gets asked her opinions about the home. The risk assessments for two people living at the home were sampled. These were generally satisfactory and had been subject to regular review. Areas of risk that had been assessed included the use of bed rails, fire evacuation, pressure care, behaviour, manual handling and accessing the community. It was initially not clear if a risk assessment had been completed for one person who has swallowing difficulties, an assessment was later found that had been completed by the Speech and Language Therapist. This identified that the person is at risk of choking but the assessment was filed in the correspondence section of the care file. It is advised that this assessment is filed within the risk assessment section to ensure staff are fully aware of the risks. Maycroft DS0000016730.V342629.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements are in place so that people generally experience a meaningful lifestyle. EVIDENCE: People who live at the home are consulted about what activities they would like to do at house meetings and as part of their care reviews. Each person has their own individual activity planner for the week ahead. Records and discussions with staff and one person who lives at the home show that a wide range of activities are on offer. This includes day trips, the library, lunch out, swimming, snoozelum, the pub, walks, shopping, college courses and the cinema. During the visit some people went out for a walk where they fed the ducks and got an ice cream. One person said they had been into Kings Heath which they enjoyed. One relative said ‘supportive in organising and taking my daughter to outdoor activities’. Maycroft DS0000016730.V342629.R01.S.doc Version 5.2 Page 13 Records and discussion with staff show there had been occasion where some activities have not gone ahead due to staffing difficulties. Staff said that during August staffing had been more difficult due to people having annual leave and being off sick. Records show that where an activity has been cancelled an alternative is usually offered. However more thought needs to be given to this. For example, one person had an outing to the pub cancelled and so went on a drive out instead, however the next day the planned outing was also a drive out and this went ahead. Perhaps the pub visit could have been offered the next day instead of a repetitive activity and this would have reduced the disappointment to the person if they knew the activity would be rearranged. There was evidence in care notes and when talking with people that family contact is maintained. This can be in person, by letter and phone. It was positive to hear of one person being supported to visit family who live out of the local area. Food records sampled show that people do not always eat the same meal and get a choice of what to eat. One person who lives at the home said ‘ I get the food I like, it’s a good home’. Staff said that the menus had been recently updated so that the meals were more suited to the summer, they said that the menus were not rigidly stuck to if someone wanted something else. Food records and food stocks showed that people have a good level of vegetables and fruit in their diet. Generally, the meals on offer are of an English cultural type but this does not reflect the background of everyone living at the home. One staff said that one person did not seem that interested in trying foods of their cultural background but said perhaps they could try to find foods they liked. Records of house meetings showed that people would like opportunities to try foods from different cultures, a recent meeting recorded that people would like West Indian food once a month. Whilst records and discussion with staff show that people have a diet that is varied and nutritious for one person their diet does not always follow recommendations made by the Speech and Language Therapist. Sometimes they have been snacks that may put them at risk of choking, this is detailed within the health section of this report. Maycroft DS0000016730.V342629.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Health care records do not always clearly state how individual’s needs are to be met and in some cases this could place them at risk of poor health. Generally people receive their medication safely and as prescribed by the GP. EVIDENCE: Attention had been given to individual’s personal care. The people living there were dressed appropriately to their age, gender, the weather and the activities they were doing. Each person had an individual hairstyle and it was evident that people had their hair cut regularly so that their appearance was well maintained helping to maintain their self - esteem. Care plans stated how individuals are to be supported with their personal care. Manual handling plans were assessed. They had been reviewed on a regular basis and contained a good level of detail. One person has not been able to access the bath as it is broken. This person is unable to access the shower and so has had no choice but to have bed baths from staff, this is not ideal. This is further detailed in the environmental section of this report. Some people who live at the home have had a change in their health needs since the last inspection. One person has been diagnosed with diabetes and Maycroft DS0000016730.V342629.R01.S.doc Version 5.2 Page 15 the other has dysphagia (risk of choking) and nutritional needs due to their low weight. Records show health professionals have been fully consulted about the health care needs of these individuals and two staff spoken with had a satisfactory level of knowledge of people’s needs. It is good that arrangements were made for all staff to receive diabetes training soon after the diagnosis was made. Unfortunately the care plans had not been updated to reflect peoples needs, this puts them at risk of not getting the care they need. It was worrying that one person’s eating plan said they should be offered toast at supper yet their dysphasia assessment said this was a high-risk food. Discussion with staff indicates that this person does not actually like toast and so in practice does not