Inspection on 26/04/05 for Maycroft

This inspection was carried out on 26th April 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 31 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 25/10/05

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 B14 5HG Lead Inspector Alison Ridge Unannounced 26 April 2005 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 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 Stationary 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 E54_ S16730_ Maycroft_ V222754_ 260405_ Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Maycroft Address 791 Alcester Road South, Kings Heath, Birmingham, B14 5HG Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 474 5394 0121 474 5394 TRACS Vacant CRH 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Maycroft E54_ S16730_ Maycroft_ V222754_ 260405_ Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 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. Date of last inspection 03 December 2004 Brief Description of the Service: Maycroft is a dormer style bungalow, located on the main Alcester Road in South Birmingham. The service users accomodation 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 accomodates both male and female service users, who have a learning disability or acquired brain injury. The service caters for people who display some behaviours that challenge. The home is currently without a registered manager. Maycroft E54_ S16730_ Maycroft_ V222754_ 260405_ Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors undertook this unannounced inspection. During the visit to the home they were pleased to meet six of the eight service users accommodated, staff on duty and the acting manager. Inspectors undertook a tour of the premises, examined records and documents, observed service user and staff interaction, and spoke with service users about their experience in the home. TRACS Maycroft has previously caused the CSCI serious concern. Following the last visit to the home, TRACS have implemented a number of measures that has resulted in the situation improving, and the outcomes for service users becoming more favourable. What the service does well: What has improved since the last inspection? Maycroft E54_ S16730_ Maycroft_ V222754_ 260405_ Stage 4.doc Version 1.30 Page 6 The inspection identified that numerous improvements have been made at Maycroft since the last inspection. It was also pleasing to hear that plans to improve on the premises, service offered and management support are in hand. Maycroft was a home that the CSCI had serious concerns about. Improvements have been made in all the areas previously identified as being of concern. Some further work was identified as being necessary to fully meet the requirements, and to fully meet service users needs. What they could do better: 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 E54_ S16730_ Maycroft_ V222754_ 260405_ Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Maycroft E54_ S16730_ Maycroft_ V222754_ 260405_ Stage 4.doc Version 1.30 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 standard(s) 2,4,5 Generally the home has implemented a comprehensive pre admission procedure to ensure it assesses service users needs prior to them moving in. EVIDENCE: Since the last inspection one new service user has been admitted. The work undertaken prior to this person moving in to the home was assessed. It was pleasing to find that an assessment of the person’s needs had been undertaken. This was thorough and covered all areas listed in standard 2. Maycroft had made a record of a visit to the home made by the potential new service users relatives. The potential new service user had visited the home after this but that no record of the visit had been maintained. This must be undertaken as part of the pre-admission assessment. The service user had been issued with a contract detailing the terms and conditions of their placement in the home. The service user had signed this document. Maycroft E54_ S16730_ Maycroft_ V222754_ 260405_ Stage 4.doc Version 1.30 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 standard(s) 6,7,9, Service users are supported to make decisions about their lives where-ever possible, to enable them to influence their own life choices. The home has improved upon care planning and risk assessment but continues to require some work to ensure service users needs are fully recorded and met. EVIDENCE: The individual plan of three of the service users accommodated were assessed. One plan had been assessed at previous inspections and it was pleasing to see that this had been significantly developed as was previously required. The plan of one recently admitted service user was assessed. It was pleasing to see that the plan and risk assessments were developed and in place prior to the service user moving to the home, and that they have subsequently been reviewed with the service user and relevant others. One service users plan, not previously assessed was inspected. This was found to require significant work to ensure that the service users needs are clearly stated, and that consistent methods for meeting the needs are detailed. Maycroft E54_ S16730_ Maycroft_ V222754_ 260405_ Stage 4.doc Version 1.30 Page 10 It