Inspection on 02/11/05 for The Maples

This inspection was carried out on 2nd November 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

The Maples 06/12/07

The Maples 11/12/06

The Maples 28/06/05

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE The Maples 66 Bence Lane Darton Barnsley South Yorkshire S75 5PE Lead Inspector Jayne Barnett-Middleton Unannounced Inspection 2nd November 2005 10:00 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 The Maples DS0000063554.V261114.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. The Maples DS0000063554.V261114.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Maples Address 66 Bence Lane Darton Barnsley South Yorkshire S75 5PE 01226 382 688 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) Mrs Parvin Riaz Khan Mr Rizwan Iqbal, Mr Asif Riaz Khan Miss Karen Stephenson Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places The Maples DS0000063554.V261114.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th June 2005 Brief Description of the Service: The Maples is an extended detached bungalow and is registered to provide personal care for 15 persons over the age of 65. The home is set back from the road amid mature gardens. The Maples is situated in the village of Darton and is approximately three miles from Barnsley town centre and a few minutes drive from the M1 Motorway junction 38. There is adequate car parking at the front of the home. The Maples DS0000063554.V261114.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out from 10am to 2.45 pm. Most of the service users were seen during the inspection. Eight service users, three staff, one visitor and the manager were spoken to. A sample of records was examined and a partial inspection of the building was carried out. Throughout the inspection positive and professional relationships were observed between staff and service users. The inspector wishes to thank the manager, staff and service users for their time and co-operation throughout the inspection process. What the service does well: What has improved since the last inspection? The majority of previous requirements had been met. The corridor carpet had been repaired and the lounge had been redecorated to a good standard. Staff had received training in adult protection and the protection of vulnerable adults. The Maples DS0000063554.V261114.R01.S.doc Version 5.0 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 Maples DS0000063554.V261114.R01.S.doc Version 5.0 Page 7 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 The Maples DS0000063554.V261114.R01.S.doc Version 5.0 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 5. Service users were not admitted to the home without their needs being assessed, to ensure the home was able to meet their health, social and care needs. Service users and their relatives were given the opportunity to visit the home prior to their admission. EVIDENCE: A full needs assessment was carried out for all service users prior to their admission. Staff from the home also visited prospective service users prior to their admission. This confirmed that the service was appropriate for the service user, and provided staff with the information to formulate an individual plan of care. The Maples DS0000063554.V261114.R01.S.doc Version 5.0 Page 9 Service users and their relatives were invited to visit the home prior to their admission, to assess the quality, facilities and suitability of the home. The manager confirmed that service users were able to spend a day at the home prior to moving into the home. Several service users confirmed that they had visited the home prior to their admission. The home does not provide an intermediate care service. The Maples DS0000063554.V261114.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Service users individual needs were assessed and their changing needs were reflected in their plan of care. Service users had good access to health care services, which met their assessed needs. A policy and procedure to ensure that staff adhered to the safe administration of medication was in place. Service users privacy and dignity was respected. EVIDENCE: Three Care plans set out in detail the action that was required by staff to ensure that all aspects of service users care needs were met. Service users and their representatives had been given the opportunity to confirm that their plan of care was a true reflection of their individual needs. One Care plan had not been reviewed on a regular basis to reflect the changing care needs of the service user. One care plan did not evidence that the service user had been consulted about their preferred funeral arrangements, to ensure that any specific requests and spiritual needs could be respected. The files checked were generally of a good standard and information was accessible and easy to track. The Maples DS0000063554.V261114.R01.S.doc Version 5.0 Page 11 Records of healthcare visits were maintained and these evidenced that healthcare professionals, e.g. general practitioner, chiropodist and optician were visiting service users. Nutritional screening had been undertaken and weight monitoring records were maintained on a monthly basis. Service users said that their health care needs were met and were able to describe the visits and care that they received. The manager confirmed that three service users were suffering from pressure sores. Appropriate equipment for the promotion of tissue viability was provided and district nurses were visiting the service users on a frequent basis. There was a policy and procedure to ensure that staff adhered to safe practices regarding medication and the protection of service users. The recording and storage of medication was checked on a sample basis. Medication had been administered appropriately. Staff had received medication training, which promoted the safe administration of medication. Service users were observed to be receiving personal care in a manner that respected their privacy and dignity. Service users were well dressed and had received a good standard of personal care. All service users and one relative spoke positively about the standard of care provided commenting, “ I am very well cared for” and “I know that in my absence mum is well cared for”. The Maples DS0000063554.V261114.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. The daily routines within the home were flexible and promoted service user choice. Service users were encouraged to maintain contact with their family, friends and the local community as they wished. A good choice of menu was offered and special dietary needs were catered for EVIDENCE: The daily routines within the home were flexible. Service users said that they could spend the day as they wished and described how they spent their day “ I always go out for a daily walk ” and “ read and watch TV”. Several service users were observed to be spending time in the lounges whilst other’s had chosen to spend the day in the privacy of their bedroom. Service users said that they could get up and go to bed as they wished and confirmed that the staff respected their choices. Service users were encouraged to maintain links with their family and friends. Service users confirmed that their relatives were welcome to visit them at anytime. A good choice of menu was offered. The cook confirmed that menus were reviewed on a regular basis based on service users likes and dislikes. The Maples DS0000063554.V261114.R01.S.doc Version 5.0 Page 13 One member of staff commented that food supplies were on occasions allowed to run low. However, discussions with the manager and a check of the food supplies confirmed that there was sufficient stock to meet the weekly menus. Service users said that they enjoyed their meals and described the food as “good”, “good choice” and “always plenty ”. One relative who visited the home at mealtimes commented that the food was “excellent”. The lunch meal was observed. Table presentation was good