have it. Food records sampled confirmed that toast had not been given but showed that crisps another high-risk food are given regularly. This could put the person at risk of choking and crisps should not be given unless the Speech and Language Therapist confirms it is safe to do so. Since the last key inspection health action plans have been completed in an easy read format that includes pictures, making them easier for people to understand. These are an individual plan about what the person needs to do to stay healthy. Unfortunately these plans had not been updated to reflect people’s changing health needs to include diabetes, nutrition and dysphasia. Records show that people are supported to attend regular health monitoring appointments with the dentist, dietician, weight clinic and diabetic clinic. Monitoring is also undertaken by staff of people who are at risk of constipation. Medication systems are generally satisfactory. Storage of medication is in a locked cabinet. A weekly check of medication is done to ensure the cupboard is clean and medication is within its use by date. Copies of prescriptions are retained so that staff can check the correct medication has been received from the chemist. The home has recently changed the chemist it uses so that the medication is supplied to the home using the monitored dosage system in blister packs. This makes it easier for staff to give the right medication at the right time. Where individuals are prescribed PRN (As required) medication a protocol is in place stating when, why and how this should be given. Medication administration records showed that one person had been given PRN medication for their behaviour frequently during August. Whilst the home kept a record of why it had been given there was no record of if the medication had worked. It is important to track the effectiveness of PRN medication to ensure people are not being given PRN medication that has little effect on them. One person at the home is prescribed cream to be used when their skin is red. Pressure care records indicated that cream had been used several times in August but the medication administration record had not been signed to say it had been used. Maycroft DS0000016730.V342629.R01.S.doc Version 5.2 Page 16 Maycroft DS0000016730.V342629.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at the home know how to make a complaint and that their views will be listened to and acted on. Arrangements are sufficient to ensure that people are protected from abuse, neglect and self-harm. EVIDENCE: The CSCI has not received any complaints regarding this home since the last inspection. The homes complaint log showed that the home had received three complaints. Two were from neighbours and did not relate to the care of people living at the home. One was from a relative about the front gates of the home. The log showed that all three complaints were responded to within Tracs timescales. A complaints procedure is available along with a complaints leaflet. This information is also available in an audiotape format for people who are unable to read. One person who lives at the home said ‘staff listen to me’. Relatives of people who live at the home confirmed they were aware of the complaints procedure. One relative said ‘if I have any concerns they are listened to and dealt with’. The CSCI has been informed of incidents when one person living there has become agitated and has hurt other people living there or the staff. One incident involved one person living at the home being bitten. The Acting Manager informed social services of this under adult protection procedures. Risk assessments are in place so that staff know how to minimise the risk of this happening again as much as possible. The person has behaviour management strategies in place so that staff know how to respond to the Maycroft DS0000016730.V342629.R01.S.doc Version 5.2 Page 18 behaviour that the person displays. Consideration is being given to moving this person from the home, however they have some health issues at the moment and staff said that a final decision would not be made until this person’s health is improved. Following the visit to the home an allegation was made against two members of staff. The home acted appropriately and suspended the staff and ensured that the CSCI and the Social Services were informed to ensure people are protected. Staff training records showed that staff have received training in the Protection of Vulnerable Adults (POVA) so they know how to identify different types of abuse and what to do if abuse is happening so they can protect the people living there. Two staff spoken with were aware of what to do to keep people safe if they had suspicions of abuse happening. Staff spoken with had good understanding about the use of Studio III (physical intervention) and that it is used only as a last resort. A money handling assessment is completed for each person to see what support they need from staff. Monies are checked daily by staff. The finance records of one of the people living there were checked. They had been supported to spend their money on personal items and on the things they chose to buy. Receipts were kept of all purchases. Each person had an inventory of their belongings so it is clear what belongs to them and if anything should go missing it can be tracked easier and hopefully found. Maycroft DS0000016730.V342629.