Inspection on 06/12/07 for The Maples

This inspection was carried out on 6th December 2007.

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

The inspector 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 11/12/06

The Maples 02/11/05

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 Christine Rolt Key Unannounced Inspection 6th December 2007 09:45 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Maples DS0000063554.V355706.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Maples DS0000063554.V355706.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Maples Address 66 Bence Lane Darton Barnsley South Yorkshire S75 5PE 01226 382 688 none none 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 Mrs Vicky Brook Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places The Maples DS0000063554.V355706.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th December 2006 Brief Description of the Service: The Maples is an extended detached bungalow and is registered to provide personal care for 15 older persons. The home is set back from the road amid mature gardens. There is off road car parking at the front of the home. The Maples is 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. The weekly fee was £364.00, which included a top up fee. Hairdressing, chiropody, personal newspapers and toiletries were not included in the weekly fee and were charged separately. The manager supplied this information during the site visit on 6th December 2007. People were issued with copies of the home’s Service User Guide and Brochure and copies of the Service User Guide were available in their bedrooms. The Maples DS0000063554.V355706.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection and comprised information already received from or about the home and a site visit. The site visit was from 9.45 am to 6.15 pm on 6th December 2007. The registered manager Mrs V. Brook completed an Annual Quality Assurance Assessment before the site visit. This document gave her the opportunity to say what the home did well, what had improved and what they were working on to improve. Various aspects of the service were then checked during the site visit. Care practices were observed, a sample of records was examined, a partial inspection of the building was carried out and service provision was discussed with the manager. The majority of people living at the home were seen throughout the day and chatted to. The care provided for four people was checked against their records to determine if their individual needs were being met. Questionnaires were sent to four people living in the home, four relatives and three health or social care professionals. Completed questionnaires were received from three people living in the home and three relatives, but none from health or social care professionals. On the day of the site visit, opportunity was taken to chat to three visitors and a community nurse. Information and comments from the surveys and the discussions are included in this report. The inspector wishes to thank people living at the home, relatives and friends, the staff, the community nurse and the manager for their assistance and cooperation. What the service does well: People considered that the home was well run, the staff were caring and the meals were good. Comments were: “I can only speak highly of the Maples from the lady in charge to the staff and the catering department. My mother is happy and content in the Maples and the home is a credit to all who run it.” “The home is well run, with an excellent lady in charge – no cause for criticism.” “They have cared for my mum very well, they have tried to make her feel truly at home and really welcome.” “Can’t speak for the other residents, but my mother always speaks well of the staff.” “As we have only been involved with the care home a short time. All the staff appear to be very dedicated and caring. The food also is excellent and very well cooked.” The Maples DS0000063554.V355706.R01.S.doc Version 5.2 Page 6 “The cooks prepare meals very efficiently. There is always a good variety and always presented well. The cooks do their job well also. The care staff also are worth a mention, nothing is too much trouble” “A very comfortable and relaxed, happy care home.” “Have only been here 2 ½ months but it seems satisfactory.” 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 summary of this inspection report can be made available in other formats on request. The Maples DS0000063554.V355706.R01.S.doc Version 5.2 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.V355706.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People had the information they needed to make an informed choice. Assessments did not provide sufficient information to ensure that people’s needs could be met. This home does not provide intermediate care. EVIDENCE: People were issued with copies of the home’s Service User Guide and Brochure and copies of the Service User Guide were available in their bedrooms. People who were asked said that they had chosen this home because “there are no stairs”, “like the bungalow style”, “came for day care for two years” and “reputation”. The assessments for four people were checked. There was no consistency in the information provided. Assessment forms were used but large areas were The Maples DS0000063554.V355706.R01.S.doc Version 5.2 Page 9 left blank. None of the four provided the full information as required on the assessment form and one was almost completely blank. The need to be consistent and obtain as much information as possible about the person was discussed with the manager. This information would enable a tailor made plan of care to be provided for each person living in the home. There was no information on files to verify that people had been informed that the home could meet their needs. The Maples DS0000063554.V355706.