Inspection on 05/08/08 for The Maples Manor Rest Home

This inspection was carried out on 5th August 2008.

CSCI found this care home to be providing an Adequate service.

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

Extracts from inspection reports are licensed from CQC, this page was updated on 28/10/2008.

CARE HOMES FOR OLDER PEOPLE The Maples Manor Rest Home 4 Lorne Road Oxton Birkenhead Wirral CH43 1XB Lead Inspector Beate Field Unannounced Inspection 5th August 2008 09:40 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 Manor Rest Home DS0000070788.V368818.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 Manor Rest Home DS0000070788.V368818.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Maples Manor Rest Home Address 4 Lorne Road Oxton Birkenhead Wirral CH43 1XB 0115 877 8891 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) Mr Rizwan Iqbal Manager post vacant Care Home 20 Category(ies) of Dementia (20) registration, with number of places The Maples Manor Rest Home DS0000070788.V368818.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only. Care home only - code PC, to people of the following gender:- Either. Whose primary care needs on admission to the home are within the following categories: Dementia - Code DE The maximum number of people who can be accommodated is: 20 Date of last inspection Not applicable Brief Description of the Service: The Maples Manor was registered under new ownership in February 2008. The home is registered to provide personal care and support for 20 older people, both male and female over the age of 65, who have dementia. The Maples Manor is situated in the residential area of Oxton, Birkenhead and is in walking distance of shops, post office and recreational facilities. At the front of the building there is a grassed area and a car park. There are well-established trees, which provide the home with some privacy. The rear garden area is enclosed and has flower beds and seating areas. The home provides two lounge areas and a separate dining room. A further room is being developed in to an activities room/quiet lounge but is currently not accessible to the people who use the service. Bedrooms are situated on three floors that are accessible by stairs or a passenger lift. There are 3 double and 14 single bedrooms. There are currently 2 shower rooms and a bathroom with a bathing aid situated over the 4 floors. There are plans to make further bathroom facilities available. Toilets are situated on all floors and are close to bedrooms and communal areas. At the time of the visit the fees for the service were £400.00 per week. The fees do not cover newspapers, hairdressing, chiropody, clothing, toiletries and any items of a luxury or personal nature. A statement of purpose and a service user guide are available for people thinking of using the service, their relatives and health and social care professionals to refer to. The Maples Manor Rest Home DS0000070788.V368818.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection is based on a site visit to the home over a 6 hour period and is also informed by information received about the service since it was registered and by questionnaires completed by the people who use the service and staff. During the site visit to the home time was spent in the office looking at a sample of records and policies and procedures and talking to the manager. A tour of the home was undertaken. The inspector spoke with the people who use the service, relatives and staff and made observations of the care given by staff. What the service does well: What has improved since the last inspection? The Maples Manor Rest Home DS0000070788.V368818.R01.S.doc Version 5.2 Page 6 This is the first inspection of The Maples Manor since it was registered under new ownership in February 2008. 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 Manor Rest Home DS0000070788.V368818.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 Manor Rest Home DS0000070788.V368818.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, 2, 3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A service is only offered to people whose needs can be met. People thinking of using the service and their relatives benefit from being able to visit the home to see if it is right for them before moving in. EVIDENCE: A statement of purpose and a service user guide are available that give information about the services provided and includes information about the qualifications and numbers of staff and the complaint process. The service user guide should be further developed into a format that the people who use the service may be able to better understand. The Maples Manor Rest Home DS0000070788.V368818.R01.S.doc Version 5.2 Page 9 Records showed that an assessment is undertaken before any person moves to the home. The assessments of two new people were seen. These assessments provided the basis from which a plan of care can be developed. For people who are self funding and without a Care Management Assessment the assessment is always undertaken by the manager or deputy manager. The assessment involves the individual, and their family or representative, where appropriate. Where the assessment has been undertaken through care management arrangements the manager ensures that they have access to a summary of the assessment and a copy of the care plan. People thinking about using the service are given the opportunity to spend time in the home. An individual member of staff is allocated to give them information and to help them understand how the home is organised and run and the facilities and services available. Completed contracts between the service and the people using the service were not available at this visit. The manager explained that new contracts have been drawn up that reflect the change in the ownership of The Maples Manor and issued to the people who use the service and their representatives. These will be looked at, at the next visit to the home. Intermediate care is not provided at the home. The Maples Manor Rest Home DS0000070788.V368818.