Inspection on 25/10/05 for Maycroft

This inspection was carried out on 25th October 2005.

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

Other inspections for this house

Maycroft 23/08/07

Maycroft 25/05/06

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 Alison Ridge Unannounced Inspection 25th October 2005 09:20 Maycroft DS0000016730.V260956.R02.S.doc Version 5.0 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.V260956.R02.S.doc Version 5.0 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.V260956.R02.S.doc Version 5.0 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.V260956.R02.S.doc Version 5.0 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. 24/04/05 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. 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 caters for people who display some behaviour’s that challenge. The home is currently without a registered manager. Maycroft DS0000016730.V260956.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors undertook this unannounced visit over one day. Information in the report was collected by talking with people who live in the home, and some of the staff on duty. The deputy home manager and senior carer also provided some information. Inspectors looked at all the shared areas of the home, and in some people’s bedrooms. Records about care, staffing and health and safety were also used. The inspectors raised concern with TRACS regarding large number of requirements that remain outstanding from previous inspections. The inspectors extend their thanks to everyone who helped with this inspection. What the service does well: What has improved since the last inspection? What they could do better: The manager must ensure that people admitted to the home fit into the homes category and conditions of registration. The manager must ensure assessment information is kept up to date. Plans of care need to be kept up to date when peoples needs change. The staff and manager need to show that the person is involved in their individual plan. Maycroft DS0000016730.V260956.R02.S.doc Version 5.0 Page 6 When someone identifies something they would like to do, staff must show how they are going to help the person achieve it. The inspectors raised lots of concerns about healthcare and how people are supported with staying healthy. There is a lot of work to do, to get better in this area. Some people who live at Maycroft have challenging behaviour. The way this is planned and recorded must get better. Other people who live in the home must be kept safe when challenging behaviour occurs. 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. The manager must apply to the CSCI for registration. Records on the use of physical intervention require improvement to ensure they meet current good practice guidelines. The home must also ensure they inform the CSCI of any incident where physical intervention has been used. 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.V260956.R02.S.doc Version 5.0 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 Maycroft DS0000016730.V260956.R02.S.doc Version 5.0 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): 2, 4 TRACS offers potential service users and other people important to them a chance to visit the home prior to moving in. An assessment is undertaken. The information collected is not kept up to date, or used to make preparations for the service users admission to the home. EVIDENCE: The work undertaken with one service user prior to admission to the home was tracked. Records showed that the service user, their family and existing carers had been enabled to visit the home and “Test-drive” it, prior to deciding to move in. A comprehensive assessment had been undertaken. This was dated some six months before the service user moved into the home. Good practice would be to evidence that this had been reviewed, and changes in the intervening period taken into account. The pre-admission assessment identified that staff required training in the specific needs of the new service user. Inspectors were informed in the providers action plan that information had been obtained and circulated amongst the staff team. Further training is planned in 2006. Maycroft DS0000016730.V260956.R02.S.doc Version 5.0 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, 8, 9, 10 Care documents do not consistently show service users involvement, timely review or how all service users needs are to be met. Information is stored and transmitted in a sensitive, confidential way. EVIDENCE: The complete plan of two service users and parts of a further two plans were assessed. A current photo of the service user was required on one file. One plan sampled show a recent IPP review had been held. The home has previously been complimented on the pre-meeting work undertaken with service users in preparation for the review. It was not evident this had been undertaken. It was positive that the service user attended the review, but minutes showed no involvement or consultation by him. The minutes of the IPP showed the goals set in the meeting. It was not evident how these had been agreed on, as they were not relevant to the meeting minutes. The provider informed the CSCI in their action plan of the difficulties experienced consulting with this service user. Maycroft DS0000016730.V260956.R02.S.doc Version 5.0 Page 10 The minutes evidenced consultation with an Occupational Therapist two months prior to the meeting. Evidence that the recommendations of that assessment had been implemented were