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People live in a homely, comfortable, safe and clean environment that generally meets their individual needs. EVIDENCE: Since the last key inspection a lot of work has been done to improve the premises for the benefit of the people living there. Work to the front driveway and walls has been completed. This area is now safer and provides better security to the home. Additional parking is also available. New settees were in the lounge, one person spoken with at the random visit said they were really nice and comfortable. One person now has a new ensuite bathroom, this meets their needs as they like to have frequent baths throughout the day. Work has also been done to widen some of the doors in the home to make it easier for staff to manoeuvre one person in his wheelchair round the home. A new carpet has been fitted in the hallway, this makes this area look cleaner and more welcoming. Maycroft DS0000016730.V342629.R01.S.doc Version 5.2 Page 20 Each person has their own bedroom, which is well decorated and furnished to the individuals’ tastes and interests. One person commented that they had everything they needed in their bedroom. One person’s bedroom carpet was very stained. An audit of the home in March recorded this carpet needed replacement. Records show that quotes for a new carpet are being obtained, senior managers said there is money allocated for this and the carpet will be fitted within four weeks. This needs to be done as it is over five months since it was established a new one is needed. Communal rooms were observed to be in good decorative order and were homely in style. At the time of the visit the assisted bath was not in working order. Staff said this meant that one person was having to have bed baths as they could not use the shower. Records showed that engineers had been out to repair the bath but it had broken the next day. When engineers came back to the home they said they had to order a part. Discussion with staff and records indicate that Tracs see it as a high priority to make sure the bath is quickly repaired. Following the visit a telephone call with a senior Tracs manager indicated the bath was still not repaired as the part that had been ordered was the wrong part. This means it is several months since one person at the home has been able to bath and this is not acceptable. The home must take action to ensure the speedy repair of the bath. Satisfactory infection control procedures are in place. The laundry is sited away from the kitchen and dining room. Hand washing facilities are available with liquid soap and hand dryers. The home was observed to be clean. A recent Environmental Health Officer report said there were generally satisfactory standards of hygiene in the home. Maycroft DS0000016730.V342629.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at the home benefit from a generally well trained and supported staff team that can support them to meet their individual needs and achieve their goals. People are protected by the home’s recruitment practices. EVIDENCE: Support to people who live at the home is given in a warm and friendly manner, and staff were seen to be polite, considerate and patient. Approximately 50 of staff have achieved an NVQ in care so they have the skills and knowledge to meet the needs of the people living there. Staff rota’s were sampled and these show that usually there are at least five staff on duty during the day, this appears to be sufficient to meet people’s needs. One staff said that staffing the home during August had sometimes been difficult due to staff annual leave and sickness. The rota showed that during this time the home had not had to use agency staff but had used staff from their other homes to cover the deficit. It was not possible to sample staff recruitment records during the visit, the Operations Director said the Acting Manager, who was on annual leave had the Maycroft DS0000016730.V342629.R01.S.doc Version 5.2 Page 22 key. Following the visit evidence was sent to the CSCI to show that Tracs had followed robust recruitment procedures for two recently recruited staff. Staff records sampled showed that new staff had completed an induction when they first started working at the home. This ensures they know about the home and how they are to support the people who live there to meet their needs and achieve their goals. However one staff had transferred to Maycroft from another Tracs home, there was no record to show that any induction to the home had been completed. Staff training records were sampled. These showed that staff generally receive regular training. Some of this is done in house by watching videos and completing workbooks. Staff have received training that includes studio III (physical intervention), food hygiene, fire, first aid, medication, infection control and the protection of vulnerable adults. Since the key inspection staff have received training specific to people’s individual needs that includes makaton (a form of sign language) and diabetes. As one person has recently been diagnosed with dysphagia consideration should be given to arranging training on this for staff. One person at the home uses a wheelchair and relies on staff for moving around the home. Records showed that only twelve of the nineteen staff had done manual handling training. Some who had done the training had not had a refresher for two years, it is recommended this should be done annually. The Operations Manager said that this training had been scheduled for November. Records and discussion with staff show that staff receive regular supervision and staff meetings are usually held monthly so that staff are kept up-to-date with the running of the home and organisation and the changing needs of the people who live there. Maycroft DS0000016730.V342629.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The views of people who live at the home underpin all self-monitoring, review and development of the home. People’s health and safety is generally promoted and protected. EVIDENCE: Since the last key inspection the Manager of the home has been successful in becoming registered with the CSCI. The Manager has completed the Registered Managers Award and is now completing an NVQ 4 in care. At the time of this visit the Manager was on maternity leave but was due to return to work soon. In the absence of the Manager the home has had an acting manager in place who has management experience, qualifications and previous experience of working at the home. Systems to ensure quality are in place, these include the views of people who live at the home, staff and others. Monthly visits to the home are made by a Maycroft DS0000016730.V342629.R01.S.doc Version 5.2 Page 24 Manager who completes a report. Audits are carried out periodically to include health and safety, financial and an audit called ‘first impressions’. Where improvements