was pleasing to see that the plans did show consultation with the service user and their supporters where possible. The plans included some aspects of life planning, and personal development as well as meeting basic care needs. Two staff members and a student nurse spoken to at the inspection clearly demonstrated commitment to helping service users communicate and decision make. Risk assessments were assessed. It was pleasing to find these are now filed with care plans, and cross referencing is possible to a greater extent. The inspection identified some anomalies within risk assessments, other care documents and staff practice. Work to ensure all documents are consistent and that staff actions are in line with guidance must be undertaken. Manual handling risk assessments were observed to require some further development for one of the service users sampled, who is currently undertaking a physiotherapy programme. All risk assessments showed sign of recent review. Maycroft E54_ S16730_ Maycroft_ V222754_ 260405_ Stage 4.doc Version 1.30 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 standard(s) 11,12,13,14,15, The range of activities to service users both in the home and community was varied, to enable service users to live an interesting and meaningful life. EVIDENCE: The activity plan, and records of activities undertaken for three of the eight service users accommodated were assessed. During the inspection a range of activities was offered that included watching TV, playing games, attending college, a 1-1 community activity, undertaking house shopping, a local walk, and purchasing personal goods. Staff and service users were observed to interact well during the day, and time was spent chatting with, and reassuring service users. The range of activities planned was varied and it was evident that service users had expressed personal preferences. It was not possible in all cases to track how the identified activity or goal was being delivered. It was not always apparent from the daily record if the activity Maycroft E54_ S16730_ Maycroft_ V222754_ 260405_ Stage 4.doc Version 1.30 Page 12 had been offered or delivered, or the reason why the activity had not gone ahead. Care plans included planning for personal development and achieving life goals as well as personal care. Maycroft reported supporting service users to maintain contact with their family and friends where possible. This included writing letters, phone calls, and visits to family and family occasions even when the family do not live locally. Maycroft E54_ S16730_ Maycroft_ V222754_ 260405_ Stage 4.doc Version 1.30 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 standard(s) 18,19,20 Health care needs, including medication management were being generally well addressed. EVIDENCE: All the service users were well presented and dressed in a very individual style. Very detailed morning and evening programmes were observed in the service users plan. A record of the care given had been maintained. Inspectors have identified the need to develop bathroom facilities in the home to protect service users dignity. (See standards 24-30). Service users at Maycroft have a wide range of healthcare needs. In the files sampled it was evident that service users had been supported to attend appointments with the dentist, optician and chiropodist as required. One service user who has some mental health care needs was tracked. The care plan did not detail these, give any indicators of well being, or how to care for the service user in the event of him becoming unwell. One service user who requires a low cholesterol diet was tracked. The home agreed in January 2005 to develop a personal menu that accommodated this. To date this has not been undertaken. Maycroft E54_ S16730_ Maycroft_ V222754_ 260405_ Stage 4.doc Version 1.30 Page 14 It was evident that some reduced fat foods had been obtained and served, but the records of food eaten also identified some very inappropriate foods being served. One service user needs to increase weight. It was pleasing that this person was being regularly weighed. It has been required that the home liaise with the supporting dietetic department to obtain advice on serving foods that have a higher calorie and fat content to further help weight gain. It had previously been required that the home develop systems to plan for and monitor health care needs such as bowel care, epilepsy, mental health, and weight management. At this inspection it was apparent that monitoring had improved, and in some of the files sampled planning had also improved. This was not the case in all of the files sampled, and it has been required this work be considered for all of the service users, and that healthcare needs be clearly assessed, planned and monitored as required for each individual. Records for each service user must contain consistent information. Some significant anomalies were identified that could compromise the safety or welfare of service users, and which do not promote consistent working practices. Medication management was generally good. Stocks of medication were in good order and appropriately stored. Not all medication had been signed as received. Audits against medication received, given and available were therefore hard