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Inspection on 22/06/07 for Maycroft Residential Home

Also see our care home review for Maycroft Residential Home for more information

This inspection was carried out on 22nd June 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Observations of staff at work dealing with residents demonstrated their kindness and dedication, and in the main, were being treated with dignity and respect. At the time of the visit, the main meal was served and staff including the cook was present in the lounges to support residents. Residents were well presented physically with smart hair and fingernails. They appeared to be content and relaxed. Contact with family and friends were being encouraged. Training records viewed indicated that staff members have received mandatory training that ensures safe working practice. overall, they appeared enthusiastic and committed. They were very positive about their work and spoke favourably of the support they receive from the management team.

What has improved since the last inspection?

There were 2 requirements and two recommendations arising from the last inspection report dated 26.06.06; these have been achieved. The implementation of the requirements and recommendations has resulted in an improved standard of health and safety for residents and the introduction of a system for reviewing and improving the quality of care at the home. Equally, care plans including risk assessments were being reviewed monthly to reflect any changes. Minor improvement has been made with respect to the variety of activities for residents. Quality Assurance systems are in operation to ascertain the views and experience of service users, relatives and significant others. These are extremely valuable as they promote the welfare and quality of life for residents.

What the care home could do better:

There are 7 requirements and 3 recommendations arising from this report, which need addressing. The level of details regarding health and social care needs in the home`s preadmission assessments should be improved, to adequately guide staff members. It is crucial that the identified needs of each resident are comprehensively reflected in their care plan, including details of how these needs are to be met and the action required by staff. This would ensure a more holistic approach from staff in meeting the individual`s needs. In terms of health and safety, a comprehensive health care risk assessment including reason for or indication of current risk level must be available. Equally important is the safe custody of the keys to the medicines trolleys, at all times. An immediate requirement notice was served about this. Hot water temperatures must be maintained close to 43 degrees Centigrade to prevent residents from scalding. The fire drills record must be available at all times at the home. The implementation of the above matters would protect and promote the welfare of the resident. Adequate numbers of staff must be available at all times to meet the needs of the people in residence. Training in Dementia is crucial as this will improve staff`s understanding of dementia needs. Maintaining a record of activities and undertaking a review of the level and variety of activities that have taken place, would ensure that residents receive adequate stimulation for their general well being. In terms of protection for residents, two suitable references and a recent photograph must be obtained for all employees. The administrative records for residents` allowance should include the signature of a second staff for any money credited/debited. Following this inspection, the CSCI has received a letter from the Manager on 29 June 2007 indicating how she intends to address some of the aboveshortfalls. Whilst this is welcomed, a comprehensive action plan would be required from the Manager after receiving the draft report

CARE HOMES FOR OLDER PEOPLE Maycroft Residential Home 73 High Street Meldreth, Royston Hertfordshire SG8 6LB Lead Inspector Neil Fernando Unannounced Inspection 22nd June 2007 10:45 X10015.doc Version 1.40 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 Residential Home DS0000047648.V344100.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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 Residential Home DS0000047648.V344100.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Maycroft Residential Home Address 73 High Street Meldreth, Royston Hertfordshire SG8 6LB 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) 01763 260217 F/P 01763 260217 www.aermid.com Aermid Health Care Limited Joan Ogden Care Home 25 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (24), Old age, not falling within any other of places category (25) Maycroft Residential Home DS0000047648.V344100.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service user under the age of 65 with a diagnosis dementia may be admitted 26th June 2006 Date of last inspection Brief Description of the Service: Maycroft is situated in the High Street in Meldreth, and within walking distance of the village amenities. The home is on 2 floors, with a passenger lift to the upper floor. The residents have a variety of sitting and dining areas, and sufficient space to move around the home. All rooms are single occupancy and there are currently no en-suite facilities. There are extensive gardens where service users can sit or walk, weather permitting and access has been improved, allowing more service users to enjoy the gardens if they choose. The home offers care to a maximum of 25 older people and older people with dementia. The cost of a placement is between £550 and £595 per week, with extra charges for hairdressing, chiropody and toiletries. Maycroft Residential Home DS0000047648.V344100.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on 22 June 2007. The inspection was undertaken by two Inspectors and lasted for 7 hours. 