Inspection on 25/08/05 for Mrs Floretta McLune

This inspection was carried out on 25th August 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Mrs Floretta McLune 29/09/07

Mrs Floretta McLune 20/02/07

Mrs Floretta McLune 23/02/06

Mrs Floretta McLune 23/02/05

Mrs Floretta McLune 16/09/04

Mrs Floretta McLune 23/03/04

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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 Maple Leaf Drive 10 Maple Leaf Drive, Marston Green Solihull B37 7JB Lead Inspector Sarah Bennett Announced 25 August 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. Maple Leaf Drive E54_S4550_MapleLeafDrive_V239395_250805Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Maple Leaf Drive Address 10 Maple Leaf Drive Marston Green Solihull B37 7JB 0121 770 8931 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) Floretta McLune Floretta McLune Care Home 4 Category(ies) of Learning Disability (4) registration, with number of places Maple Leaf Drive E54_S4550_MapleLeafDrive_V239395_250805Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Three permanent places for adults with a learning disability. 2. One respite place for an adult with a learning disabilty, who is known to, and has been assessed as compatible with, the permanent service user group. 3. Use of the room measuring 7.9sq metres to be reviewed when vacated by the current permanent service user, and prior to the possible admission of any future service users to this room. Date of last inspection 23rd February 2005 Brief Description of the Service: 10 Maple Leaf Drive is an attractive five bedroomed family home in the Marston Green area of Solihull. It is situated in a pleasant newly built private estate. There is a bus route and local amenities within walking distance of the home. The main Chelmsley Wood shopping centre is a short car or bus ride away. The home caters for younger adults who have a learning disability. It is registered to provide care for three people on a long-term basis and one person for short-term respite care. The condition that is placed upon this service by the Commission for Social Care Inspection is that the residents who reside at the home must know the person that is receiving respite care and be happy for them to stay at their home. Each resident has their own bedroom. The respite bedroom has an en suite shower and WC. There is a separate bathroom with a bath, shower and WC. There is a WC on the ground floor. Care and support, is provided in the main by Mrs McClune and her family. Mrs McClune lives in the property with her husband. One of their nieces is employed on a full time basis to assist the residents, other family members are employed on a part time basis. The philosophy of the home is that the residents are considered to be members of the family. Maple Leaf Drive E54_S4550_MapleLeafDrive_V239395_250805Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over six hours. Three residents were spoken to. The owner, her husband and a member of staff were spoken to. Care, staff and health and safety records were looked at. Two residents records were sampled. A tour of the premises took place. All three residents completed comment cards, two comment cards were received from relatives/friends and two from professionals involved in the care of residents. The Assistant Manager completed the pre-inspection questionnaire before the inspection. What the service does well: What has improved since the last inspection? A quality assurance system has been put in place so that the owner can monitor and if necessary improve the service they are providing. The owner has started formal supervision sessions with staff so that their performance can be monitored and improved where necessary and any training needs can be identified. Maple Leaf Drive E54_S4550_MapleLeafDrive_V239395_250805Stage 4.doc Version 1.40 Page 6 Staff have received all the relevant training to help them to meet the needs of each resident. 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. Maple Leaf Drive E54_S4550_MapleLeafDrive_V239395_250805Stage 4.doc Version 1.40 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 Maple Leaf Drive E54_S4550_MapleLeafDrive_V239395_250805Stage 4.doc Version 1.40 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) 1, 5 Prospective residents have the information they need to make an informed choice about where to live. Each resident has an individual written contract so that they are aware of the terms and conditions of their stay at the home. EVIDENCE: The statement of purpose of the home and the service users guide to the home include all the relevant and required information. The speech and language therapist is helping to put the service users guide into an accessible format for the residents. Photographs have been taken and a draft copy was seen. Residents records included individual contracts that stated the terms and conditions of their stay at the home. The resident and the owner had signed the contract. Maple Leaf Drive E54_S4550_MapleLeafDrive_V239395_250805Stage 4.doc Version 1.40 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, 8, 9 Resident’s assessed needs and goals are reflected in their individual care plans so that staff know how to support each individual. Resident’s are consulted on, and participate, in many aspects of life in the home. Residents are supported to take positive risks within a risk assessment framework. EVIDENCE: Resident’s records included individual care plans that included how staff are to support residents with their personal hygiene, nutrition, money, medication, health needs, daily routines, activities, going out in the community, relationships and behaviour. The