not available. Some of the service users accommodated have changing needs. It was not evident that their plan had been reviewed in response to this, and goals reviewed or new ones set. Regular service user meetings had been held. It was not always evident that the ideas from the meeting had been actionned. It is recommended that ways of presenting the agenda and minutes in a format accessible to the service users be explored. Service users were observed, and they reported being able to participate in the running of the home. One person reported how they like undertaking their job of testing and recording the fridge/freezer temperatures. Risk assessments were overdue for review, but this had been booked for the day of inspection. Reviews must better evidence how the review has been undertaken, examples of “No change” being recorded were frequent, this doesn’t evident how the review took place, or the documents/events considered. Risk assessments must be reviewed periodically, but also as needs change. An example of one-service users changing needs that had not resulted in the development of the risk assessment was identified and shared with staff. Some basic risk assessments had been developed for a person recently admitted to the home. These had not been signed or reviewed since admission. A document was available admitting this person had been unable to participate in fire training, and that a risk assessment was required. This hadn’t been developed. Staff interactions with service users were positive and inclusive. No breaches of confidential information were noted. Maycroft DS0000016730.V260956.R02.S.doc Version 5.0 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): 11, 12, 13, 14, 15, 17 Service users are offered opportunity to access the community, and undertake developmental activities. This is not always the activity chosen or requested by the person, due to shortfalls in the service. Service users are supported to maintain contact with their family and friends. Service users are offered a wide range of food, but the choice available at each meal is limited. EVIDENCE: Service users identify at their reviews the activities they would like to try and continue. In some instances it was clear these wishes had been translated onto the activity planner, and work towards the goal was being achieved. It was not evident activities are reviewed as needs change. Examples of one service user (who’s needs had changed) being scheduled to iron and clean skirting boards were identified. Inspectors could not see how this person would be able or safe to undertake these activities. Staff and service users commented that planned activities do not always go ahead, as they are dependent on staffing levels and drivers. Maycroft DS0000016730.V260956.R02.S.doc Version 5.0 Page 12 The inspectors read entries in daily notes that activities had not gone ahead as there was ”No driver” or a “Staff shortage”. How this is audited and the service developed to meet these shortfalls is an outstanding requirement. The frequency of community activities achieved with one service user was very positive (Twelve days out of fourteen) Some entries read, “Drive out” but did not state where, or why the planned activity to a pub had not gone ahead as planned. The purpose of the activities was not clear, and the staff must support the service user with life planning to establish what they hope to achieve, and how this can be worked towards. 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. Staff and service users identified a weak point in the planning and preparing of food. It was identified that this is no-ones favourite job and that it is a big task. Service users comments about food included, “It’s alright” and “We have a lot of food that helps us stay healthy.” One service user said, “We always get a choice of two things at lunch and tea” Inspectors were informed that the home has purchased some new recipe books, and that an activity of looking at these and choosing new foods has commenced. The inspectors commented that the choice of foods on the menu was limited, for example you could have vegetable curry or prawn curry, lasagne or spaghetti bolognaise, lemon chicken or southern fried chicken. These are not varied choices. There was a good stock of fresh fruit and vegetables. The record of food eaten evidenced that choices are given and service users all have different meals, to suit their taste. Maycroft DS0000016730.V260956.R02.S.doc Version 5.0 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, 19, 20 Service users undertake personal hygiene to a good standard, and are supported by staff in a sensitive and timely way. Service users healthcare needs are not well planned for or met. This must improve to ensure service users safety and welfare. Medication is generally well managed. EVIDENCE: Service users files sampled contained a detailed plan of care regarding the morning and evening routine. Some guidelines were not dated, and inspectors could not establish if they were current. Service users all appeared well dressed and presented. During the inspection personal care was offered sensitively as required by the individual. The staff record health appointments on an Other Medical Details (OMD) sheet. These were not all complete for example an admission in to hospital had been recorded but no discharge. The record detailed regular chiropody appointments and flu jabs for all the people sampled. It was not evident all service users had seen the optician or dentist as they required. Maycroft