6 residents, 7 members of staff including the Deputy Manager and cook were spoken to. A range of documents was viewed and a tour of the premises was also undertaken. Comment cards have been left at the home for residents and relatives, requesting feedback about the service. The Annual Quality Assurance Assessment has also been left for the Manager to complete. Feedback would be included in the next inspection report as appropriate. Overall, residents spoken with expressed satisfaction with the services offered. Comments included “Staff are great”; Treated well by staff”; “I am very happy at this home”; “ The food is excellent” “The cook always talks to us about food”; “I have my own room”; “I choose to do what I want” and “staff have routinely explained to residents how to make a complaint”. Whilst residents have various degree of dementia, it is noted that 5 of the residents spoken with had good verbal communication skills. The shortfalls identified are indicative of the potential effect on the safety and welfare of residents. With this in mind, this home has now become a ‘level two’ service. What the service does well: What has improved since the last inspection? There were 2 requirements and two recommendations arising from the last inspection report dated 26.06.06; these have been achieved. Maycroft Residential Home DS0000047648.V344100.R01.S.doc Version 5.2 Page 6 The implementation of the requirements and recommendations has resulted in an improved standard of health and safety for residents and the introduction of a system for reviewing and improving the quality of care at the home. Equally, care plans including risk assessments were being reviewed monthly to reflect any changes. Minor improvement has been made with respect to the variety of activities for residents. Quality Assurance systems are in operation to ascertain the views and experience of service users, relatives and significant others. These are extremely valuable as they promote the welfare and quality of life for residents. What they could do better: There are 7 requirements and 3 recommendations arising from this report, which need addressing. The level of details regarding health and social care needs in the home’s preadmission assessments should be improved, to adequately guide staff members. It is crucial that the identified needs of each resident are comprehensively reflected in their care plan, including details of how these needs are to be met and the action required by staff. This would ensure a more holistic approach from staff in meeting the individual’s needs. In terms of health and safety, a comprehensive health care risk assessment including reason for or indication of current risk level must be available. Equally important is the safe custody of the keys to the medicines trolleys, at all times. An immediate requirement notice was served about this. Hot water temperatures must be maintained close to 43 degrees Centigrade to prevent residents from scalding. The fire drills record must be available at all times at the home. The implementation of the above matters would protect and promote the welfare of the resident. Adequate numbers of staff must be available at all times to meet the needs of the people in residence. Training in Dementia is crucial as this will improve staff’s understanding of dementia needs. Maintaining a record of activities and undertaking a review of the level and variety of activities that have taken place, would ensure that residents receive adequate stimulation for their general well being. In terms of protection for residents, two suitable references and a recent photograph must be obtained for all employees. The administrative records for residents’ allowance should include the signature of a second staff for any money credited/debited. Following this inspection, the CSCI has received a letter from the Manager on 29 June 2007 indicating how she intends to address some of the above Maycroft Residential Home DS0000047648.V344100.R01.S.doc Version 5.2 Page 7 shortfalls. Whilst this is welcomed, a comprehensive action plan would be required from the Manager after receiving the draft report Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Maycroft Residential Home DS0000047648.V344100.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Maycroft Residential Home DS0000047648.V344100.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 5. Standard 6 is not applicable. Quality in this outcome area is adequate. Prospective residents and relatives have sufficient information available to them to enable them to know what services the home offers. The home’s pre-admission assessments do not provide enough information to guide staff and this may impact on the quality of care for the resident. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a statement of purpose and ‘Service User Guide’. Information gathered indicates that a copy of the guide is made available to the resident, their representative and professionals, as appropriate. A copy of the guide and the most recent inspection report from the Commission for Social Care Inspection is also available in the home. Staff members including the Deputy Manager reported that visiting relatives and professionals are encouraged to Maycroft Residential Home DS0000047648.V344100.R01.S.doc Version 5.2 Page 10 read them as they wish. It was also positive to note that members of staff read the inspection report to residents, as appropriate. The files for three residents were viewed and information gathered provides good evidence that a member of the management team undertakes a preadmission assessment, involving the prospective resident, their relatives and the Social Worker where possible. Whilst this appears to be a routine part of the admission procedure, the home’s pre-admission assessments did not include enough information on health and social care needs to adequately guide staff members. This is an area that requires improving. Information from residents and staff members, including the Deputy Manager provides some evidence that prospective residents and families are encouraged to visit the home prior to admission, to enable them to make an informed decision whether the facilities offered are suitable to their needs. Maycroft Residential Home DS0000047648.V344100.