Inspection on 28/06/05 for The Maples

This inspection was carried out on 28th June 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 02/11/05

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 S75 5PE Lead Inspector Susan Smith Unannounced 28 June 2005 07:40 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 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 J51 63554 The Maples V237097 28.06.05 UI Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Maples Address 66 Bence Lane Darton Barnsley S75 5PE 01226 382688 01226 382688 None Mrs Parvin Riaz Khan Mr Rizwan Iqbal Mr Asif Riaz Khan Miss Karen Stephenson PC Care home only 15 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) Category(ies) of OP - Old age (15) registration, with number of places The Maples J51 63554 The Maples V237097 28.06.05 UI Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 28 October 2004 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 J51 63554 The Maples V237097 28.06.05 UI Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place from 07:40 to 14:30. Opportunity was taken to tour the premises, examine records and talk with service users and staff. All of the service users were seen during the inspection. Six service users and one visitor were spoken to. All expressed their views of the service provided. On my arrival it was positive to see service users getting up as they pleased in a relaxed atmosphere. Staff and service users were friendly and welcoming and there was a positive rapport between staff and service users. What the service does well: What has improved since the last inspection? 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 J51 63554 The Maples V237097 28.06.05 UI Stage 4.doc Version 1.40 Page 6 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 Standards Statutory Requirements Identified During the Inspection The Maples J51 63554 The Maples V237097 28.06.05 UI Stage 4.doc Version 1.40 Page 7 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 standard(s) 1,2,3,4 and 5. Six is not applicable to this home. All service users had been provided with the statement of purpose, service user guide and a statement of their terms and conditions. Service users had had their needs assessed to ensure the home was able to meet their health, social and care needs. EVIDENCE: The contract / statement of terms and conditions contained the range of information required. All had their own copy of the service user guide. The admission process was well managed and all service users had their needs assessed prior to their admission. Three service users files contained a copy of the full needs assessment. The service users and or their representatives had been included with the drawing up of these plans. Service users said that they and their relatives had visited the home prior to making their minds up that this was the home for them. All felt well informed about the home before and after their arrival. The Maples J51 63554 The Maples V237097 28.06.05 UI Stage 4.doc Version 1.40 Page 8 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 standard(s) 7,8,9,10 and 11. Three care plans checked set out in detail the service users needs and the action to be taken by care staff to ensure these needs were met. A range of health care professionals visited the home to assist in maintaining the health care needs of the service users. Service users were treated with respect, privacy and dignity by staff. Service users were encouraged to be responsible for their own medication and medication was dispensed safely. The Maples J51 63554 The Maples V237097 28.06.05 UI Stage 4.doc Version 1.40 Page 9 EVIDENCE: Files checked did demonstrate that the service users had been given the opportunity to confirm that their plan of care was a true reflection of their individual needs. Each service user had a care plan that included risk assessments. Three care plans tracked set out in detail the service users needs and the action to be taken by the care staff to ensure these could be met. Nutritional screening had been undertaken and weight-monitoring records were maintained on a monthly basis. However there was no evidence recorded that the care plans had been reviewed monthly. The six service users and one relative spoken with said the quality of personal care could not be faulted. Service users confirmed that their health care needs were being met. They were able to give examples of this during the inspection. The manager confirmed that three service users were suffering from pressure sores. The district nurse was visiting on the day of inspection and the treatment provided was reviewed on a regular basis. Appropriate equipment was provided for the promotion of tissue viability. Relatives spoken with said the quality of care could not be faulted. Service users said that they were happy at the home and felt staff had the time to listen. If they had a problem staff were available to help them with it. Administration of medication was observed and was considered safe. Threeservice users medication and records (MAR) were checked and found to be correct and up to date. Throughout the inspection staff were observed to treat service users with dignity and respect. One relative said, “That she could leave her mother knowing that she was being well cared for by a caring and committed staff group”. She visited regularly and was always made welcome. Her mother was always well dressed and her room clean and fresh. Service users were well dressed in clean clothes and looked well cared for. Policies and procedures for handling dying and death were in place and observed by staff. The Maples J51 63554 The Maples V237097 28.06.05 UI Stage 4.doc Version 1.40 Page 10 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 standard(s) 12,13,14 and 15. Service users had a varied choice of lifestyle within the home. Visitors were encouraged and they were able to maintain contact with family, friends and the local community. Meals served at the home were of a good quality and offered choice. EVIDENCE: Service users were observed spending their day as they wished. The majority of service users were in the lounges talking with other service users and listing to music of their choice. Service users said that they were happy with the daily activities provided. The service users had recently been to the local theatre and stated that they had enjoyed it. Two service users said that