Inspection on 25/05/06 for Maycroft

This inspection was carried out on 25th May 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 18 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Maycroft 23/08/07

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 Unannounced Inspection 25th May 2006 09:05 Maycroft DS0000016730.V289921.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 Maycroft DS0000016730.V289921.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. Maycroft DS0000016730.V289921.R01.S.doc Version 5.1 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) TRACS Vacant Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Maycroft DS0000016730.V289921.R01.S.doc Version 5.1 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 October 2005 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 three 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. The providers are aware that the physical layout and size of rooms at Maycroft does not meet National Minimum Standards. Plans to improve upon this have been explored within the organisation and the CSCI. Maycroft is well located for local amenities, and transport links. The home has a vehicle to facilitate access into the community. Maycroft accommodates both male and female service users, who have a learning disability or acquired brain injury. The service currently caters for some people who may display some behaviour’s that challenge. The home is currently without a registered manager. Maycroft DS0000016730.V289921.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the field work visit taking place a range of information was gathered to include notifications received from the home and reports from the provider. The unannounced fieldwork visit was carried out over seven and a half hours. This was the homes first key inspection for the inspection year 2006 to 2007. Conversations with some service users were limited due to their complex needs and limited verbal communication. The inspectors met with two service users and time was spent observing care practices, interactions and support from staff. A tour of the premises took place. Care, staff and health and safety records were looked at. The inspectors extend their thanks to everyone who helped with this inspection. What the service does well: Staff had undertaken some good pre-meeting work with service users in preparation for their review meetings. The staff are very good at helping people stay in touch with their family. This includes making phone-calls, writing letters and in person. The home has a satisfactory complaints procedure that ensures complaints are appropriately investigated. The appropriate recruitment checks are undertaken on new staff. Service user bedrooms were observed to be personalised. One service user commented that he had everything he needed in his room. Support to service users is given in a warm and friendly manner, and staff were seen to be polite, considerate and patient. Service user feedback on the service is sought on an annual basis. Maycroft DS0000016730.V289921.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Care plans must set out in detail the care required to be carried out by staff to ensure all aspects of the health, personal and social care needs of service users are being met. Risk assessments must be consistent with information in the care plan to ensure service users are supported safely and appropriately by staff. Maycroft DS0000016730.V289921.R01.S.doc Version 5.1 Page 7 Records of food provided to service users must be improved so that there are no gaps and to show that service users are offered a healthy and balanced diet. All service users with a Learning Disability must be supported to obtain a Health action plan. Minor improvement is needed to the medication administration system to ensure service users get the medication they need. The manager must ensure staff get all the training and support they need to do their job and to support the people who live in the home. Work needs to continue to ensure the home meets the needs of the service users in terms of its design and available space. Removal of, or effective odour management must be achieved in all areas of the home so that it is a pleasant place for service users to live. Service users health and safety is not always promoted and protected. 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. Maycroft DS0000016730.V289921.R01.S.doc Version 5.1 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.V289921.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 and 5 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. TRACS offers potential service users and other people important to them a chance to visit the home prior to moving in. A full assessment is undertaken. EVIDENCE: The home was observed to have copies of the service user guide and statement of purpose available. These are comprehensive documents. Information recorded in the documents indicates that an audio tape version is available to make the information more easily available to some service users. The work undertaken with one service user prior to admission to the home was tracked. Records showed that the service user and their family had been enabled to visit the home and “Test-drive” it, prior to deciding to move in. A comprehensive assessment had been undertaken. A letter from the service users relative expressed their gratitude to the staff at the home and said that in a few short weeks the service user had become happy and motivated. The contract with one service user was sampled. This included details on the room allocated and terms and conditions but had not been signed by the service user or their representative. Maycroft DS0000016730.V289921.