Inspection on 05/07/07 for Hawthorns

This inspection was carried out on 5th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hawthorns 15/01/07

Hawthorns 14/06/06

Hawthorns 03/02/06

Hawthorns 23/05/05

Hawthorns 02/09/04

Hawthorns 06/05/04

Hawthorns 13/10/03

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

CARE HOME ADULTS 18-65 Maytrees 2 Bushey Ground, Brize Norton Road Minster Lovell Witney Oxfordshire OX29 0SW Lead Inspector Catherine Kane Unannounced Inspection 5th July 2007 10:30 DS0000028948.V340668.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000028948.V340668.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000028948.V340668.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Maytrees Address 2 Bushey Ground, Brize Norton Road Minster Lovell Witney Oxfordshire OX29 0SW 01993 776336 01993 709056 princecres@aol.com 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) Meriden Homes Limited Miss Spiwe Shana Care Home 6 Category(ies) of Learning disability (0) registration, with number of places DS0000028948.V340668.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD). The maximum number of service users to be accommodated is 6. Date of last inspection 15th January 2007 Brief Description of the Service: The home is registered to provide care for up to six adults under 65 with a learning disability. The needs of residents have been described as mild to moderate learning disabilities and autistic spectrum disorder. The home is not registered to admit those requiring care mainly because of their physical disablement, dementia or mental disorder but strives to continue to care for those who become so, as long as it can continue to meet their needs. Residents’ mental health needs are secondary to their learning disability and these are met by the community mental health services. The fees for this service range from £1,500 to £2,100 weekly. Extras include toiletries, hairdressing, magazines and newspapers, spending money for holidays and some activities. No fee is charged for transport. DS0000028948.V340668.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 10.30am on Thursday, 5 July 2007 and was in the service for five and a half hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s owner or manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the service and other people seen during the inspection or who responded to questionnaires or surveys that the Commission had sent out. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. At the time of the visit the manager responsible for the service was present. Three members of staff were on duty. The inspector also met with the proprietors of the home. The inspector spoke with three of the four residents living in the home; one resident was currently staying away from the home at a treatment centre. She saw how staff help residents look after and take their medicines. She also looked at the resident’s care plan and other records kept in the home and made a tour of the part of premises. The inspector would like to thank the residents who shared their experience of this home. She also thanks the manager, staff on duty and the proprietors for their assistance with the inspection visit and all those who responded to CSCI surveys. What the service does well: What has improved since the last inspection? General cleanliness was seen to have improved to make the home a more pleasant and hygienic place for residents to live in. The home has improved how it carries out its staff recruitment procedures to comply with regulations. Staff have completed some training that will help them do their jobs better. DS0000028948.V340668.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. DS0000028948.V340668.R01.S.doc Version 5.2 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 DS0000028948.V340668.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2. Quality in this outcome area is good. The admission procedure is good although not tested, as there have been no new residents admitted to the home since the last inspection visit. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No residents have moved out nor any new residents have been admitted to the home since the last inspection visit. At the time of the inspection visit the home had two vacancies. Generally, admissions would not made to the home until a full needs assessment has been undertaken. The home would then be able to confirm that they can meet the needs of the individual through the service they deliver. DS0000028948.V340668.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 6, 7 and 9. Quality in this outcome area is good. The care planning system in place to provide staff with the information they need and for assessing risk is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection the inspector viewed three residents’ care plans. These were easy to understand, written in plain language, considered all areas of the individual’s life including health, personal and social care needs. Where appropriate, the plan contained relevant information in relation to the Care Programme Approach (CPA) as defined by Mental Health legislation. The plan is regularly reviewed and includes comprehensive up dated risk assessments. From the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. DS0000028948.V340668.R01.S.doc Version 5.2 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17. Quality in this outcome area is good. Opportunities for people who use this service to take part in a variety of interesting activities are good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection the inspector was in the home during the morning and afternoon. For most of that time all three residents accompanied by staff were out and about in the community doing planned activities that included lunch out. The inspector spoke with all three resident before they went out and spent more time with them when they returned. Two residents were able to provide the inspector with a very good idea about what it is like for them to live in this home. Another resident had more difficultly expressing their views but was able with the help of staff and care plan notes to give