resident, their relatives where appropriate, the owner, staff and any professionals involved in the residents care are involved in developing and reviewing the care plan. Staff have made referrals to speech and language therapy for their help to improve individual residents communication skills. Guidelines from the speech and language therapist are in place so that all staff can help residents to communicate their needs and wants well. Maple Leaf Drive E54_S4550_MapleLeafDrive_V239395_250805Stage 4.doc Version 1.40 Page 10 Monthly residents meetings take place in the home. Minutes showed that all residents are involved in these and discuss holidays, college classes, activities, complaints and inspections. Resident’s records included individual risk assessments for mobility, using hot water, behaviour, road safety, using public transport independently, self-harm, and using the kitchen. The owner said that she is trying to find a suitable video that residents can watch so they can have a greater understanding of the risks of fire and how they can help to prevent a fire starting in the home. Maple Leaf Drive E54_S4550_MapleLeafDrive_V239395_250805Stage 4.doc Version 1.40 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) 13, 14, 15, 16, 17 Arrangements are in place so that people living at the home experience a meaningful lifestyle. Resident’s are offered a variety of food, enjoy their meals and have a healthy diet. EVIDENCE: Each resident has their individual activities during the day either accessing day centres and college classes or doing activities in the home or the local area supported by staff. Where residents are able to they travel independently using their bus pass. One resident was at the day centre during the day. The other two residents went out shopping and for lunch at a Chinese restaurant supported by staff. Later in the afternoon they went out for a local walk. Residents said and records indicated that they go swimming, play football, badminton, go to computer classes, go for walks, visit the cinema, discos, shopping, library, pubs, go on day trips to Weston and Stratford and visit restaurants. Maple Leaf Drive E54_S4550_MapleLeafDrive_V239395_250805Stage 4.doc Version 1.40 Page 12 In addition residents said and records indicated that they play card games, bingo and pool in the home. They also do some art and craft activities if they want to. There are regular DVD evenings in the home. Residents use public transport, ‘Ring and Ride’ and the vehicle provided by the home to access the community. Residents said that they went on holiday to Wales for a week earlier in the summer and had a good time. Throughout the day residents participated in household tasks including making drinks, preparing food, laying the table and washing up. Residents talked about visits from and to their friends and family where they sometimes stay overnight. One resident has an advocate. Where appropriate special diets are taken into consideration and catered for. Fresh fruit and vegetables were available. Culturally appropriate foods are provided if residents wish to have these. Maple Leaf Drive E54_S4550_MapleLeafDrive_V239395_250805Stage 4.doc Version 1.40 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 Resident’s receive personal support in the way they prefer and require. The arrangements for meeting all resident’s health needs are not adequate. Some arrangements for the management of the medication are not adequate to ensure residents health care needs are fully supported and protected. EVIDENCE: Residents care plans stated how each individual is to be supported by staff with their personal care and how staff are to support residents to develop these skills. Where appropriate health professionals are involved in the care of residents. These include psychologists, psychiatrists, speech and language therapists and dietician. Each resident is registered with a local GP. Residents have regular check ups with the dentist, optician and chiropodist if appropriate. Residents are weighed each month and a record of this is kept. Weight charts showed that resident’s weights are fairly stable. Health Action Plans are not in place. Information about these was sent to the owner after this inspection. Medication is stored in a locked cabinet. Boots supply the resident’s medication using the monitored dosage system. Medication administration records were signed and cross-referenced with the monitored dosage system, indicating that medication had been given as prescribed. One resident is prescribed PRN (as Maple Leaf Drive E54_S4550_MapleLeafDrive_V239395_250805Stage 4.doc Version 1.40 Page 14 required) medication. The owner said when this medication would be given to the resident but a written protocol stating this was not in place. Maple Leaf Drive E54_S4550_MapleLeafDrive_V239395_250805Stage 4.doc Version 1.40 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) 22, 23 The arrangements for managing complaints ensure that resident’s views are listened to and acted on. There are adequate arrangements to ensure that residents are protected from abuse, neglect and self-harm. EVIDENCE: The complaints policy included all the relevant and required information including the role of the CSCI in dealing with complaints. There have been no complaints since the last inspection. Resident’s records included individual behaviour management guidelines. These had been drawn up with the help of the psychologist and focused on distracting residents to minimise any ‘difficult’ behaviours and not on physical intervention. Staff have received training in the prevention of abuse. Individual risk assessments are in place where residents are at risk of selfharm and strategies