DS0000016730.V260956.R02.S.doc Version 5.0 Page 14 Weight had not been consistently recorded. In one file no record had been made in May, June, August, September or October 2005. This was of particular concern as this was identified as being an indicator of satisfaction. It was positive that dietetic support had been sought for another of the service users tracked. In one persons pre-admission assessment it had been identified referral was required to the Speech and Language therapist and Physiotherapist. Records and discussion with staff did not confirm this had occurred. The plan of care for one service user with epilepsy was tracked. There was no plan that informed staff about a normal seizure duration and presentation, how to support the service user and when to seek further assistance. Bowel monitoring records were in place for some service users. These records showed big gaps, an example being only four entries made in October 2005(25 days) nothing between September 25th 2005 and October 11th 2005. Pressure care plans were tracked. Inspectors were informed the home is waiting for support from a district nurse regards this. No interim plan had been devised. Staff tracking of pressure areas was ad-hoc. The chart in place had not been completed daily, and it was not evident what staff were to be looking for. Service users accommodated who have a Learning Disability must be supported to develop and obtain a Health Action plan as identified in the Government white paper Valuing People. (Timescale for implementation now overdue-summer 2005) The eating and drinking plan for one service user was tracked. Staff practice observed during the inspection was different to the plan of care. This must be explored. Some of the service users accommodated have challenging behaviour. Records to underpin this were not all clear and included entries such as, “A bit agitated.” The strategies in place for some known behaviours (e.g. being nude in a public place) were tracked. These were purely reactive-give a towel; but no information was given regarding reducing or avoiding this situation occurring. In one care plan for psychological /mental health needs, it was identified these were to be reviewed monthly. It was not evident this was being undertaken, by the manager, clinical nurse, or consultant. The plan of one service user identified they had a social phobia. It was not evident what was being done or offered to help or support the person. The reactive management plan (RMP) of one service user was tracked, as five notifications of incidents had been reviewed by the CSCI. Maycroft DS0000016730.V260956.R02.S.doc Version 5.0 Page 15 The plan had not been periodically reviewed, or reviewed in light of these incidents. The plan gives direction in the event of the service user hitting out at staff. All five incidents had involved other service users. No mention was made of this in the plan. Evidence of the incidents being reviewed and used to evaluate or develop care documents was not available. The Department of Health “Guidance for Restrictive Physical Interventions” requires homes that use restraint to record incidents in a book with numbered pages, and should record the names of the staff involved, the reason that physical intervention was used rather than another strategy, type of physical intervention, date and duration, if the service user or anyone else experienced injury. Manual handling plans were assessed. Most were suitable for the service users needs. Two were not acceptable, one had been undertaken at a previous placement and had not been reviewed re current issues and risks in this environment, another file had two risk assessments for manual handling on file. The old document required archiving to ensure staff follow current guidelines. Medication management was sampled. Medication is stored in a number of locations, and it is required this be reviewed and rationalised. If necessary new storage or a suitable size must be obtained. Protocols for as required medicines (PRN) must improve. They must clearly state the rationale for dose to be administered (when this is variable), when to administer e.g. how do you know the person is in pain, or after how many days do you administer a laxative? The protocol must be signed and dated, and kept under review. Old medication information should be archived, with the relevant MAR sheet. One service users medicine was not signed or checked upon receipt. It was of concern that sore skin was noted on one service user, yet a PRN cream for this had not been utilised. Maycroft DS0000016730.V260956.R02.S.doc Version 5.0 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, 23 TRACS investigates complaints in a robust way. A record of the investigation and outcome is maintained. It was not evident that the home is run in a way that keeps service users safe. EVIDENCE: The home received one complaint in July 2005. Evidence that this had been investigated and resolved was available. The home had an open culture, and encourages comments and complaints to be made. Information about how to do this was available in the home. Adult Protection training is provided on a cyclical basis. The manager must ensure new staff are given awareness training in this area. The provider informed the CSCI is this provided routinely in the staff induction. 