needed are identified a ‘corrective action plan’ is formulated. One relative said ‘happiness and wellbeing of all the residents is always at the forefront’. The West Midlands Fire Service said in April 2007 that fire precautions in the home were satisfactory. Fire records showed that staff regularly test the fire equipment to make sure it is working. Unfortunately the test was overdue at the time of this visit, records showed this was unusual and so it may have been due to the acting manager being on annual leave. The Operations Manager ensured a fire test was done that day. Staff had received regular training in fire safety. Regular fire drills are held so that staff and the people living there would know what to do if there was a fire. An engineer had tested the fire system in July to make sure it was in good working order. A fire risk assessment was completed by an external consultant in May 2007 and this identified that the home did not have an up to date certificate available for the electrical hard wiring of the home. A health and safety audit completed by a Tracs Manager in July also recorded a certificate was not available. It was therefore disappointing that despite being highlighted on two earlier occasions on the day of this inspection visit a report that covered the premises was still not available to show electrical installations were safe. Certificates were available to show that equipment such as the hoists are regularly serviced to make sure they are safe for people to use. Staff test the water temperatures weekly to make sure they are not too hot or cold. When they were recorded as being higher than they should be to ensure people do not get scalded this was reported and action taken to reduce the temperature. Staff test the fridge and freezer temperatures daily and records showed that these were within the limits for safe food storage. As stated earlier in this report the home has had new gates fitted to the driveway. A risk assessment completed in May records that the gates must be kept shut at all times due to the danger to people living in the home from the busy road. On arrival at the home the gates were observed to be open and remained open for a couple of hours until brought to the attention of staff. Staff meeting minutes from June and July show that staff had been reminded to keep the gates shut. The home has received a complaint from a relative of someone who lives at the home about the gates. The relative feels it is dangerous to park on the road whilst having to open the gates. The risk assessment sampled did not evaluate this risk. The Operations Manager said that as a result of the complaint it had been agreed to change the way the gates opened so that it was not necessary to park on the road. The Operations Manager said that quotes for the work had been obtained but acknowledged it had been some months since they had been obtained and agreed to chase up this work. Maycroft DS0000016730.V342629.R01.S.doc Version 5.2 Page 25 Maycroft DS0000016730.V342629.R01.S.doc Version 5.2 Page 26 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 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 2 27 2 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 X 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 3 X 3 X X 2 X Maycroft DS0000016730.V342629.R01.S.doc Version 5.2 Page 27 NO Are there any outstanding requirements from the last inspection? 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 YA6 Regulation 15 Requirement Ensure care plans reflect people’s changing health needs (such as dysphasia and diabetes) to ensure they get the care they need to stay healthy. Ensure that where people are assessed as having dysphasia foods that are assessed as high risk are avoided to reduce the risk of the person choking. When cream prescribed ‘as required’ are administered by staff the medication administration record must be signed to show people have the medication they need. The bath must be repaired to ensure the personal care needs of people who are unable to access the shower are met. Ensure that control measures detailed within risk assessments are followed to ensure people are not put at risk. DS0000016730.V342629.R01.S.doc Timescale for action 30/10/07 2 YA19 12 (1) 30/09/07 3 YA20 13 (2) 30/09/07 4 YA27 23(2) 02/10/07 5 YA42 13(4) 30/10/07 Maycroft Version 5.2 Page 28 6 YA42 13(4) An up to date certificate to show the electrical installations in the home are safe must be available. A copy must be sent to the CSCI. 30/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA6 YA6 YA12 Good Practice Recommendations Care plans should be updated when people’s needs change so that staff have up to date information on how to meet individual needs. People’s cultural and religious needs should be further detailed within their care plan. Make arrangements to ensure staffing difficulties do not impact on people’s planned activities, where activities are unavoidably cancelled they should be rearranged as soon as possible to avoid disappointment to the person. Review the menu to ensure people are offered culturally appropriate meals. Where ‘as required’ medication is used to manage behaviour its administration should be monitored to ensure it is effective and people are not having excess medication with little or no benefit. The bedroom carpet that is stained should be replaced as soon as possible so that this room is a pleasant place for the person to spend time in. Staff should receive manual handling training on an annual basis so that staff know how to move people safely. Consideration should be given to arranging training for staff on dysphagia so that they have a better knowledge on meeting individual needs. Change the direction of the way the front driveway gates open so that staff and visitors to the home do not have to park on the busy road whilst opening the gates. 4 5 YA17 YA20 6 7 8 9 YA26 YA35 YA35 YA42 Maycroft DS0000016730.V342629.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Maycroft DS0000016730.V342629.R01.S.doc Version 5.2 Page 30 - 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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