they enjoyed spending time sitting in the garden. Visitors said they were always made welcome at any time and refreshments were available. Service users commented on the daily choice of food and said it was good. The menus were balanced and flexible to accommodate individual likes and dislikes. The breakfast and lunch meal were observed and service users were given sufficient time to eat in a relaxed manner. Table presentation was good and the meals served looked appetising and well presented. Several service users required assistance and this was given appropriately and discreetly. The cook had a good knowledge of the service users special diets and likes and dislikes. The Maples J51 63554 The Maples V237097 28.06.05 UI Stage 4.doc Version 1.40 Page 11 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 standard(s) 16,17 and 18 The home had a complaints procedure that was clear and accessible. Complaints made by service users and their relatives were listened to and action was taken to deal with them promptly. Staff had an understanding of the procedure to be followed should they suspect any abuse at the home EVIDENCE: The complaints procedure was displayed at the home. The service users spoken with said that if they had any concerns they would feel comfortable talking to the manager. Discussions with service users confirmed that they felt they had nothing to complain about and were happy and well cared for. The home had an adult protection policy and procedure that promoted the protection of service users from harm or abuse. Not all staff had received formal training on adult abuse. The Maples J51 63554 The Maples V237097 28.06.05 UI Stage 4.doc Version 1.40 Page 12 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 standard(s) 19,20,23,,24 and 26 The environment within the home was on the whole well maintained and clean providing a comfortable and safe environment for service users. EVIDENCE: The grounds were well kept, safe and accessible to all service users, who said they enjoy spending time out side in the summer months. The home was welcoming and clean, with no unpleasant odours. Service users spoken with said the home was comfortable and clean. All were able to personalise their rooms and said they were happy and settled. The home had the appropriate amount of sitting, recreational and dining space. A full range of the appropriate aids and adaptations were provided. These included grab rails, adapted baths and a mobile hoist. One of the seams on the ground floor corridor carpet was worn. The front lounge was in need of redecoration. The majority of staff had undertaken infection control training. The Maples J51 63554 The Maples V237097 28.06.05 UI Stage 4.doc Version 1.40 Page 13 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30 Staff were employed in sufficient numbers to meet the needs of service users in accordance with agreed staffing levels. A training and development programme was in place, which met the changing needs of services users. EVIDENCE: The staff rota identified that the numbers and skill mix of staff was meeting service users needs. Staff spoken with felt that the staff numbers were adequate to meet the needs of service users. Over fifty percent of care staff had achieved their level two NVQ qualification. The staff stated they worked effectively as a team and said that the training opportunities available to them were good. Three staff files were seen and these did contain all the relevant documentation required. All staff had undertaken induction and foundation National Training Organisation (NTO) workforce training. The manager stated that she was very committed to staff training. The stafftraining files clearly demonstrated that staff had attended a full range of training appropriate to their job role. The Maples J51 63554 The Maples V237097 28.06.05 UI Stage 4.doc Version 1.40 Page 14 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,35,36,37 and 38 The manager is competent and experienced. Service users benefited from her management approach by ensuring staff were trained to meet their needs. Safe working practices were in place to promote health, safety and welfare of service users. The Maples J51 63554 The Maples V237097 28.06.05 UI Stage 4.doc Version 1.40 Page 15 EVIDENCE: The manager had kept up to date with current practice and is presently working towards her NVQ level four. Service users, visitors and staff described the manager “As good and very approachable. All felt their opinions really mattered and were taken into account when choices were being made. Service users families were invited to their in house entertainment and outings. This was reinforced on the day when speaking to service users. Records examined indicated that staff were receiving formal supervision. Procedures were in place that promoted the health, safety and welfare of staff. The fire equipment was checked weekly and fire drills were held regularly. Mandatory health and safety training was ongoing. The manager stated that approved contractors had checked all the major systems. The Maples J51 63554 The Maples V237097 28.06.05 UI Stage 4.doc Version 1.40 Page 16 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 x x 3 2 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 2 2 3 3 x 3 3 3 3 The Maples J51 63554 The Maples V237097 28.06.05 UI Stage 4.doc Version 1.40 Page 17 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 7 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. All staff must undertake training in adult abuse and protection of vunerable adults. All parts of the home used by service users must be maintained in good condition includiong the corridor carpet. (Previous time scale 23rd December 2004 not met by previous owner). The lounge requires a programme of redecoration. Timescale for action 2nd August 2005. 2. 3. 18 19 13 16 20th September 2005. 2nd August 2005. 4. 19 16 20th September 2005. 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 31 Good Practice Recommendations The registered manager should achieve the managers award by 2005. J51 63554 The Maples V237097 28.06.05 UI Stage 4.doc Version 1.40 Page 18 The Maples Commission for Social Care Inspection 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 J51 63554 The Maples V237097 28.06.05 UI Stage 4.doc Version 1.40 Page 19 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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