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. Discussion with staff and examination of records did not identify any tangible way in which this had been explored or addressed. Maycroft DS0000016730.V260956.R02.S.doc Version 5.0 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): 24, 25, 26, 27, 28, 30 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: The inspectors undertook a tour of the premises. It was evident that ongoing building and redecoration will greatly enhance the building once complete. The bedrooms inspected were very personalised, and one service user said, ”I have everything I need.” Another service user said, “I like my room, and we got a colour chart so I could choose the colour” The size of some bedrooms was not adequate to house all the equipment the person needed. An offensive odour was noted in some rooms. This must be removed or effectively managed. The home has a pleasant rear garden. Work is urgently required to the front of the home to make the driveway and retaining wall safe. Maycroft DS0000016730.V260956.R02.S.doc Version 5.0 Page 18 It was positive that changes had been made to the kitchen, in order to increase accessibility. It was noted re-decoration was required around this, and had been planned. Food hygiene was good. It was noted that the current arrangements for storage of clinical waste are inadequate. It is required these be improved. Maycroft DS0000016730.V260956.R02.S.doc Version 5.0 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, 34, 35, 36 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: The inspectors interviewed three people on duty. It was pleasing to hear that they felt morale in the staff team was good and that they felt well supported. Staff gave examples of the support and follow up given to them after a critical incident, which is positive. Staff reported that the induction given is detailed, and the allocation of a “buddy” is an effective way to get to know the home. It was positive to hear staff are provided with awareness of the service users perspective. One service user commented that staff are, “Very Helpful” Five of the staff have achieved NVQ level 2. Training was assessed. Records were not in an auditable format. It was not possible to establish that all staff have received mandatory training to the required level. Recruitment records were generally good. One file sampled was short of one piece of identification. Maycroft DS0000016730.V260956.R02.S.doc Version 5.0 Page 20 The quality of supervision was good. Records showed the meetings were supportive and developmental. The frequency of these does not meet the National Minimum Standards. Maycroft DS0000016730.V260956.R02.S.doc Version 5.0 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): 37, 41, 42 Management of the home has stabilised, with a manager and deputy in post. It is anticipated this will have a positive impact on the outcomes for service users. Health and safety is generally well maintained. Minor improvements are required. EVIDENCE: A manager has been recruited to the home since the last inspection, and the deputy manager has returned to the home, after a period of leave. The inspector hopes the management and operation of the home will improve when this situation settles. Record keeping requires improvement. Both the quality of records made, and the storage of records must be attended to. Historical records must be archived to ensure staff are provided with current, consistent practice guidance. Daily records must be numbered, secure and contemporaneous Maycroft DS0000016730.V260956.R02.S.doc Version 5.0 Page 22 Staff meetings are held regularly. These appear to be an open forum. 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. It is required that records of the Fire drill list the participants to ensure staff undertake this twice yearly. The number of incidents recorded in the home exceeded those reported to the CSCI under Regulation 37. Some incidents that staff disclosed in interview, could not be tracked at all, and it is required this area be reviewed and improved upon. Maycroft DS0000016730.V260956.R02.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 1 X 3 X Standard No 22 23 Score 3 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 2 1 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 2 1 3 X 2 LIFESTYLES Standard No Score 11 3 12 2 13 2 14 2 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 X 3 2 2 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 1 2 X Standard No 37 38 39 40 41 42 43 Score 2 X X X X 2 X Maycroft DS0000016730.V260956.R02.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2. Standard YA2 YA6 Regulation 14 12.1,2,3 15 17.1,a S3.3 Requirement The pre-admission assessment must be kept up to date. Unmet from the previous inspection. Requirement partly met. (Element met has been deleted) Care plans, reactive management plans and daily recording must be developed for individual service users. Records must be consistent and cross-referenced. Ways in which service users’ goals are to be met need to be tranferred in to the daily plan/care plan. A current photograph must be available on the service users file. Action as required by the multi-disciplinary team must be undertaken. Changing needs must be kept under review, and care documents amended and developed to reflect this. Timescale for action 01/01/06 01/02/06 3. YA6 12(1a) 01/02/06 4 5 YA6 YA19 YA6 YA6YA19 17(1a) Sch 3 13(1b) 01/12/05 01/01/06 6 15(2,b) 01/12/05 Maycroft DS0000016730.V260956.R02.S.doc Version 5.0 Page 25 7 YA6YA8 12(2) 8. YA9 13(4,a-c) 9 10 11 YA9 YA9 YA9 13(4) 13(4) 13(5) 12 13. YA12 YA12 12(2) 16(2)(m-n) 16(2)(m-n) 14 YA12 16(2)(m-n) 15. YA12 16(2)(m-n) 16 17 18 YA17 YA18YA41 YA19 16(2)(i) 15 17 