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and social care needs of the people who use the service would be better met if the care plans and risk assessments contained more detailed information for staff to refer to. EVIDENCE: 3 care plans were seen. These provide information around the health, personal and social care needs of the people who use the service. The care plans are easy to follow and are updated on a monthly basis. The care plans need some further work to ensure they contain the information staff require to meet the health and social care needs of the people who use The Maples Manor Rest Home DS0000070788.V368818.R01.S.doc Version 5.2 Page 11 the service. Further information needs to be recorded about how the dementia of the people who use the service presents itself and how best to manage this. Further work with relatives and/or social and health care professionals may be needed to gather this information. Where a person can display aggression, there needs to be clear information for staff around how this behaviour is to be managed. Although the care plans contain some information around how to promote the independence of the people who use the service this could be more detailed. Information around the social interests of the people who use the service is currently being gathered by the activities co-ordinator. The manager and staff would benefit from further training in meeting the needs of people with dementia as this will assist them in care planning. Care needs to be taken to ensure that the standard assessment tools used for nutrition and falls clearly show what the result of the assessment is and the action that needs to be taken as a result. The people who use the service who returned surveys said they “always get the care and support needed. Staff listen and act on what they say. Staff are always there when they are required. They always get the medical support needed.” The staff who returned surveys all said that the people who use the service receive a good standard of care and support at the home from the staff. Some comments made were “We provide care and support 24/7. We try to meet all needs and encourage independence and have daily activities for groups and 1:1 activities to stimulate the residents.” “The service tries to do well by working as a team and ensuring all service users needs are met following each personal care plan.” “ A lot of staff have worked at the home for a while, so there are familiar faces which the service users can relate to.” “There is a relaxed atmosphere at the home which helps service users to do more for themselves and keep their independence.” Clear records have been made of visits to the people who use the service by health care professionals and the outcome. Policies and procedures for handling and recording medication are available. Medication is well organised and securely held. A sample of the medicine administration record (MAR) sheets and corresponding medications were inspected and found to be correctly maintained. The majority of staff who administer medication have had a brief training session in the safe handling and administration of medication from a local pharmacist. This was over a couple of years ago for some staff and training to update and refresh the staff in this area should be provided. The manager is currently assessing all staff who administer medication to ensure that they are competent for this task. None of the people who use the service manage their own medication. The Maples Manor Rest Home DS0000070788.V368818.R01.S.doc Version 5.2 Page 12 Staff were observed to speak to the people who use the service in a respectful manner. A relative spoken with said that the staff are “friendly” and “polite.” The Maples Manor Rest Home DS0000070788.V368818.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service have access to activities that provide them with the stimulation they need and are being further developed according to their interests. They receive varied, well-balanced meals. EVIDENCE: An activities co-ordinator is employed for 20 hours per week. A variety of activities are organised for the people who use the service and include games, musical quizzes, film shows and entertainment. The manager and the activities co-ordinator have been on training to help develop activities further for people with dementia. An activity room is in the process of being established at the home. The Maples Manor Rest Home DS0000070788.V368818.R01.S.doc Version 5.2 Page 14 The activities co-ordinator is working on finding out more about the interests of the people who use the service before they came to live at The Maples Manor. This will assist further in developing the range of activities available. The gardens have been further improved and new outdoor furniture has been made available providing a pleasant setting for the people who use the service to spend time. The people who use the service have been involved in planting flowers in pots and helping the gardener to decide where to place new plants. Visitors can visit at any reasonable time of the day, a visitor’s room is available or visitors may be seen in bedrooms or the communal lounges. A relative said that they are always made to feel welcome by the staff. The people who use the service go to church or receive visits from a lay preacher in accordance with their wishes. People who use the service can bring personal possessions to the home, however a number of bedrooms had few personal items. The manager is looking at the best ways to give the bedrooms a more homely appearance and is looking at personalising the bedrooms further. The menus were seen for a 4-week period. There is a choice of meal at lunchtime and a choice for tea. The meals provided are varied and balanced. The dislikes and likes of the people who use the service are recorded in their care plans. The lunchtime meal was seen and was attractively presented and appetising. Staff were seen to appropriately assist the people who use the service with their meals. The people who use the service told the inspector that they enjoy the food at the home. The dining room has been repainted and new dining furniture made available. The Maples Manor Rest Home DS0000070788.V368818.