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People were treated with respect and their right to privacy was generally upheld. Some health needs were met. Medication procedures were followed correctly. Full information of people’s health, personal and social care needs was not set out in individual plans of care. EVIDENCE: People and their relatives considered that people’s needs were always or usually met. Staff treated people with respect. Comments were, “My mum fell one evening. I was very pleased with the help and support I was given while at the hospital and later” “ Looks after and cares well for the resident”, “They look after my … mother in a very relaxed and considered manner”. The Maples DS0000063554.V355706.R01.S.doc Version 5.2 Page 11 The files for four people were checked. The previous requirement for improvements to care plans, risk assessments and daily records had not been met. The assessments that were checked had not been completed fully (see previous section); therefore some people’s specific needs were not included when planning their care. There was insufficient information about some identified physical needs. Information on how needs were to be met was broad based and did not provide sufficient details. Also some care plans identified specific care needs that were in fact not care needs e.g. “Eats and drinks well – no problems”. Some records of actions taken were kept but these were not completed daily and did not provide full and consistent information of whether people’s needs or preferences had been met. The manager said that these were only completed when there was something to record; therefore there was no verification that people’s daily needs had been met. The manager said that people’s care needs were recorded on a checklist but this was not kept with the care plan and did not relate to the care plan. There was no information of people being bathed. The manager said that separate records were kept but these were not seen. People were well dressed, clean and tidy. There was some good information of recognising when action needed to be taken regarding people’s health matters and this cross-referenced to the information sheet of visits by health professionals. However, other aspects of proactive health care were not available on each person’s file e.g. nutritional assessments and weight charts. The manager said that separate records were kept for weighing but these were not seen. The manager was advised to obtain a copy of the Malnutrition Universal Screening Tool, which she did before the end of the site visit. Some risk assessments were missing, particularly for people who had their beds against the wall. The manager was advised to assess the risks to the person and also to staff. There were no records to show that people who had had accidents or falls were monitored. The manager was advised to implement a 72-hour monitoring sheet to ensure that any injuries not apparent at the time of the accident were picked up quickly. She was also advised to implement a monthly accident analysis to determine if there were any patterns to accidents or falls. Inventories did not provide sufficient information to identify people’s private property. At the previous inspection, the manager was advised to collate all information relating to each person and provide individual files to be used as working documents. These individual files would ensure that no information was forgotten or overlooked. This had not been done. Care plans need to include information of each person’s individual physical, health, social and emotional needs, with records of how these are being met on a day-to-day basis. This was discussed again with the manager. The previous requirement for people to be consulted about their care plans had not been met. There were staff signatures and dates against the care The Maples DS0000063554.V355706.R01.S.doc Version 5.2 Page 12 plans, which indicated that staff had reviewed the care plans but there was no information to demonstrate consultation with the relevant person. People who were asked during the site visit said that they had not been consulted. Medication was securely stored. Medication records were up to date with no gaps. Photographs and people’s allergies were also recorded which is good practice. The Controlled Drugs Register was checked and this had been completed correctly with two signatures and a diminishing total. Medication that required refrigeration was kept in a metal lockable box on its own shelf in the domestic refrigerator. People living at the home were well dressed and alert. There were good interactions between them and the staff. They seemed happy and there was a very positive atmosphere. When relatives and others were asked whether people living in the home were treated with respect, they all said “yes”. Personal files contained information that people were offered keys to their bedrooms but there was no information of whether they had been offered keys to their lockable facilities. The bedrooms contained facilities with locks but people occupying those rooms said that they had no key for these facilities. This was brought to the attention of the manager. The Maples DS0000063554.V355706.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People received nutritious and appetising meals. Contact with family and friends and the local community was promoted. Personal choices and control were generally promoted. The lifestyle within the home did not always meet people’s expectations and preferences. EVIDENCE: The Annual Quality Assurance Assessment provided information on activities both inside and outside the home. However information received from people living in the home and relatives and visitors indicated that activities were only available sometimes and that people would like more outings in the community. There was no programme of activities displayed to inform people of forthcoming activities. This was discussed with the manager. There was no information on people’s files of any activities or social interactions they had participated in. People considered that they were helped to keep in touch with their families. During the site visit friends and family visited people living in the home. A The Maples DS0000063554.V355706.R01.S.doc Version 5.2 Page 14 comment received was, “…I live near my mum and visit several times in the week plus bringing her to my home on a weekend” People felt that that they were supported to make their own choices and on some of the files there was information of people’s preferences but this information was not consistent across all files. (See Choice of Home section). People said that they always liked the meals. A comment about the food was, “The cooks prepare meals very efficiently. There is always a good variety and always presented well. The cooks do their job well also.” The dining room had recently been refurbished and was a pleasant place to dine. A menu board informed people of the meals on offer. Condiments were available on each table. The lunchtime meal of ham, new potatoes, fresh carrots and cabbage was well presented and nutritious. People said the meal was good. Dessert was bread and butter pudding with cream. Alternatives were available. The Maples DS0000063554.V355706.