Care Home: Maple Dene

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What the care home does well Any person considering moving into Maple Dene is given assurance that the home can meet their needs, they are assessed prior to moving in and are encouraged where possible to visit the home before making any decisions. The home is kept exceptionally clean and people who use the service and their visitors commented on this as being important to them. The home works in partnership with other professional bodies to ensure the best outcome is reached for the people who use the service. Communication and information exchange with all relevant parties is excellent. Peoples descriptions of the home were as follows: " It reaches my expectations, absolutely!" "We are free, but we are cared for." Visitors said, including a visiting professional: "They see the whole person and respect privacy and dignity." "I think the staff understand privacy and dignity and treat people who use the service really well, they speak very kindly." The registered manager and staff are transparent and open and welcome discussions around continually taking their service forward. The manager, Leisha is considered approachable by people who use the service and staff alike. The home operates a person centred approach and demonstrates a very good understanding of individuals care needs. Plans of care are in place for everyone, containing good levels of information for staff to meet people`s needs well, the staff are encouraged to read care plans so that they can provide the correct care and support. The home also takes pride in supporting staff and ensuring staffs individual needs are identified and met accordingly. The staff receive equality and diversity training, this training reinforces the need for staff to see people as individuals with their own specific needs and wishes. The home ensures staff are not employed without full employment checks therefore confirming they are suitable people to work with older people. All newly appointed staff undergo an induction programme to promote good practice, confidence and understanding in the service delivery; there is a commitment to National Vocational Qualification training for all staff. What has improved since the last inspection? Requirements made at the last `Key` inspection in August 2007 have been met; they were as follows: We said the home must make suitable arrangements for accurate recording of all medicines onto medication administration charts. On this occasion we are happy that robust systems are now in place and we saw the medication administration charts are suitably completed. This means people who use the service are adequately protected. We also said the home must make sure each person who uses the service has a plan of care that identifies the specific support required. This is so the staff can take care of people who use the service in a way they prefer and at the times they require. We saw that plans of care are now extremely detailed and give a good picture of the people who use the service so everyone knows exactly what to do and when it is required. CARE HOMES FOR OLDER PEOPLE Maple Dene 10-14 St Agnes Road Moseley Birmingham West Midlands B13 9PW Lead Inspector Rachel Davis Key Unannounced Inspection 6th August 2008 09:30 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 Maple Dene DS0000016913.V369575.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. Maple Dene DS0000016913.V369575.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Maple Dene Address 10-14 St Agnes Road Moseley Birmingham West Midlands B13 9PW 0121 449 7677 0121 449 6155 leisha.cooper@anchor.org.uk keri.sherwood@anchor.org.uk Anchor Trust 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) Leisha Cooper Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40), Physical disability (40) of places Maple Dene DS0000016913.V369575.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to accommodate 40 adults over the age of 65 who are in need of care for reasons of old age, not falling within any other category (40 OP) and Physical Disability over 65 years of age (40 PD(E)) The home can accommodate up to six service users who are in need of care for reasons of dementia. 6 DE(E) In addition to the manager and ancillary staff minimum staffing levels must be maintained to at least 4 care staff at all times during the waking day 14th August 2007 2. 3. Date of last inspection Brief Description of the Service: Maple Dene is a large detached three-storey property that is situated in a quiet residential area of Moseley, within easy reach of public transport and other amenities. The Home is owned and managed by Anchor Trust, Leisha cooper is the on site manager. The building has been adapted and extended to provide residential accommodation for 40 people for reason of old age, six older people with dementia care needs can live at the Home. Maple Dene charges £484:00 and £555:00 per week dependant on the needs of the individual and the rooms chosen. Items not covered by the fee include hairdressing, chiropody and telephone calls. Accommodation is provided in 38 flats offering single accommodation and one flat offers double accommodation. Each flat has a small kitchen with a fridge suitable for the preparation of snacks and a number of flats have a separate lounge area. There is a call bell facility in each flat for people to use in order to summons assistance or help. People who use the service are able to smoke in their flats if deemed to be safe to do so however smoking is not permitted elsewhere in the building. Each flat has an en-suite facility that consists of a toilet and low-level bath or shower. There are assisted communal bathing facilities on each floor as the low level baths may not be suitable for everyone. The staff are available to provide assistance with bathing as required. Communal facilities consist of a lounge and dining room situated on the ground floor. A spacious conservatory offers an alternative sitting area for people who Maple Dene DS0000016913.V369575.R01.S.doc Version 5.2 Page 5 use the service. The internal environment of the Home and external secure garden areas are suitable for wheelchair users. Two passenger lifts give access to all areas of the home and there are aids and adaptations available to meet the needs of people with disabilities. Maple Dene DS0000016913.V369575.