and the meals served looked appetising and well presented. One service user confirmed that they liked to get up early in order to take their time in getting washed and dressed for breakfast. They commented that they used to be offered a morning drink prior to their breakfast, however that this routine appeared to have ceased. The Maples DS0000063554.V261114.R01.S.doc Version 5.0 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. The complaints procedure was clear and accessible. Complaints made by service users and their relatives were listened to and action was taken to deal with complaints promptly. There was an adult protection procedure and all staff had received adult protection training. EVIDENCE: The complaints procedure ensured that service users and their relatives were aware of how to make a complaint and who would deal with them. Service users stated that they were satisfied with the care provided and they had no complaints. There was an adult protection policy and procedure that promoted the protection of service users from harm or abuse. A previous requirement to ensure that all staff had received adult protection training had been met. The Maples DS0000063554.V261114.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,23,24,25 and 26. The home was clean, comfortable and well maintained. Service users were provided with an environment that was safe, accessible and homely. EVIDENCE: The home had a warm and welcoming atmosphere. The home was very clean and presented a hygienic environment. One relative said that the home was “always clean”. The grounds of the home were attractive and well maintained. Several service users commented that they had enjoyed spending time outside during the warm weather. Previous requirements to repair the corridor carpet and to redecorate the front lounge had been met. The Maples DS0000063554.V261114.R01.S.doc Version 5.0 Page 16 Several bedrooms were checked and all were very clean and attractively decorated. All the rooms had been personalised by the service user with photographs and mementoes, which encouraged service users to retain their own identity. Service users confirmed that they liked their bedrooms and described how they were able to bring small items of furniture on their admission. Laundry facilities were sited away from food preparation and service users areas, to ensure that any soiled linen was not carried through areas where food was prepared and did not intrude on service users. Staff confirmed that they had attended Infection Control training, to promote a hygienic environment to control the risk of infection. The Maples DS0000063554.V261114.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28,29 and 30. A training and development programme was in place. Staff received regular training, which enabled them to meet the needs of service users. The home operated a recruitment procedure. Staff files did not contain all of the required information. EVIDENCE: Service users and relatives spoke positively about the staff team and described them as “very good” and “brilliant”. The manager commented that there was a low turnover of staff, which promoted a consistent quality of care to service users. Over 50 of the staff team held a level 2 or 3 National Vocational Qualification in Care, which developed the skills and competence of staff, to enable them to meet the changing needs of service users. A training and induction programme for staff was in place that met National Training Organisation (NTO) workforce training targets to enable them to meet the assessed and changing needs of service users. Staff confirmed that they had attended various training courses that included food hygiene, adult protection, moving and handling and infection control. The staff files demonstrated that a good range of training was available for staff appropriate to their job role. The Maples DS0000063554.V261114.R01.S.doc Version 5.0 Page 18 A recruitment policy and procedure was in place that promoted the protection of service users. Staff files checked did not contain a full employment history of the employee. One file checked did not contain a recent photograph of the employee or proof of the person’s identity. All staff employed had undertaken a Criminal Records Bureau Check at the enhanced level. The Maples DS0000063554.V261114.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,35 and 38. Service users and staff benefited from the ethos, leadership and management approach. Service users financial interests were safeguarded by the procedures at the home. The homes policies and procedures promoted the health, safety and welfare of residents and staff. EVIDENCE: The registered manager was due to resign post and was in the process of inducting the new proposed registered manager. The proposed manager had worked at the home for two years and had a good understanding of the staff team and service users needs. She commented that she had received a good induction and appeared positive in her new role. The Maples DS0000063554.V261114.R01.S.doc Version 5.0 Page 20 Service users were encouraged to manage their own finances, which enabled them to maintain their independence. Arrangements were in place for service users who were unable to manage their monies due to their mental health. Monies were securely stored and records checked evidenced that service users were able to access their monies for hair care and personal items as they wished. The records checked were well maintained and safeguarded the financial interests of service users. Records demonstrated and staff confirmed that they were receiving supervision on a regular basis. Staff meetings were held to enable staff to contribute to the development of the service. Due to management changes, a recommendation was made to increase the frequency of staff meetings. Fire drills were being conducted on a regular basis. Records demonstrated that staff had received regular drills to ensure that they were fully conversant with the action that they needed to take in the event of a fire. Detailed Records of accidents and injuries were maintained to ensure that service users were provided with the appropriate observation and supervision required. The staff had received regular training, which promoted safe working practices and the health, safety and welfare of service users and their colleagues. The Maples DS0000063554.V261114.R01.S.doc Version 5.0 Page 21 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 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X 3 3 3 3 STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X 3 X X 3 The Maples DS0000063554.V261114.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement The plan of care must be reviewed at least once a month to reflect the changing needs and current objectives for health and personal care.(Timescale of 2nd August 2005 not met) Service users preferences regarding funeral arrangements must be recorded on their care plan. Drinks must be available at all times and offered regularly. Staffs’ personal files must contain a recent photograph of the employee. Timescale of 1st August 2005 not met. Staffs’ personal files must contain a record of the employee’s full employment history. Any gaps in employment must be accounted for and recorded. Timescale of 31st August 2005 not met. Staffs personal file must contain proof of the person’s identity. Timescale for action 05/12/05 2. OP7 12,13 05/12/05 3 4 OP15 OP29 16 19 01/12/05 10/12/05 5 OP29 19 10/12/05 6 OP29 19 10/12/05 The Maples DS0000063554.V261114.R01.S.doc Version 5.0 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 OP31 OP32 Good Practice Recommendations The registered manager should achieve the managers’ award. The frequency of staff meeting should be increased. The Maples DS0000063554.V261114.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 The Maples DS0000063554.V261114.R01.S.doc Version 5.0 Page 25 - 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!