to complete. PRN (As required medication) was all underpinned with a protocol. Some as required medicines are prescribed as ”one or two” tablets. The protocol needs to make clear when to use one and two. The protocol also needs to refer the reader to other related documents such as reactive management plans and risk assessments. An immediate requirement was made regarding making safer the administration of a short-term medication. Maycroft E54_ S16730_ Maycroft_ V222754_ 260405_ Stage 4.doc Version 1.30 Page 15 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 standard(s) 23 It was not evident how the home is run in such a way to keep service users safe. EVIDENCE: It has previously been required that the provider ensures that service users be protected from physical and psychological harm. This requirement was made as service users accommodated at Maycroft present some level of risk to each other, due to their challenging and complex behaviour needs. Recent regulation 37 reports show that challenging incidents have occurred. While no service users have been physically harmed, the inspector believes the impact on service users psychologically must be significant. Evidence of how the home is proactive in protecting the service users from harm was not available, and it has been required such systems be formalised, to further ensure service users welfare and safety One service user complained about feeling intimidated and being disturbed by another service user during the day and night. The inspector has previously identified the need to assess the risks people pose to each other, and to demonstrate how the home is working pro-actively to protect people and as far as possible reduce the likelihood of harm occurring. This could include activity planning, staff allocations, mealtime guidelines, or risk assessments for example. Some work to address this matter has been undertaken, but that it is not available to assess in a coherent form. Maycroft E54_ S16730_ Maycroft_ V222754_ 260405_ Stage 4.doc Version 1.30 Page 16 It remains a requirement that the home addresses this issue. The inspection identified that staff at the home are quick to make placing authorities aware of issues concerning the service users they fund. Maycroft E54_ S16730_ Maycroft_ V222754_ 260405_ Stage 4.doc Version 1.30 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 standard(s) 24,25,26,27,28,30 Some progress has been made towards redecoration and refurbishment of the home to provide an attractive and homely environment for people to live in. 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: Maycroft is a detached dormer style bungalow. The provider has recently undertaken significant work to decorate and refurbish many of the rooms, and communal areas. Maycroft was presented to a higher standard than has previously been observed, and complimented the home on what has been achieved, and was pleased to hear of further work to follow. At the time of inspection cleaning and repairs were required in some areas of the home. The acting manager had available a schedule of development and improvement for the premises that included building additional laundry facilities, decoration of the external premises, redecoration of the dining room and new carpets in some areas. Maycroft E54_ S16730_ Maycroft_ V222754_ 260405_ Stage 4.doc Version 1.30 Page 18 The front drive and garden continue to require attention. Low retaining walls are still broken, and present a hazard. This work is planned to be undertaken in conjunction with work planned by the Highways agency. The acting manager informed inspectors it is being pursued. Other environmental works as identified at the last inspection have been addressed. Inspectors found service users bedrooms were attractively decorated, and reflected their interests, age, gender and personality. Some rooms are not big enough to accommodate all the furniture as listed in standard 26. Rooms of service users that utilise a wheelchair fall below the requirement of 14sq.m for a new registration. One service users bedroom chair required replacement (New chair on order), and one service users sink pipe casing required repair. Bathrooms and toilets have all been renovated in the past nine months and appear much improved. The home has some service users without full mobility. At present these service users have to be dressed and undressed in their room, and transported to and from the bathroom in a state of undress. The separate shower room is very small. Inspectors have expressed concern for service users and staff safety and comfort, as the room is difficult to exit from in event of an incident, and does not allow sufficient space for service users to dress, again requiring them to return to their room in a state of undress. Any building works considered at the home must take into account improving on these resources. The communal lounge space was well presented. New lounge furniture has bee provided in here. The dining room requires re-decoration. Drinks had been spilt on the curtains, wall and ceiling and this requires attention. The redecoration of the dining room was detailed on the homes maintenance schedule. The home does not appear to have adequate storage space for domestic items such as the