12(1)(a) Evidence of service user involvement in the care review and the care plan must be available. Risk assessments and care documents must contain consistent and current information. All identified risks must be subject to risk assessment and planning. Evidence of how risk assessments have been reviewed must be available. Current Manual Handling risk assessments and guidelines must be provided for all service users. Activities identified by the service user must be translated into goals/action Adequate resources must be provided to ensure activities planned with service users can be undertaken. The range of activities offered/planned must be consistent with service users current needs and interests. A record of activities offered must be maintained, and audits undertaken to establish that they have gone ahead as planned, or to establish if the reason they were not undertaken. The choice of foods available at each meal must be varied. Care records must be signed and dated. Staff must fully record service users health appointments. 01/01/06 01/01/06 01/01/06 01/01/06 01/12/05 01/02/06 01/01/06 01/01/06 01/01/06 12/12/05 12/12/05 12/12/05 Maycroft DS0000016730.V260956.R02.S.doc Version 5.0 Page 26 19 YA19 12(1)(a) 20 YA19 12(1)(a) 21 YA19 12(1)(a) 22 YA19 12(1)(a) Healthcare appointments and monitoring must be undertaken, as each service user requires. (To include optician, dentist, weight bowel care, pressure care and mental ill health.) All service users with a Learning Disability must be supported to obtain a Health action plan. Needs identified prior to admission must be planned for and implemented. Referrals identified prior to admission must be made. Behaviour management plans must contain information on both reactive and pro-active strategies. Behaviour management plans must reflect service users needs, and incidents. Records on the use of physical intervention require improvement to ensure they meet the Department of Health guidance for restrictive physical interventions (2002). Requirement partly met. (Element met has been deleted) Service users’ health care needs including bowel care, epilepsy, personal hygiene, mental health and weight management must be planned. 01/01/05 01/03/06 01/02/06 01/02/06 23 YA19 12(1)(a) 01/02/06 24. YA19 12(1,a) 13(1,b) 01/02/06 Maycroft DS0000016730.V260956.R02.S.doc Version 5.0 Page 27 25. YA19 12(1,a) 13(1,b) Care documents and practice must be reviewed and developed as service users needs change. Not assessed at this inspection. Recording/monitoring as required by health professionals must be undertaken. Requirement partly met. (Element met has been deleted) Protocols for as Required Medications must be linked with behaviour management plans. PRN protocols must be further developed to evidence how the medication is to be used. As required (PRN) medicines must be offered and used as prescribed Adequate secure medication storage must be provided in the home. Adult Protection training must be provided at induction for all new staff Service users must be protected from physical and psychological harm. Work in progress at the time of inspection. The environment must be reviewed and plans made to enable it to better meet the needs of service users developed. 01/01/06 26. YA20 13(2) 01/02/06 27 28 29 30. 31. YA20 YA20 YA23 YA23 YA24 13(2) 13(2) 13(6) 18(1,c,i) 13(4,a-c) 13(6) 23(1,a-b) 01/12/05 01/01/06 01/02/06 01/12/05 01/03/06 Maycroft DS0000016730.V260956.R02.S.doc Version 5.0 Page 28 32. YA24 23(2,b) Requirement partly met. (Element met has been deleted) The front walls and driveway must be made safe and repaired. Toilets and bathrooms must be reviewed and work to ensure they meet service users’ needs. Bathing equipment must be reviewed to ensure it meets service users’ needs. Adequate secure storage for clinical waste must be provided at the home. Removal of, or effective odour management must be achieved in all areas of the home. Records of training must be auditable and evidence training has been undertaken to the required standard. Staff must receive documented supervision sessions, at least six times per year. A suitably qualified and experienced manager must be recruited, and make application to the CSCI for registration. Records held in the home must be secure, up to date and in an order from which they can be audited. Not assessed at this inspection. Risk assessment in relation to the building requires development. In particular those for surface temperatures of radiators. 01/02/06 33. YA27 23(2,n) 01/03/06 34 35 YA30 YA30 16(2)(k) 16(2)(j)(k) 01/12/05 01/12/05 36 YA35YA41 18(1)(a)(c)(i) 01/02/06 37. YA36 18(2) 01/02/06 38. YA37 8 01/01/06 39 YA41 17 01/03/06 40. YA42 13(4,a-c) 23(2,a-b) 01/02/06 Maycroft DS0000016730.V260956.R02.S.doc Version 5.0 Page 29 41. YA42 13(4,a-c) Not assessed at this inspection. Risk assessments for visitors, maintenance, hoists and food must be developed and reviewed. 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. 01/02/06 42. YA42 13(4,a-c) 13(5) 01/12/05 43 YA42 44 YA42 Doorway widths must be reviewed, and action as identified undertaken. 23(4)(c)(iii)(v) Records of fire drills must list all participants. All staff must undertake two fire drills each year. 37 Notification of incidents and accidents must be forwarded to the CSCI without undue delay. 01/01/06 01/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Maycroft DS0000016730.V260956.R02.S.doc Version 5.0 Page 30 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. 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