are followed to minimise the risks. Maple Leaf Drive E54_S4550_MapleLeafDrive_V239395_250805Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26, 27, 28, 30 Residents live in a homely, comfortable, safe and clean environment that meets their individual needs. EVIDENCE: All areas of the home are well decorated and maintained. On the ground floor there are two lounges, a kitchen/dining room and a conservatory, which is used as a lounge/dining room. Sky TV is provided in one of the lounges. There is a pool table in the conservatory. Resident’s bedrooms are on the first floor. The respite bedroom has an en suite shower and WC. There is a separate bathroom with a bath, shower and WC. There is a WC on the ground floor. Resident’s bedrooms were decorated according to individual tastes and interests and contained many personal possessions. Residents said that they have a lot of their own things and are supported by staff to buy what they want. To the rear of the home there is a garden with grassed areas, flowerbeds and a patio with garden furniture. One of the residents said they like helping with the gardening. The home was clean and free from offensive odours. Maple Leaf Drive E54_S4550_MapleLeafDrive_V239395_250805Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35, 36 Residents are supported by an effective staff team who receive the appropriate training and support to meet individual residents needs. EVIDENCE: Regular staff meetings take place and minutes of these are kept. The majority of the staff employed are members of the owner’s family and have worked at the home for a number of years. Residents said that staff support them and that they are caring. Residents and staff talked to each other throughout this inspection and it was obvious that the staff knew the residents well. The Assistant Manager said that they are leaving the home to take up a new position although they will still have contact with the residents. A local agency has been contacted and candidates are to be interviewed by the owner to cover this vacancy. Staff have received training in first aid, food hygiene, health and safety, the prevention of abuse, medication, moving and handling, autism, dealing with aggression, infection control, bereavement, continence and communication. The owner has completed NVQ level 4 and the Assistant Manager is currently undertaking this. The owner and her husband will be doing the Learning Disability Award Framework (LDAF) training in September 2005. Maple Leaf Drive E54_S4550_MapleLeafDrive_V239395_250805Stage 4.doc Version 1.40 Page 18 Since the last inspection staff have received formal supervision sessions with the owner. An appraisal system has been put in place that will be completed for all staff each year. Maple Leaf Drive E54_S4550_MapleLeafDrive_V239395_250805Stage 4.doc Version 1.40 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 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) 39, 42 Resident’s views underpin the self-monitoring of the home. The safety and welfare of residents is not adequately promoted or protected. EVIDENCE: Since the last inspection a quality assurance system has been put in place. This is detailed and includes comments from residents. A fire alarm system is not provided in the home. There are smoke detectors in each room. Fire records showed that these are tested weekly to make sure they are working. A fire drill took place on 5th August 2005. The records of this stated who was involved and how they reacted during the evacuation of the home. The fire extinguishers were serviced in February 2005. An engineer services the gas equipment yearly. An electrician tests the portable electrical appliances yearly. Fridge and freezer temperatures are taken and recorded daily to make sure they are at the correct temperature to store food appropriately. Cleaning materials and hazardous products are stored in a locked cupboard. Maple Leaf Drive E54_S4550_MapleLeafDrive_V239395_250805Stage 4.doc Version 1.40 Page 20 Incident records showed there had been two incidents where a resident had been physically aggressive to staff. These had been reported to Social Services but not to the CSCI as required. Maple Leaf Drive E54_S4550_MapleLeafDrive_V239395_250805Stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x x x 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 4 x 3 3 3 x 3 Standard No 11 12 13 14 15 16 17 x x 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x x 3 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Maple Leaf Drive Score 3 2 2 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 2 x E54_S4550_MapleLeafDrive_V239395_250805Stage 4.doc Version 1.40 Page 22 No 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 19 20 Regulation 12 (1) (a) 13 (2), (4) ( c) Requirement Each resident must have a Health Action Plan in line with the Valuing People document. For each resident who is prescribed PRN (as required) medication a protocol must be in place. This must state when, why and how much of the medication is to be given. Any event that affects the well being of a resident must be reported to the CSCI. Risk assessments must be in place for fire safety and food storage and preparation. Timescale for action 31st January 2006 30th September 2005 & ongoing Immediate & ongoing 31st October 2005 3. 4. 42 42 37 13 (4) (a, b, c), 23 (4) (a), HSWA 1992 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 Good Practice Recommendations Maple Leaf Drive E54_S4550_MapleLeafDrive_V239395_250805Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Maple Leaf Drive E54_S4550_MapleLeafDrive_V239395_250805Stage 4.doc Version 1.40 Page 24 - 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!