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People using this service were protected from abuse. They and their relatives and friends were confident that their complaints would be dealt with appropriately. EVIDENCE: The complaints procedure was displayed and the complaints book was checked. There had been one complaint to the Commission for Social Care Inspection and this had been handled appropriately. People said that they knew who to speak to if they weren’t happy and knew how to complain. One person’s response was that they knew how to complain, “But never needed to make complaints”. All staff had undertaken adult protection training. The manager had recently attended a familiarisation session on the new South Yorkshire safeguarding procedures. There were no allegations of abuse. The Maples DS0000063554.V355706.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home was generally clean and hygienic but some areas required attention. Furniture, furnishings and décor were showing signs of wear and tear. EVIDENCE: People considered that the home was always fresh and clean and a comment was, “It is in excellent condition and all the staff always have chores to do”. The dining room had been completely refurbished, and new carpets were fitted in the lounge, sun lounge and corridors. Some new lounge furniture had been purchased. The Maples DS0000063554.V355706.R01.S.doc Version 5.2 Page 17 At the last inspection there was an overpowering offensive odour in one of the bedrooms. This bedroom was checked and the odour had gone. The manager said that they had discovered that blocked drains had been the cause. During this inspection however, there was an odour on the corridor outside the bedroom and also an overpowering offensive odour in another bedroom. The manager said that the room had been cleaned but the odour remained. Further investigations must be done to determine the source of the odour and it was suggested that blocked drains might again have caused this. Unlike most care homes, this home does not have a handyperson to carry out general maintenance work. Since the last inspection, there was no indication that any work had been carried out on refurbishing bedrooms. Bedroom walls were marked and scraped. Some radiator guards had not been painted. Furniture was damaged with missing handles and in one bedroom the drawer front was hanging off. The curtains in one bedroom needed re-hanging. Bedding looked faded, worn and mismatched. Duvets and pillows were either lumpy or flat. Some carpets were stained and others had not been vacuumed. Beds were placed against the bedroom wall and had not been risk assessed to determine the risk to the person or the staff. There were no keys available for the lockable facilities in people’s bedrooms. The bathroom was cluttered and was not fit for purpose. The manager was informed that the commode pans and other items that do not belong in the bathroom needed removing. The Maples DS0000063554.V355706.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staffing levels and an improving skill mix met people’s needs. The home’s recruitment procedures did not fully protect people. EVIDENCE: People considered that staff were always or usually available and there were sufficient care staff on duty during the site visit. Some staff had undertaken some skills training in catheter care and pressure care. It was recommended that this training be extended to all care staff. It was also recommended that dementia care and sensory awareness be considered. These training courses would ensure that staff had the knowledge and skills to meet people’s individual needs. Induction training to Skills for Care standards was undertaken and all Skills for Care training was promoted. The manager said that all staff were expected to undertake National Vocational Qualifications in care and this expectation was discussed during employment interviews. According to the manager, staff were enrolled for NVQ training as places became available. The Maples DS0000063554.V355706.R01.S.doc Version 5.2 Page 19 At the last inspection the manager was given a copy of the CSCI ‘In Focus’ booklet “Safe and Sound?” to assist her in improving her recruitment procedures. During this site visit, three staff files were checked to determine whether the recruitment procedure had improved. Files still did not contain Criminal Record Bureau disclosures, which were still being held by the umbrella body. This issue had not been addressed since last year’s inspection. The manager said that there was also some confusion about POVAFirst disclosures. This was again discussed. The manager needs to action this and ensure that Criminal Record Bureau and POVAFirst disclosures are available for inspection. The application forms for two people had not been checked properly. On one file there were no dates of employment and on another there were gaps in employment and insufficient information. There was no information on file to verify that these discrepancies had been discussed. The manager was informed that the procedures must be tightened to ensure that the system is robust. The Maples DS0000063554.V355706.