ironing board, hoover, and mops. These had been stored in the dining room. This situation must be improved upon as the items are a potential hazard and unsightly. Maycroft E54_ S16730_ Maycroft_ V222754_ 260405_ Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,34,36 Staff do not currently receive the level of supervision required to ensure that they are able to constantly meet service users needs. The homes recruitment procedure is generally well developed and applied with the area of positive CRB disclosures requiring further attention to ensure service users are protected. EVIDENCE: The inspectors observed staff practice and spoke in detail with two staff and a student nurse. Observations and discussions identified that staff had a clear understanding of their role, and responsibilities. The recruitment records of two staff were assessed. Both files contained all documents as listed in Schedule 2 of the Care Homes Regulations. Concern was raised regarding one staff’s CRB disclosure, and the work undertaken by TRACS to ensure service users are safeguarded. This was left as an immediate requirement at the time of inspection. The inspector has subsequently been informed that a review of action taken in the event of a positive disclosure has been undertaken, and a formal risk assessment is completed. Maycroft E54_ S16730_ Maycroft_ V222754_ 260405_ Stage 4.doc Version 1.30 Page 20 A matrix completed by the acting manager had worked out which staff require supervision and appraisal. She informed inspectors this would be addressed, although at the time of inspection this area had fallen behind. Maycroft E54_ S16730_ Maycroft_ V222754_ 260405_ Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,41,43 Whilst there have been a number of improvements in the management of the home further progress is required to ensure that service users health, safety and best interests are well planned for and safeguarded. EVIDENCE: The homes management has undergone significant changes in the past four months, with an acting manager in place, and a new deputy manager recently appointed. The inspection identified that while a permanent manager still needs to be recruited, this situation is working well in the interim. The outcomes for service users had been improved, and was pleased to hear from the two staff and student nurse interviewed that they felt well supported in their role, and found the acting manager approachable. . The rota showed, and inspectors were informed that the staff team is largely stable in the home, and that use of bank and agency staff is minimal. Maycroft E54_ S16730_ Maycroft_ V222754_ 260405_ Stage 4.doc Version 1.30 Page 22 Record keeping had generally improved since the last inspection. Records were all completed respectfully, about each individual service user. It was pleasing to see that each persons care documents are now stored in one personal file, enabling much better cross referencing and easier access to information. Records do need to be audited to ensure that information contained in the file is consistent. Some significantly different information was observed in relating documents for the same people. This does not promote consistent working practices, and in some instances could compromise the safety of welfare of the service user. Weekly tests of the fire alarm and monthly tests of the emergency lighting had been undertaken as required. Service records of electrical, lifting and gas appliances were available and up to date. A large number of cigarette ends were observed at both the front and back of the home. This must be explored, cigarette ends cleared away, and provision made for safe and hygienic disposal of smoking materials in future. Part of the back wall of the home is low. It has been required this be risk assessed re security for people both entering and leaving the premises. Any identified action must be taken. One service user who utilises a moulded wheelchair. He was seen to catch his arms on door frames, and had previously sustained a graze to that area. Ways of improving the environment to further meet this persons needs, and awareness training for staff when supporting this service user must be undertaken. One fire extinguisher in the lounge required securing to the wall. A large number of training wires were seen in service users rooms, from appliances, or decorative lights. This must be assessed, and safer ways of presenting the wires explored and undertaken. Maycroft E54_ S16730_ Maycroft_ V222754_ 260405_ Stage 4.doc Version 1.30 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 3 x 2 3 Standard No 22 23 ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 1 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 1 2 1 2 x 2 Standard No 11 12 13 14 15 16 17 3 2 2 2 3 x x Standard No 31 32 33 34 35 36 Score 3 x x 1 x 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Maycroft Score 2 2 2 x Standard No 37 38 39 40 41 42 43 Score 2 x x x 1 2 x E54_ S16730_ Maycroft_ V222754_ 260405_ Stage 4.doc Version 1.30 Page 24 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. 2. Standard YA4 YA6 Regulation 14 12(1) a, b (2)(3) 15(1)(2) 17(1) a Schedule 3(3) j, k, l, m, n, q Requirement Keep a record of trial visits potential new service users to the home. Requirement partly met. (Element met has been deleted) Timescale for action 30/6/05 31/7/05 3. YA6 4. YA9 5. YA9 6. 