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 and 10 The quality outcome in this 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 support service users in a manner that meets individual needs. EVIDENCE: The care plans for three service users were sampled. Plans were generally individualised, satisfactory and up to date. The key-worker for each service user completes a monthly care plan review sheet that details areas of significance the previous month. One care plan was observed to require some improvement to detail the support the individual required if they had a seizure. Information regarding their religious and cultural needs also need to be added as this section had been left blank in the care plan. The food records for one service user recorded that they often refused a meal. The care plan needs further development to guide staff on how to encourage this individual to maintain a healthy diet. Maycroft DS0000016730.V289921.R01.S.doc Version 5.1 Page 11 One service user had recently had a IPP review meeting. The home had undertaken some good pre-meeting work with the service users in preparation for the review. The outcome of the review was available in an easy to read format that include pictures. It is good that regular service user meetings are held. Issues discussed included activities that they would like to attend. One service at a recent meeting had requested that he would like to decorate the home for the football World Cup. The date to achieve this action had been recorded as August, unfortunately the World Cup will be finished by then. Service user risk assessments were sampled. These were generally satisfactory and had been subject to regular review. One service user had a night time care plan that directed staff to complete an audio check on them three times during the night. However a risk assessment for epilepsy recorded that it had been agreed that observations were now not required. The risk assessment needs to be updated to direct staff to complete audio checks in line with the care plan. Staff interactions with service users were positive and inclusive. No breaches of confidential information were noted. Maycroft DS0000016730.V289921.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 and 17 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place so that service users experience a meaningful lifestyle. EVIDENCE: Service users identify at their reviews the activities they would like to try and continue. At the last inspection the Inspectors read entries in daily notes that activities had not gone ahead as there was ”No driver” or a “Staff shortage”. How this was audited and the service developed to meet these shortfalls was an outstanding requirement. A system to audit the activities undertaken by service users has now been introduced. The key workers complete a list on a monthly basis of all the activities undertaken, when these have not taken place these are also recorded. It was noticeable that frequently swimming activities which some service users enjoy did not take place. One record showed it did not occur as staff could not go but did not give the reason why. Maycroft DS0000016730.V289921.R01.S.doc Version 5.1 Page 13 Another entry recorded it did not occur as staff had not got their swimming costumes. The manager said this issue had been discussed at the recent staff meeting and that some staff now kept their swimming costume at the home to ensure that this activity is undertaken. Records show a variety of activities are undertaken to include making festive cards, pub lunches, shopping, walks and picnics. The manager said that a weekly snoozlum session has recently been arranged for service users and would commence once all the necessary risk assessments had been completed. The manager felt that the arrangements for activities had improved since a member of staff had been designated the lead role in arranging activities. She felt this contributed towards better planning of the activities and resources needed. Activities were being undertaken during the visit. One service user was cleaning his room, one was playing with musical toys and another sat with staff looking at photographs from a recent day trip. Other service users were out. There was evidence in care notes and when talking with service users that family contact is maintained. This can be in person, by letter and phone. It was positive to hear of service users being supported to visit family who live out of the local area. A short term goal for one service user was to send a letter and photographs to their Father, this had been done with the support of staff. Food supplies were observed to be satisfactory. The record of food eaten evidenced that choices are given and service users all have different meals, to suit their taste. The variety of choices available has been improved since the last inspection. However the records did contain some gaps where no meal had been recorded pie and chips had also been given to service users on two consecutive days. Maycroft DS0000016730.V289921.