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. Care plans and health care risk assessments lack the necessary details to enable staff to care for residents in a consistent, holistic and safe manner. Leaving the keys to the medication trolleys on the kitchen window sill, with the window wide open, is poor practice and does not adequately protect residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Based upon the pre-admission assessment, a care plan is formulated. Care plans for 3 residents were examined and these provided very basic details, which reflected some aspect of the residents’ identified health, personal and social care needs. The guidance for staff on how to address each identified need was limited, for example “needs assistance with bathing”, which does not indicate the level and kind of assistance required. However, another care plan Maycroft Residential Home DS0000047648.V344100.R01.S.doc Version 5.2 Page 12 did give information about what staff need to do to meet personal care needs, but it did not indicate what the person was able to do for himself. Records in one care file showed there had been six incidents of aggression/agitation from one resident in the previous two months. The care plan, however, did not show how these had been managed when they occurred and if other health care professionals were involved. This means that although these incidents were not serious the home is not seeking advice early enough. The home makes use of turn charts, bruise and pressure sore forms and skin condition risk assessments. Although the use of these was not included in the residents’ care plans. There is some conflicting advice in care plans, for example, one person had ‘needs prompting at all times with personal care’ written in one section. But another section indicated that the resident ‘is able to wash and dress herself with little prompting’. This means that it is not always possible to confirm if care needs are being met and may lead to staff members not providing adequate care. Monthly reviews of care plans are being carried out to reflect the changing needs for health and personal care for each person accommodated. Each resident also has an annual review involving their Social Worker, home staff, relatives and the resident as appropriate. Staff spoken with said that all residents are registered with a GP, who refers people to other health care agencies when required. Four residents confirmed that the GP visits them at the home, as soon as requested. Everyone at the home who returned surveys also said they get medical support when they need it. Medication is stored in locked trolleys, which are attached to a corridor wall with locked metal cable. The keys of the medication trolleys were kept in a tub on the kitchen windowsill, with the window wide open. This is not good practice and places people at the home at risk. However, staff said this is not common practice and the staff member in question had forgotten to pick the keys up again after being in the kitchen. At the time of the inspection, there was no resident self-medicating, although staff said that they would support anyone who wishes to and is able to do so. They were however clear that a risk assessment would be undertaken prior to self-medicating. Medication records (MAR sheets) for 4 residents were viewed and these were noted to be satisfactory. Most staff members have received medication training provided by Boots Community Pharmacist. All residents had a risk assessment carried out with respect to their health care. These assessments provided very basic information and they did not show how the current risk level was assessed, which is needed to enable staff take correct action to lower the risk. Maycroft Residential Home DS0000047648.V344100.R01.S.doc Version 5.2 Page 13 Residents spoken with informed the Inspectors that their needs were being met satisfactorily. All residents were appropriately dressed and were correctly addressed by staff members. All personal and intimate care practices are carried out behind closed doors. The GP and District Nurses also see residents in the privacy of their own rooms. Nearly 90 of people visiting the home that returned surveys said their relatives care needs are met, that staff give the care that is expected to be given and they are able to meet different types of needs. Everyone living at the home who returned surveys said they get the care and support they need. Maycroft Residential Home DS0000047648.V344100.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 14 and 15 Quality in this outcome area is good. People’s interests, expectations and aspirations are being sought and addressed. Maintaining a record of activities and undertaking a review of the level and variety of activities that have taken place, would ensure that residents receive stimulating choices. The meals offered are of a good quality but if sufficient staff are not available at meal times, it may impact on how staff assist residents to eat their food. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents were being assisted to follow the lifestyle of their choice to an extent, as discussed and agreed during assessment. Those people spoken to expressed satisfaction in this area. The Inspectors spent time discretely observing staff interactions with residents. The residents were engrossed in what they were doing and clearly enjoying each other’s company. There was a lot of laughter from residents and encouragement from staff members. Over 60 of visitors and relatives returning surveys said the home supports people to do and live how they want to each day. Maycroft Residential Home DS0000047648.V344100.R01.S.doc Version 5.2 Page 15 A recruitment drive is in progress to appoint an Activities Co-ordinator. The home also plans to purchase a mini-bus and staff said that having their own transport would assist them access a greater level of outside activities for residents - this is welcomed by the CSCI. The home maintains an activities programme, which range from board games, bingo, quizzes, and outside entertainers. There was a mixed reaction from people returning surveys about the activities available, and not everyone thinks people at the home have enough stimulation, but that they can be left alone for long periods of time. Considering the dependency levels of the people in residence, in particular those with dementia, it is recommended that a record of the social and recreational activities, which have occurred be maintained. A review of the level and variety of activities offered should also be carried out and action taken as appropriate. Contact with family, friends and significant others are being encouraged and supported. Residents are encouraged to express their opinions regarding how their expectations and preferences are being met. Regular residents’ and relatives’ meetings are held