7. YA9 YA9 Care plans, reactive management plans and daily recording must be developed for individual service users. Records must be consistent and crossreferenced. 12(1)(a) Ways in which service users goals are to be met need to be transferred in to the daily plan/care plan. 12(1) a, b Requirement partly met. 13(4)(6) (Element met has been deleted) Individual risk assessments must be adhered to. 13(4)(a-c) Activities including visiting new premises purchased by one service user must be risk assessed and any required action taken 13(4)(a-c) Risk assessments and care documents must contain consistent, current information 13(5) Manual handling risk assessments and guidelines must be provided for all service E54_ S16730_ Maycroft_ V222754_ 260405_ Stage 4.doc 30/6/05 30/6/05 30/6/05 30/6/05 30/6/05 Maycroft Version 1.30 Page 25 users. 8. YA12 16(2)(mn) 16(2)(mn) Adequate resources must be 30/6/05 provided to ensure activities planned with service users can be undertaken. A record of activities offered 30/6/05 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. Requirement partly met. 30/6/05 (Element met has been deleted) Service users health care needs including bowel care, epilepsy, personal hygiene, mental health and weight management must be planned. 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. The diet of one service user must be reviewed with the dietician. Requirement partly met. (Element met has been deleted) 9. YA12 10. YA19 12(1)(a) and 13(1)(b) 11. YA19 12(1)(a) and 13(1)(b) 30/6/05 12. 13. YA19 YA20 12(1)(a) and 13(1)(b) 13(2) 30/6/05 30/6/05 14. YA20 13(2) 15. YA20 13(2) 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. The system for dispensing one 27/4/05 short course of medication must be reviewed to ensure the system in place is robust. All medication must be signed 30/6/05 when received into the home and checked. Version 1.30 Page 26 Maycroft E54_ S16730_ Maycroft_ V222754_ 260405_ Stage 4.doc 16. 17. YA23 YA24 18. YA24 13(4)(a-c) Service users must be protected and 13(6) from physical and psychological harm. 23(1)(aThe environment must be b) reviewed and plans made to enable it to better meet the needs of service users developed. 23(2)(b) Requirement partly met. (Element met has been deleted) The front walls and driveway must be made safe and repaired. Repair casing around sink of one wash hand basin in one bedroom. 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. The dining room must be redecorated.(Included in maintenace schedule) The dining area (including curtains) must be maintained to an acceptable standard of cleanliness. 30/6/05 Action plan to be provided to CSCI 31/8/05 19. 20. YA26 YA27 23(2)(n) 23(2)(n) 30/6/05 Action plan to be forwarded to CSCI. 30/6/05 21. YA24 23(2)(ab) 22. YA30 23(2)(ab) 23. YA33 13(6) AND 19 Storage for mops, buckets and hoovers must be provided. Work scheduled, to be completed 31/7/05 by July 2005. The laundry facilities are inadequate for the needs of the service users living at the home. The home must inform the CSCI of their proposals to address this matter as it has been raised on a number of occasions. The provider must evidence that 30/6/05 positive disclosures from CRB checks have been risk assessed, and the potential consequence to service users accomodated considered and minimised. Version 1.30 Page 27 Maycroft E54_ S16730_ Maycroft_ V222754_ 260405_ Stage 4.doc 24. 25. YA36 YA39 26. Y 27. YA42 Staff must receive documented supervision sessions, at least six times per year 8 A suitably qualified and experienced manager must be recruited, and make application to the CSCI for registration. 13(4)(a-c) Not assessed at this inspection. and Risk assessments in relation to 23)(2)(a- the building require b) development. In particular those for surface temperatures of radiators 13(4)(a-c) Not assessed at this inspection. Risk assessments for visitors, maintenance, hoists and food must be developed and reviewed. 18(2) 30/6/05 30/6/05 31/7/05 28. 29. YA42 YA42 13(4)(a-c) and 23(4)(a) 13(4)(a-c) 30. YA42 Disposal of used smoking materials must be hygienic and safe. The fence panel at the back of the home must be assessed, and ways of increasing security considered and actionned. 13(4)(a-c) A review of the way in which and 13(5) 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. 13(4)(a-c) Trailing wires from appliances must be safely arranged. 13(4)(a-c) The fire extinguisher in the lounge must be secured to the wall 30/6/05 30/6/05 30/6/05 31. 32. 33. YA42 YA42 30/6/05 31/5/05 Maycroft E54_ S16730_ Maycroft_ V222754_ 260405_ Stage 4.doc Version 1.30 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 YA29 Good Practice Recommendations It is recommended that suitable adaptations be made in the kitchen for those service users with physical disabilities to enable them to participate in tasks in this area. Maycroft E54_ S16730_ Maycroft_ V222754_ 260405_ Stage 4.doc Version 1.30 Page 29 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Laywood 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 E54_ S16730_ Maycroft_ V222754_ 260405_ Stage 4.doc Version 1.30 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!