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The wellbeing of the people who use the service is safeguarded by the procedures and practices for responding to complaints and adult protection matters. EVIDENCE: There is a complaints procedure available, which is displayed in the reception area of the home. A relative spoken with said that they would know how to complain if they needed to. No complaints had been recorded in the home’s records since the new registration of the home and no complaints have been made to the CSCI. The manager and staff interviewed were aware of the action to be taken should a complaint be made to them. Thank you cards are displayed in the reception of the home and show that a number of relatives have been happy with the service provided at The Maples Manor. Records showed that staff are trained in safeguarding adults from abuse during their induction period and receive further in-depth training. Records showed that the manager has planned for refresher courses later this year. The The Maples Manor Rest Home DS0000070788.V368818.R01.S.doc Version 5.2 Page 16 manager and staff interviewed were very well aware of the procedure to follow should they suspect abuse. There is a summary of Wirral Borough Council’s safegaurding procedures available at the home. The manager was advised to obtain the complete version. The CSCI is kept informed of any matters that affect the welfare of the people using the service. The Maples Manor Rest Home DS0000070788.V368818.R01.S.doc Version 5.2 Page 17 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, 21, 24 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home needs further upgrading to ensure that the people who use the service live in a homely and well-maintained environment. The people who use the service would benefit from the home environment being made more accessible for people with dementia. EVIDENCE: The Maples Manor Rest Home DS0000070788.V368818.R01.S.doc Version 5.2 Page 18 Since the new registration of the home a number of works have taken place to improve the home environment for the people who use the service. This includes the replacement of windows, 2 shower rooms being made available, the decoration of some communal areas and some bedrooms and the garden being made into a more inviting area. At this visit there are still a number of areas of the home that need attention. The manager reported that the new owners have plans to address these areas. A plan of the works to be completed, together with the timescale has been requested from the owners. The main areas identified as needing improvement are as follows: The flooring in the entrance hall needs to be replaced. The carpet had been damaged by a recent flood. Replacement carpet was available at the home at the time of the visit. The doors to some rooms in this area now require some attention as they are difficult to open following the flood. These doors were not fire doors. The carpet in the lounge/dining area is showing signs of wear and tear. Although intact, one area is beginning to fray, there were several areas that looked stained, although the manager reported that this carpet had been recently cleaned. Carpets in the hallways on all floors is showing signs of wear and tear as are some bedroom carpets. The flooring in the activities room needs to be replaced. At the time of the visit the carpet had been removed. This room is not currently accessible to the people who use the service as it is in the process of being made into an activities room and was being used to store various equipment. A tour of the home showed that some bedroom furniture was marked and appeared worn, some needed repair. 2 new shower rooms have been made available since the new registration of the service, however, the decoration in the remaining bathrooms and in some toilets needs attention. The bathrooms on the second floor are not currently used as they require work to enhance their appearance and make them accessible. The windows in some bedrooms would benefit from either net curtains or blinds being fitted to promote further privacy. The front of the home could be made to look more welcoming. Some areas would benefit from re-plastering and repainting. The Maples Manor Rest Home DS0000070788.V368818.R01.S.doc Version 5.2 Page 19 Steps have been taken to make the home safe for the people who use the service. Most of the radiators are covered and the manager reported that temperature regulators have been fitted to those that do not have them. The newly replaced windows are fitted with restrictors to limit the width that they can be opened. Water is temperature regulated. The manager was asked to ensure that a record is kept of the tests of water temperatures. At the time of the visit toiletries and prescription cream had been left accessible to the people who use the service in the first floor bathroom. The manager removed these items during the visit and said she would address this issue with staff as a matter of urgency. Staff spoken with during the visit said that individual toiletries are kept for each person who uses the service in lockable areas. People who use the service can bring personal possessions to the home, however a number of bedrooms had few personal items. The manager is looking at the best ways to give the bedrooms a more