and good opportunity exists to discuss/raise any issues that matter to them. Relatives and visitors to the home said they are kept up to date with issues and if possible staff help their relative keep in touch. Menus are planned taking into account residents’ taste and preference. The menu viewed included good variety, the provision of good nutrition and choice. All residents spoken with and all those returning surveys expressed satisfaction about food – “the food is excellent” and “lovely, always get plenty to eat”. The lunch was unhurried with assistance and encouragement given by staff. However, two observations are made: condiments such as vinegar and tomato sauce were not available on the tables in one dining room, when fish and chips had been served; some residents had to ask for these; a member of staff was assisting two people to eat at the same time, which was not dignifying. The Deputy Manager said that it was because they were short of staff. This issue is more appropriately dealt with under standard 27 of the report. Maycroft Residential Home DS0000047648.V344100.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. The complaint procedures are well publicised and this would encourage people to make a complaint, if necessary. The protection systems in place are adequately robust and this should ensure the safety of the people accommodated. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has procedures on how to make a complaint. All five residents spoken with said that they would not hesitate to speak to a staff if they were worried or concerned about anything. This was echoed in the surveys that were returned, with one person commenting that although their relative isn’t able to complain, staff know if he unhappy or has been upset. They also showed a good degree of optimism in that the staff would resolve any concerns they might have. The complaints record indicates that there have been no complaints made to the home since the last inspection in June 2006. The home has policies and procedures on the protection of vulnerable adults and whistle blowing. Staff members were seen to interact well with people in residence. Records indicate an incident of one person pulling another person out of a chair, and advice should have been sought from the local adult protection team about this. This was necessary given that there had been six Maycroft Residential Home DS0000047648.V344100.R01.S.doc Version 5.2 Page 17 incidents of aggression/agitation from this resident, in the previous two months. There were no adult protection matters pending at the time of the visit. All staff including members of the management team have received training in Adult Protection; an element of this is also included in the induction for all new staff, one to one supervision and NVQ assessment. Evidence of CRB checks was available on the staff files viewed. Maycroft Residential Home DS0000047648.V344100.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. The environment was clean and generally fresh. The home is safe and comfortable for residents to live in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All areas of the home were found to be light and fresh with ample furniture and seating areas. People returning surveys also said the home was usually clean and fresh. A rolling programme of maintenance and redecoration is in place and this ensures a good standard of physical environment. A maintenance person is employed to carry out regular checks and repair work. The standard of decoration and furniture and fittings in communal areas and bedrooms remains satisfactory. There are extensive and extremely attractive Maycroft Residential Home DS0000047648.V344100.R01.S.doc Version 5.2 Page 19 gardens; residents spoken to said they enjoyed sitting outside when the weather permitted. Many of the rooms look out onto the front yard and gardens to the rear. Residents were complimentary about the physical environment, including their room. A good standard of cleanliness was evident throughout those areas viewed. Suitable arrangements are in place for the storage and collection of domestic and clinical waste. Although the standard of the environment is good, relative and visitors have commented that the entrance to the home is straight into a lounge area used by residents. There were two suggestions of a porch being put onto this doorway, which may reduce any disturbance to people in this area. Maycroft Residential Home DS0000047648.V344100.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. Staffing levels during the day are not always sufficient to meet the needs of residents. The home’s recruitment procedures are not robust enough, which means people are not protected. Training in Dementia is a priority for staff to ensure that they have the skills and knowledge to meet residents’ needs safely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a minimum of five care staff including the Deputy Manager between 7:30 am to 3 pm and a minimum of four care staff between 3 pm and 10 pm. The Manager’s time is not included in this calculation. At night there are two waking members of staff on duty between 10 pm and 8am and the Manager is available on call if required. Residents returning surveys said staff members are usually available when they are needed, with “only a slight delay if they are busy dealing with another resident”. However, on the day of the inspection the home was short-staffed and the Deputy Manager was assisting with care tasks. There is evidence to show that people are kept waiting at lunch times and there is no one available in another lounge. This is not acceptable and the Manager must ensure that adequate numbers of staff are available at all times to meet the needs of the people in residence. Maycroft Residential Home DS0000047648.V344100.R01.S.doc Version 5.2 Page 21 In addition to the care staff team, the home has maintenance, catering and ancillary staff members. These arrangements are adequate to meet the needs of the resident group. Training profiles for individual staff members are maintained and training received, recorded. Records for 4 members show that they have received mandatory training and a variety of other courses. There is evidence of a lack of awareness/understanding of people with dementia by some staff; for example, some staff was constantly going round, pushing