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s financial interests were safeguarded. The health safety and welfare of people living there were generally promoted and protected but improvements could be made to ensure that the home was run in their best interests. EVIDENCE: The home had a registered manager who was undertaking the Registered Managers Award. The manager said that the home had a quality assurance monitoring system but evidence of this was limited. The manager said that she combined The Maples DS0000063554.V355706.R01.S.doc Version 5.2 Page 21 residents and relatives meetings with social events. However, people who were asked said that they were not asked for their opinions and considered these meetings to be just social events. No records were available. The manager said that questionnaires were sent out. Approximately five completed questionnaires were produced as evidence of seeking people’s views. However, the information from these questionnaires had not been collated to show the action that had been taken. When people were asked if they had been asked to complete any questionnaires, they said ‘no’ or ‘not since last year. At the last inspection, advice was given on other aspects of quality monitoring that could be implemented including housekeeping and environmental checks, staff files, care plans etc. There was no evidence that any of this advice had been acted upon. The registered provider did not produce written reports of visits to the home as required by law. This is an outstanding requirement. Money held on behalf of people living in the home was stored securely. The money for three people was checked against their records and these tallied. It was recommended that the records include a column to write in the receipt number for ease of reference. The manager said that mandatory health and safety training was ongoing and there were some certificates on staff files as evidence of this. A random selection of certificates was checked as evidence that the home serviced and maintained equipment and systems within the home. There were no Landlords Certificates to verify that the gas boilers had been serviced and were safe. The manager was told to arrange for this to be done. The Commission for Social Care Inspection takes a balanced view of evidence from this inspection. It is acknowledged that people and their relatives had very positive comments about the home. However, evidence is also shown of areas requiring the manager and owners’ prompt and sustained improvement. The Maples DS0000063554.V355706.R01.S.doc Version 5.2 Page 22 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 2 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 2 The Maples DS0000063554.V355706.R01.S.doc Version 5.2 Page 23 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 OP3 Regulation 14 Requirement Timescale for action 31/01/08 2 OP7 12, 13 3 OP7 15 4 OP19 16,23 The needs of each person must be thoroughly assessed and they must be informed in writing that the home can meet their needs Care plans and risk assessments 31/01/08 must be written in sufficient detail to ensure that each person’s individual physical, health, emotional and social needs and wishes can be met. Daily records must demonstrate that people’s needs and wishes have been met. Timescale of 04/02/07 not met People living in the home or their 31/01/08 representatives must be consulted about care plan reviews. Previous timescale of 04/02/07 not met The manager must audit all 31/01/08 bedrooms and other parts of the home to determine the priority order for redecoration and refurbishment to ensure that the home provides comfortable facilities for the people living there. Previous timescale of 04/02/07 DS0000063554.V355706.R01.S.doc Version 5.2 The Maples Page 24 5 6 OP19 OP26 23 23 7 8 OP19 OP29 16, 23 13, 19 9 OP33 26 10 OP33 24 11 OP38 13 not met The clutter in the bathroom must be removed to ensure that this room is fit for purpose Keep all parts of the care home clean, (specifically identifying and eliminating the source of the offensive odour in the identified bedroom and on the corridor) Damaged bedroom furniture must be replaced. Timescale of 04/02/07 not met Staff must be deemed fit to work at the home. Action must be taken to ensure that Criminal Record Bureau disclosures and POVAFirst disclosures are available for inspection. There must also be written evidence that discrepancies in applications have been discussed and risk assessed prior to employment. Timescale of 04/02/07 not met The registered provider must produce monthly reports on the conduct of the care home as required by regulation 26 of the Care Homes Regulations. A copy of the reports must be sent to the CSCI Timescale of 04/02/07 not met A quality assurance monitoring system must be implemented to ensure that the home is run in the best interests of people living in the home. Timescale of 04/02/07 not met The gas boilers must be serviced and a Landlord Certificate produced as evidence that this has been done. 13/12/07 13/12/07 31/01/08 03/01/08 03/01/08 31/01/08 03/01/08 The Maples DS0000063554.V355706.R01.S.doc Version 5.2 Page 25 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 OP7 Good Practice Recommendations It is again suggested that there is one file per person and that this is used as a working document and includes the person’s care plan and all other relevant documents related to meeting the person’s individual needs. Inventories should provide sufficient information to enable easy identification of people’s private property. Ensure that all health needs are met by the implementation of nutritional screening and monitoring with the utilisation of the Malnutrition Universal Screening Tool. To demonstrate that people are properly monitored a 72 hour monitoring sheets should be used following accidents and falls. The implementation of a monthly analysis of accidents would determine any patterns to accidents or falls. The home should determine the risks to staff or people living in the home by the provision of risk assessments for beds placed against bedroom walls. To promote people’s privacy and dignity, keys to lockable facilities should be provided. A programme of activities suited to the needs of the people living in the home should be provided. The home should consider employing a handyperson to carry out maintenance and safety checks throughout the home. Training in catheter care and pressure care should be extended to all care staff. Dementia care and sensory awareness should also be considered. People’s financial records should include a column for receipt numbers. This would facilitate the cross checking of finances. It is again suggested that the implementation of a staff training matrix would provide an easy reference guide to staff training needs. 2 3 OP7 OP8 4 5 6 7 8 9 10 11 12 OP8 OP8 OP8 OP10 OP12 OP19 OP27 OP35 OP38 The Maples DS0000063554.V355706.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Maples DS0000063554.V355706.R01.S.doc Version 5.2 Page 27 - 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!