her an idea of some of the things they liked to do. DS0000028948.V340668.R01.S.doc Version 5.2 Page 11 From care notes seen most residents have a varied and busy programme of activities and frequently use local community facilities. One person told the inspector, proudly “I have a paper round. I’m doing it tomorrow with X (named staff member)”. Another said “I don’t like it here anymore.” Two residents completed surveys where they indicated that staff always listens to them. However, when asked in the survey ‘do staff treat you well’ two residents indicated ‘sometimes’ and “not all staff”. A relative of one resident returned a survey to the inspector. They indicated that home does well in giving people with a disability a home to be looked after. They said that they would prefer to be able to visit at short notice, not to need to phone about a week before visiting. Complex mental health needs and some other specific imposed restrictions of residents may be seen to get in the way of residents being able to make choices. However, from discussions with the residents and the manager there continues to be a commitment to ensuring that resident’s are able to fulfil their wishes as far as possible. The inspector was not in the home while any meal was being served or prepared but a variety of fresh and frozen foods and fresh fruit and vegetables were seen. Residents stated that the food served in the home was good and they were able to choose what and when they would like to eat. Regular drinks and snacks are available. Menus seen were varied and residents special dietary needs could be catered for. DS0000028948.V340668.R01.S.doc Version 5.2 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20. Quality in this outcome area is good. The personal and healthcare needs of residents are well met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Essential information needed by staff to be able to provide personal and health care support was included in residents’ files. Residents are registered with a local GP. The community learning disability team provides support and other community healthcare services are accessed when needed. The inspector saw how the home helped residents to access specialist healthcare when this was needed. Residents’ medicines are kept in a locked cabinet. The home uses a pharmacist produced medication administration record (MAR). Records seen were neat and well maintained. Most residents medicines are supplied in pharmacist produced monitored dose system. DS0000028948.V340668.R01.S.doc Version 5.2 Page 13 During the inspection the manager, who is a qualified nurse, demonstrated how a residents’ medicines are looked after and how residents are helped to take their medicines. Records were kept of staff assessed as competent to administer residents’ medicines. DS0000028948.V340668.R01.S.doc Version 5.2 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is good. The home has a protection from abuse policy and the complaints procedure is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager declared that home has received three complaints in the last year. The complaints log was seen during the visit and indicated that all complaints were dealt with in line with the home’s complaints policy. In surveys returned to the inspector two residents indicated that they knew how to make a complaint. The Commission has received information relating to one complaint in the last year. It was seen that this had been dealt with appropriately though the homes complaints procedure. Most staff has attended specific training on protecting vulnerable people from abuse and about local adult protection procedures and it was seen that training has been organised for staff to attend refresher training after three years. Staff who spoke with the inspector were clear about their responsibilities and were aware of the homes ‘whistle blowing’ policy. The manager informed the inspector that she has plans to complete training on local procedures for safeguarding vulnerable specific to her role. The Commission has received information relating to one adult protection issue since the last inspection. Information provided by the manager indicates that the home has co-operated fully and followed local safeguarding adults procedures. DS0000028948.V340668.R01.S.doc Version 5.2 Page 15 DS0000028948.V340668.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30. Quality in this outcome area is adequate. The home was tidy and generally clean at the time of the inspection visit but the décor in some areas of the home is in need of attention. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is an extended bungalow with shared areas, resident’s bedrooms, WC and bathrooms all coming off a narrow hallway. The home is situated in extensive grounds. The furniture and fittings are modern and domestic in style. The kitchen units are old and worn and need replacing. Carpets in the home are badly stained especially in the lounge and need thorough cleaning or replacing. The manager provided details of plans to decorate areas of the home and the inspector recommends that this takes place without delay. Cleaning schedules of tasks assigned to staff were seen. DS0000028948.V340668.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 32, 34 and 35. Quality in this outcome area is adequate. At the time of inspection staffing levels appeared to be appropriate for the needs of the current resident group to be met. This home has improved how it follows recruitment procedures but staff still need to complete some important training that would help them to do their jobs well. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector spoke with three members of staff on duty by telephone the day after the visit. Two members of staff had worked in the home for several years. One staff member had been recently recruited but had experience of working in the care sector. From the staffing rota seen for the previous month it was apparent that there was a moderate use of agency staff and permanent staff covering extra shifts. Declarations in staff files confirmed that staff have signed a working hours exemption and that they would agree to work longer hours. DS0000028948.V340668.R01.S.doc Version 5.2 Page 18 A social care professional stated in a survey returned to the inspector “The staff team at Maytrees have worked well in understanding my clients needs, setting boundaries and supporting him when he is anxious and restless”. The relative of one resident commented in the survey they returned, “I think they take what staff they can get. Some I have seen don’t look like they have the right skills”. The home keeps a record of training completed by staff; staff spoken with confirmed details of the training they have undertaken including the induction programme for new staff. One staff member commented that the recent training had been beneficial. The home has made efforts to improve the training programme that staff complete to cover mandatory training in first aid, food hygiene, health and safety and breakaway; some certificates were seen within staff files and details of training completed recently was seen. The manager provided details of planned training already booked with an external training provider. Specific mental health training, a requirement made at the last three inspections, was seen to be booked to take place but at the time this report was written staff had not yet completed this training. The manager explained that this is the first available opportunity of this specific training. To fully meet the needs of residents who have other identified complex care needs associated with their learning disability, including mental health issues, autistic spectrum disorders and dementia this staff team also needs to have the knowledge and skills in these areas. While many of the staff team have worked in the home for a long time, know individual residents well and show great willing they do not have the qualifications or have undertaken specific recognised training that would back up their knowledge and skills in these areas. The manager declared that of the nine permanent care staff only three have completed a relevant National Vocational Qualification (NVQ) therefore this home has not achieved the target of 50 staff trained to at least NVQ level 2. The manager declared that six other staff are working towards an NVQ qualification. The inspector viewed nine staff files including the files for one recently recruited staff member. These were organised and contained the necessary documentation including Criminal Record Bureau (CRB) checks. CRB renewals after three years for longer service staff were also seen. On the day of the inspectors visit the manager and the proprietors of the home were in process of interviewing prospective new staff. DS0000028948.V340668.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42. Quality in this outcome area is good. The registered manager has a good understanding of management areas in which the home needs to improve and has plans in place to address this. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has been in post since October 2006 and has successfully completed the process register as manager with CSCI. She is a qualified learning disability nurse. It is expected that the manager will complete further management qualifications to at least NVQ level 4 and she confirmed that she has started a Registered Managers Award course. Therefore this standard is rated as ‘standard almost met’ scored 2. The manager has sound knowledge and experience in care of people with a learning disability, quality assurance systems, equality and diversity issues, development and implementation of the DS0000028948.V340668.R01.S.doc Version 5.2 Page 20 services policies and procedures, good people skills, leadership of staff, responds to need and provides an good role model. She has a strong ethos of being open and transparent in all areas of running of the home and is aware of current developments both nationally and by CSCI and plans the service accordingly. The proprietor provided the inspector with details, outcomes and recommendations made in a recent Quality Assurance survey carried out by an external quality assurance auditor. This included the views of residents and their family representatives or advocates and all other stakeholders. The proprietors routinely carry’s out unannounced monthly visits and produces a report of their findings; these were made available in the home for inspection. The home has sound policies and procedures in line with current thinking and practice. Efficient systems are in place to monitor staff adherence to policies and procedures during their practice. The home works to a clear health and safety policy and checks take place to ensure the home meets relevant health and safety requirements and legislation. Records seen to be kept were good and were routinely completed. Where issues have been identified these have been acted upon to ensure residents’ care is not compromised. DS0000028948.V340668.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 3 X DS0000028948.V340668.R01.S.doc Version 5.2 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 23(2)(b Requirement Provide details of the maintenance, repair and renewal programme for furniture and fittings of the home with timescales to include repair or replacement of kitchen units and thoroughly clean or replace stained carpets. Provide training in mental disorder. This is an outstanding requirement with the original timescale set as 31/10/05 and 31/12/06 and 30/04/07. (At the inspection visit courses for this training were seen to be booked on the first available course. The manager must confirm in writing that when this has been completed.) Timescale for action 31/08/07 2. YA35 18(1)(c) 31/08/07 DS0000028948.V340668.R01.S.doc Version 5.2 Page 23 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 YA35 YA23 Good Practice Recommendations Ensure at least 50 of care staff are trained to at least NVQ level 2 or equivalent. The registered manager needs to complete training on local safeguarding vulnerable adults procedures. DS0000028948.V340668.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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. 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