a few people in chairs back to the tables to finish their meal; one such person was made to sit again at the table in front of her plate, but she got up this time and walked out of the room, to be brought back by the Deputy Manager and taken to sit in another chair by the door. She settled down and went to sleep. The staff that sat her down the first time did not have a good understanding of this person’s dementia needs. Although some members including the Deputy Manager have received training in Dementia, it is essential that this essential training is made accessible to all staff. There are seventeen care staff members in the team. Six staff have completed their NVQ assessment and another two members are currently undertaking the same assessment. A further two staff are currently doing NVQ Level 3. The home has therefore achieved a ratio of 35.2 of care staff with an NVQ Level 2 or equivalent. Once the four staff have completed their NVQ assessment, it would give a ratio of 58.8 of staff with an NVQ Level 2 or equivalent. A recommendation is therefore not made, as it would not serve any purpose. The personnel files for two members of staff were viewed. Each contained evidence that references and CRB/POVA checks had been undertaken before they began their employment. However, both references for one staff were from a friend and a colleague. Whilst they were both positive references, it was not suitable to protect residents – at least one of the references must be from the last employer. With respect to the second staff, gaps in employment history had not been explored; a photo/ID was not available in either case. Maycroft Residential Home DS0000047648.V344100.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, and 38 Quality in this outcome area is good. Management systems are being implemented to good effect, which means that staff members are being appropriately supported and managed. The health, safety and welfare of service users, and staff are being safeguarded to an extent. However, fire drills record must be available at all times; hot water temperatures must be maintained close to 43 degrees Centigrade, in order to protect residents from scalding. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Maycroft Residential Home DS0000047648.V344100.R01.S.doc Version 5.2 Page 23 Staff members spoken with reported that they are well supported by the management team. Observation of care practice during the visit demonstrates that staff and residents enjoy a good relationship. Residents spoken with indicated that the home ‘meets their expectations’ and that they are ‘very happy and feel valued’ in the home. The home retains a small amount of money on behalf of a few people for their day today expenses. An administrative record for money credited/debited and receipted transactions are maintained. Records indicate that the Manager predominantly signs these records. A second signature should be obtained as a matter of good practice. Quality Assurance systems are in operation to ascertain the views and experience of service users, relatives and significant others. Notifyable issues were being reported to the appropriate bodies including the CSCI. Health and safety training is provided on a rolling training programme and records show that health and safety checks had been carried out. The fire alarm system is serviced every four months. Weekly tests of break-glass points and fire drills are carried out within the required frequency; staff members interviewed were aware of the evacuation points. The Deputy Manager however could not locate the fire drills record. The local Fire Officer visited in December 2006 and requirements arising from that visit had been implemented satisfactorily. Disinfectant and cleaning materials were stored in locked cupboards and COSHH Regulations, observed appropriately. Hot water temperatures are tested monthly and a record is maintained. Records examined indicated that the hot water temperatures in at least four residents’ bedrooms, ranged between 48 and 49 degrees Centigrade. There were no other health hazards noted during this inspection. Maycroft Residential Home DS0000047648.V344100.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 X X X X X x 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 2 3 x 2 Maycroft Residential Home DS0000047648.V344100.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 (1) Requirement The identified needs of each resident must be comprehensively reflected in their care plan, including details of how these needs are to be met and the action required by staff. Each resident must have a comprehensive health care risk assessment including reason for or indication of current risk level. Storage keys for medication must not be left unattended, to ensure the safe storage of medication. Adequate numbers of staff must be available at all times to meet the needs of the people in residence. Timescale for action 31/08/07 2 OP8 13 (4) (c) 15/08/07 3 OP9 13(2) 22/06/07 4 OP27 18 (1) (a) 22/07/07 5 OP29 7,9,19 sch Two suitable references and a 2 recent photograph must be obtained for all employees to ensure the protection of residents. 15/08/07 Maycroft Residential Home DS0000047648.V344100.R01.S.doc Version 5.2 Page 26 6 7 OP30 18 (1) (c) (i) 13 (4) (c) All staff must receive training in Dementia. Hot water temperatures must be maintained close to 43 degrees Centigrade, in order to protect residents from scalding. The fire drills record must be available at all times at the home. 30/09/07 05/07/07 OP38 8 OP38 17 (3) (b) 31/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP3 Good Practice Recommendations The home’s pre-admission assessments should include enough information on health and social care needs to adequately guide staff members. i) ii) Maintain a record of the social and recreational activities, which have occurred; Undertake a review of the level and variety of activities offered, and take remedial action as appropriate. 2 OP12 3 OP35 The administrative records for residents’ allowance should include the signature of a second staff for any money credited/debited. Maycroft Residential Home DS0000047648.V344100.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Maycroft Residential Home DS0000047648.V344100.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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