homely appearance and is looking at personalising the bedrooms further. An assessment of the environment should take place by an individual with experience in dementia care with a view to making the home environment more accessible. At present there are very few aids to help people find their way around the building. This does not promote people’s independence. The home was clean at the time of this visit. A couple of bedrooms were malodorous. The manager reported that steps have been and continue to be taken to address this. The laundry is located in an outdoor building. New laundry equipment was available. A discussion took place with the manager around the benefits of further organising the laundry to prevent the mix up of people’s belongings. The Maples Manor Rest Home DS0000070788.V368818.R01.S.doc Version 5.2 Page 20 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of the people who use the service are met by the numbers of staff available, the low staff turnover and by the way staff are recruited to work at the home. EVIDENCE: The rota and a discussion with the staff and the manager indicated that there are sufficient numbers of staff to meet the needs of the people living at the home at the time of the visit. Staff spoken with and the staff who returned surveys said there are always enough staff available. The people who use the service who returned surveys and a relative spoken with said that there are sufficient staff available to meet people’s needs. There is a clear staff structure in the home that includes the manager, deputy manager, senior care staff, care staff and ancillary staff. Staff spoken with were aware of their responsibilities at the home and the responsibilities of the senior staff and manager. The Maples Manor Rest Home DS0000070788.V368818.R01.S.doc Version 5.2 Page 21 There is a low turnover of staff at the home and a number of staff have worked at the home for several years. This ensures that the people who use the service have continuity in their day-to-day care. All staff receive an induction which is based on the induction standards of Skills for Care. This includes first aid, manual handling, food hygiene, fire safety, health and safety, safeguarding adults from abuse, completing care plans, respecting privacy and dignity, maintaining confidentiality and the general operation of the home. The induction checklist shows that staff have received the training but does not indicate their level of understanding or any further training needs. A more detailed evidence based recording system should be put in place to demonstrate this. The manager reported that the majority of staff need refresher training around first aid, moving and handling, food hygiene, infection control, health and safety and safeguarding adults. The manager has put together a training programme to address this training shortfall. Staff have received a day of training in meeting the needs of older people with dementia. A more intensive programme of training needs to be made available to ensure that staff, especially the senior staff have a thorough knowledge base. This training needs to cover managing challenging behaviour that may be displayed by people with dementia so that staff are equipped to deal with any incidents that may occur. Two thirds of the staff hold an NVQ Level 2 in Care of Older People. 4 staff are currently working towards this qualification. An examination of a sample of staff files identified that appropriate procedures are being put into place for the recruitment of staff. Files contained an application form, two references, confirmation of identity and confirmation that POVA and CRB clearances had been obtained. A discussion took place with the manager around updating the reference request forms that are currently used to allow a referee to provide more information. The Maples Manor Rest Home DS0000070788.V368818.R01.S.doc Version 5.2 Page 22 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, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A registered manager needs to be appointed to ensure that the home is being run by an individual who is accountable for it’s day-to-day operation. EVIDENCE: The manager has been working at the home for 12 months. The manager has completed the Registered Managers Award and has completed some training to keep her skills and knowledge up to date. The manager has not undertaken The Maples Manor Rest Home DS0000070788.V368818.R01.S.doc Version 5.2 Page 23 any formal training in meeting the needs of people with dementia. The manager is currently looking at training courses in this area. The manager has not applied to the CSCI to be the registered manager for the service. An application needs to be submitted to the CSCI to register the manager for the home. The staff who returned questionnaires and those spoken said that they receive good support from the manager and that since she has been in post she has made a number of changes to the home that has meant the people who live there get a better service. They also said that the new owners have made big improvements to the home environment and have ensured more training is available. Some comments made were; “I have worked here for 3 years and the improvements with the new manager and owner have been vast.” “Since the new manager has been in post I am now happy to come to work due to her support. The new owners are also making improvements to the building.” The manager has taken steps to put in place some systems for reviewing and improving the quality of care provided at the home. Staff meetings are held. Questionnaires have been developed and will be sent to relatives to obtain their views about how the home operates. Questionnaires should also be sent to visiting professionals as to how the home is achieving goals for the people who live there. Steps have been taken to improve communication with