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Service users undertake personal hygiene to a good standard, and are supported by staff in a sensitive and timely way. The health needs of service users are generally met with evidence of good multi-disciplinary working taking place on a regular basis, progress towards completing health action plans is evident. Generally the medication administration system is satisfactory with only minor improvements needed to meet the standard. EVIDENCE: Service users files sampled contained a detailed plan of care regarding the morning and evening routine. Service users all appeared well dressed and presented. During the inspection personal care was offered sensitively as required by the individual. Work is planned to the premises to provide one service user with their own en-suite bathroom as they have a preference for frequent baths. Manual handling plans were assessed. They had been reviewed on a regular basis and contained adequate detail. Maycroft DS0000016730.V289921.R01.S.doc Version 5.1 Page 15 Major shortfalls were identified at the last inspection in how service users physical and emotional health needs are met, it is positive that some improvements in this area have taken place. Service users previously did not have a Health Action Plan (The Government white paper Valuing People said that everyone with a learning disability should have one). Work is now underway to complete these. One was completed but was observed not to cover all areas but will be a good starting point for further development. Previously weight of service users had not been consistently recorded. Sampled records showed an improvement and weight was recorded on a regular basis. The last inspection did not show that referrals were always made to health professionals when identified as needed. Records for one individual identified they needed input from the Speech and Language Therapist and the Physiotherapist. Referrals for input had been made. The plan of care for one service user with epilepsy was tracked. There was no plan that informed staff about how to support the service user and when to seek further assistance. The manager said that as this service user was quite new to the home this had not yet been done. The service manager agreed to ensure this was completed. A copy of a completed plan was forwarded to the CSCI a few days after the inspection visit, this was adequate. Medication management was sampled. The location of the medication storage has recently changed due to the home undergoing refurbishment. The new location did not have adequate lighting as a small lamp was the only working light source. This will need to be improved upon to ensure staff can clearly read the medication administration records. Discussion with staff indicates that they do not administer medication until they have received training. The ‘as required’ medication protocols were sampled for four service users. These were observed to be satisfactory with the exception of one which had not been dated. The detail of the protocols have improved since the last inspection. Generally the medication administration records had been appropriately completed. However for one service user their was a gap on their record for the evening before the fieldwork visit. Staff said that the service user had refused their medication, this must be recorded on the mediation record. Some topical creams were stored in the medication fridge. Unfortunately the last recorded fridge temperature had been done on 18th May. This must be done daily to ensure the fridge is maintained at a safe temperature. Maycroft DS0000016730.V289921.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): 22 and 23 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. TRACS investigates complaints in a robust way. A record of the investigation and outcome is maintained. Arrangements for training staff in the protection of service users requires review. EVIDENCE: The CSCI has not received any complaints regarding this home since the last inspection. The home’s own complaints log and discussion with the manager indicate that the home has not received any complaints. Evidence from the last inspection shows that when complaints are received these are investigated and resolved by Tracs. A complaints procedure is available along with a complaints leaflet. This information is also available in an audio tape format for service users who are unable to read. It has previously been required that the operation of the home be reviewed and developed to reduce the risk of service users being placed at risk of physical or psychological harm. Notifications received from the home, discussions with staff and sampling of records indicate that incidents have now reduced. One staff said this may be partly due to a change in the service user group. Adult Protection training is provided on a cyclical basis. This training is done via a video and booklet. The manager said that for senior staff the duration of the training is half a day but is one hour for support staff. A period of one hour is a very short time to cover the important topic of adult protection and prevention of abuse. Maycroft DS0000016730.V289921.R01.S.doc Version 5.1 Page 17 Tracs must review this training to ensure it is adequate for staff and enables them to recognise potential abuse and respond appropriately to protect service users. The previous inspection report required that the recording of the use of physical intervention needed improvement. Records and discussion with the manager indicate that no incidents requiring the use of physical intervention have occurred since the home received the report. The manager has however introduced an incident book for the recording of any future occurrences. Sampling of staff records indicates that Criminal Record Bureau checks are undertaken for new staff. The financial records of one service user were sampled. These were satisfactory, receipts were available for all expenditure. Regular financial audits of service users monies are also undertaken. Inventories of property belonging to service users had been completed. However entries on one inventory were not regular. It is recommended that the frequency of checking against the inventory is improved. This will improve the safeguards in place for the protection of service users property. Maycroft DS0000016730.V289921.R01.S.doc Version 5.1 Page 18 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): 24, 26, 27 and 30 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Building and redecoration work has made Maycroft a more pleasant environment in which to live and work. The premises have severe spatial shortfalls for the number of people accommodated, and this compromises the care afforded to people who use a wheelchair. EVIDENCE: Tracs has undertaken a great deal of work to improve the premises for the benefit of the service users. Some of this work has still to be completed. It is intended that one service user will be provided with his own en-suite bathroom. Work is soon to commence to improve the front drive way of the home, the front wall is to be removed and new gates installed. Tracs hope this will improve the parking facilities and security of the premises. Service user bedrooms were observed to be personalised and generally well maintained. One service user commented that he had everything he needed in his room. Staff said that the bedroom of the service user recently admitted to the home was soon going to be redecorated according to her individual preferences. Maycroft DS0000016730.V289921.R01.S.doc Version 5.1 Page 19 An offensive odour was noted in one bedroom. Staff said they felt this was coming form the carpet and arrangements had already been made for a carpet company to visit the following week. Bathing equipment has been reviewed as required since the last inspection. A new changing table has been installed in the shower room and a new bath more suitable to service user needs was being fitted the following week. It was noticed that the bathrooms were quite small. Staff spoken with confirmed that space limitations sometimes made it awkward to manoeuvre when using with service users who use a wheelchair. Maycroft DS0000016730.V289921.R01.S.doc Version 5.1 Page 20 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, 35 and 36 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. The staff team is committed and motivated to support the service users. Evidence that staff are provided with training at the required frequency and level, or supervised as often as required was not available. EVIDENCE: It was noted that both staff and service users appear comfortable in each other’s company and enjoy a good general rapport. Support to service users is given in a warm and friendly manner, and staff were seen to be polite, considerate and patient. Seven staff have completed an NVQ in care, this falls just short of the standard of having 50 staff trained. However there are several staff who are very near to completing their NVQ and so it is anticipated this standard will soon be met. Rotas show that a minimum of five staff are on duty during the day. Discussion with the manager indicates that the home has 23 vacant staff hours. Observation of the rota shows that the home has not had to use agency staff to cover this shortfall. Maycroft DS0000016730.V289921.R01.S.doc Version 5.1 Page 21 Staff files were sampled. These contained all the required information to show that a robust recruitment process had been followed. 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. As detailed earlier in this report it is not evident that the level of training in adult protection is satisfactory due to its short duration. The training matrix did not show that all staff had completed all mandatory training, some staff needed food hygiene and manual handling training. The majority of staff have done first aid and Studio III. The manager said that there was a more up to date matrix but that is held by the training coordinator and she did not have a copy. This needs to be available in the home to evidence that staff have received all the training they need. Evidence was seen that staff are currently learning about autism, using workbooks. The quality of supervision was good. Records showed the meetings were supportive and developmental. The frequency of these fell just short of the National Minimum Standards for two staff but was satisfactory for two staff who were new to the home. Staff meetings are held on a regular basis, the agenda is available for staff to contribute to. Minutes of the meetings are available for staff. Maycroft DS0000016730.V289921.R01.S.doc Version 5.1 Page 22 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): 37, 39, 41 and 42 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. The manager has applied for registration. Adequate arrangements are in place to ensure that service users views underpin development by the home. Health and safety is generally well maintained. Minor improvements are required. EVIDENCE: The home has a manager in post who has applied for registration with the CSCI. She does not hold a relevant care qualification but is currently undertaking the Registered Managers Award. Tracs are providing opportunities for the manager to be mentored by more experienced staff. Systems are in place to assure quality. This includes monthly visits to the home by a service manager who completes a report. Maycroft DS0000016730.V289921.R01.S.doc Version 5.1 Page 23 Audits are carried out periodically to include health