relatives when there are specific issues affecting a person using the service. Events are held to which relatives are invited which provides an informal way of gathering their views. The views of the people who use the service are briefly recorded in the care plans and the manager said that their views are sought by their key workers. Further work should take place around obtaining the views of the people who use the service as there was little evidence available to show how this takes place. The home looks after the personal allowances for several people who use the service. The records of 3 peoples personal allowances were checked and were accurately maintained. The manager reported that she is currently catching up with staff supervisions. Some records showed that some staff had not received supervision since September 2007. The manager now has a programme in place to address this. A sample of safety check records were seen for servicing of the fire safety systems, gas safety, bathing aid, portable appliances and nurse calls and were appropriately maintained. The electrical wiring certificate does not indicate when the next test is due. The manager agreed to follow this up. As already indicated training records showed that staff are due for refresher training in safe working practices. The manager has put together a training The Maples Manor Rest Home DS0000070788.V368818.R01.S.doc Version 5.2 Page 24 programme to address this shortfall. All staff have received fire safety training this year, however, the night staff have not received this within the recommended intervals of every 3 months. The records of staff checks of the fire alarm and emergency lighting showed that these are not occurring at the recommended frequencies. The records of fire drills could not be located. The Maples Manor Rest Home DS0000070788.V368818.R01.S.doc Version 5.2 Page 25 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 2 2 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 2 The Maples Manor Rest Home DS0000070788.V368818.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Not applicable 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 (1) Requirement The registered person must ensure that the care plans contain clear and sufficient information around the social and health care needs of the people who use the service. This is to ensure that staff have access to the information they need to appropriately support them. Timescale for action 05/09/08 2. OP19 OP21 23 (d) 05/09/08 The registered person must provide the Commission for Social Care Inspection with a plan of the works to be undertaken (with timescales) to improve the standards of decoration and furnishings at the home. The registered person must do this in order to show the plans to improve the home environment are to be attended to within a reasonable timescale. The registered persons must 05/11/08 ensure that all staff are provided with further training around meeting the needs of people with dementia in order to ensure that staff have the skills necessary DS0000070788.V368818.R01.S.doc Version 5.2 Page 27 3. OP30 18 (1) (c) (i) The Maples Manor Rest Home for the work they perform. 4. OP31 9 (1) The responsible individual must ensure that an application is made to the CSCI to register the appointed manager for the home. This is to enable the CSCI to assess whether the appointed manager is competent for this position and to ensure that there is a person accountable for the day-to-day operation of the service. The registered manager for the service needs to have undertaken a relevant qualification in meeting the needs of older people with dementia. This is to ensure that the manager has the knowledge and skills necessary to manage the service. 05/11/08 5. OP31 9 (2) (b) (i) 05/11/08 6. OP38 23 (c) (iv) (d) The registered person must 05/08/08 ensure that regular checks of the fire alarm and emergency lighting are undertaken and that fire drills occur on a regular basis. This is to ensure that in the event of a fire the fire equipment is working adequately and the staff and people who use the service know what to do. 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 OP1 Good Practice Recommendations The service user guide should be developed into a format DS0000070788.V368818.R01.S.doc Version 5.2 Page 28 The Maples Manor Rest Home that the people who use the service may be able to better understand. 2. OP2 Each person who uses the service is to be provided with a written contact/statement of terms and conditions with the home. Staff who administer medication should be provided with training to update their skills and knowledge in this area where this is needed. An assessment of the environment should take place by an individual with experience in dementia care with a view to making the home environment more accessible. A record is to be made of the tests that are undertaken of water temperatures. The bedrooms would benefit from being personalised subject to the needs and wishes of the people who use the service. The reference request forms that are currently used should be updated to allow a referee to provide more information. A more detailed evidence based recording system should be put in place to demonstrate that staff have understood the induction training and any further training needs. Staff should receive formal supervision at least 6 times a year. Further work should take place around ways of obtaining the views of the residents. Questionnaires should be sent to visiting professionals as to how the home is achieving goals for the people who live there. Night staff should receive fire safety training every 3 months. 3. OP9 4. OP19 5. 6. OP19 OP24 7. 8. OP29 OP30 9. 10. 11. OP36 OP33 OP33 12. OP38 The Maples Manor Rest Home DS0000070788.V368818.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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