and safety, financial and an audit called ‘first impressions’. Service user feedback on the service is also sought on an annual basis. The last inspection identified that record keeping required improvement. Both the quality of records made, and the storage of records needed attending to. Records were observed to be improved with service user records generally well maintained. It is however recommended that some of the health and safety records are reorganised to archive historical information. For example in the fire file there were three fire risk assessments and lots of old service certificates. It is recommended that the home has one file for current information with old certificates archived. This would make it easier for both staff and CSCI inspectors to locate required information speedily. The staff rota was observed to require improvement as this record did not include the full names of staff. Environmental Health Officers visited the home in September 2005. The report was very positive. Testing and service of fire, electrical and gas appliances and systems were evident. As required at the last inspection records of the fire drill list the participants to ensure staff undertake this twice yearly. Staff were undertaking in-house fire training during the inspection visit. Records of water temperatures are maintained. Some records showed that the water was either too hot or too low but there was no record about what had been done to address this. Records showed that fridge temperatures were running high, the manager said that a new fridge had been ordered and was being delivered in three days time. Maycroft DS0000016730.V289921.R01.S.doc Version 5.1 Page 24 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 3 2 3 3 X 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 2 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 1 X 3 X 2 2 X Maycroft DS0000016730.V289921.R01.S.doc Version 5.1 Page 25 YES 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 YA5 Regulation 5(1) Requirement Service user contracts should be signed by the service user or their representative or a record made of why this has not been possible. Care plans must set out in detail the care required to be carried out by staff to ensure all aspects of the health, personal and social care needs of service users are being met. Ensure actions agreed with service users are achieved within acceptable timescales. Risk assessments and care documents must contain consistent and current information. Outstanding requirement from 01/01/06 Records of food provided to service users must be improved so that there are no gaps. The manager must ensure DS0000016730.V289921.R01.S.doc Timescale for action 30/08/06 2. YA6 12(1) 15(2) 30/07/06 3. YA7 12(1) 30/06/06 4. YA9 13(4,a-c) 30/06/06 5. YA17 16(2)(i) 30/06/06 Maycroft Version 5.1 Page 26 6. YA19 12(1)(a) 7. YA20 13(2) 8. YA35YA23 13(6) 18(1)(c) YA24YA27 23(1,a-b) 9. that service users are not given the same meal on consecutive days unless that is clearly recorded as their personal choice. All service users with a Learning Disability must be supported to obtain a Health action plan. Outstanding previous requirement from 01/03/06. Medication: Ensure all written protocols for the administration of ‘as required’ medication are dated. Ensure the temperature of the fridge is monitored on a daily basis. The registered provider must review the duration of the adult protection training provided to staff. Previous requirement. The environment must be reviewed and work undertaken to enable it to better meet the needs of service users developed. Work in progress. 30/07/06 30/06/06 30/07/06 30/09/06 10. YA24 23(2,b) Previous requirement. The front walls and driveway must be made safe and repaired. Work scheduled to take place. 30/07/06 11. YA30 16(2)(j)(k) Removal of, or effective odour management must be achieved in all areas of the home. DS0000016730.V289921.R01.S.doc 30/06/06 Maycroft Version 5.1 Page 27 Previous requirement. 12. YA35 18(1)(a)(c)(i) Records of training must be auditable and evidence training has been undertaken to the required standard. Previous requirement. Staff must receive documented supervision sessions, at least six times per year. Previous requirement from 01/02/06 Ensure the staff rota records the full names of staff. A review of the way in which service users who utilise wheelchairs are supported to mobilise around the home must be undertaken, to ensure their welfare and safety. Doorway widths must be reviewed, and action as identified undertaken. Previous requirement from 01/12/05. 16. YA42 13(4) Water temperatures must 30/06/06 be maintained at a safe and comfortable temperature for service users, not exceeding 43°C. 30/07/06 13. YA36 18(2) 30/07/06 14. 15. YA41 YA42 17 13(4,a-c)13(5) 30/07/06 30/07/06 Maycroft DS0000016730.V289921.R01.S.doc Version 5.1 Page 28 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. Refer to Standard YA41 YA23 Good Practice Recommendations It is recommended that further work is done on the homes administration system to better organise files and archive historical information. It is recommended that the frequency of checking against the service user inventory is improved. This will improve the safeguards in place for the protection of service users property. Maycroft DS0000016730.V289921.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Maycroft DS0000016730.V289921.R01.S.doc Version 5.1 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. 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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