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means people who use this service experience good outcomes. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, national minimum standards of practice and focuses on aspects of service provision that may need further development. A quality rating is provided throughout the report based on each outcome area for the people who use the service. These ratings are described as excellent, good, adequate or poor based on findings of the inspection. Before visiting the home on this inspection, survey information was completed and returned to us by people who use the service and the staff. Seven people who use the service returned survey forms to us with their views, two staff also returned questionnaires to inform us on how they feel they are supported, trained and managed. The visit took place over one day and staff and people who live at the home did not know that we were coming. We focus on a small number of people who use the service which involves discovering individual experiences of living at the home by meeting them, discussing their care with staff, looking at medication and care files and reviewing areas of the home relevant to these people, in order to focus on outcomes. This helps us to understand the experiences of people who use the service. We look around the home to make sure that it was warm, clean and comfortable. We look to see whether people who use the service are being protected and the arrangements the service has for listening to what people think about Maple Dene. There were no requirements made after this visit. This means that there was nothing of significant importance that needed to be done to make sure people stayed safe and well. Maple Dene DS0000016913.V369575.R01.S.doc Version 5.2 Page 7 Our inspection reports can be obtained directly from the provider or are available on our website at www.csci.org.uk What the service does well: Any person considering moving into Maple Dene is given assurance that the home can meet their needs, they are assessed prior to moving in and are encouraged where possible to visit the home before making any decisions. The home is kept exceptionally clean and people who use the service and their visitors commented on this as being important to them. The home works in partnership with other professional bodies to ensure the best outcome is reached for the people who use the service. Communication and information exchange with all relevant parties is excellent. Peoples descriptions of the home were as follows: “ It reaches my expectations, absolutely!” “We are free, but we are cared for.” Visitors said, including a visiting professional: “They see the whole person and respect privacy and dignity.” “I think the staff understand privacy and dignity and treat people who use the service really well, they speak very kindly.” The registered manager and staff are transparent and open and welcome discussions around continually taking their service forward. The manager, Leisha is considered approachable by people who use the service and staff alike. The home operates a person centred approach and demonstrates a very good understanding of individuals care needs. Plans of care are in place for everyone, containing good levels of information for staff to meet people’s needs well, the staff are encouraged to read care plans so that they can provide the correct care and support. The home also takes pride in supporting staff and ensuring staffs individual needs are identified and met accordingly. The staff receive equality and diversity training, this training reinforces the need for staff to see people as individuals with their own specific needs and wishes. Maple Dene DS0000016913.V369575.R01.S.doc Version 5.2 Page 8 The home ensures staff are not employed without full employment checks therefore confirming they are suitable people to work with older people. All newly appointed staff undergo an induction programme to promote good practice, confidence and understanding in the service delivery; there is a commitment to National Vocational Qualification training for all staff. 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. Maple Dene DS0000016913.V369575.R01.S.doc Version 5.2 Page 9 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 Maple Dene DS0000016913.V369575.R01.S.doc Version 5.2 Page 10 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 and 3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Maple Dene delivers a professional, flexible, reliable and focussed service. Information offered ensures that people can make an informed choice about the home. EVIDENCE: The service user guide and the statement of purpose give clear information about the service provided at the home, including the fees for the service. Copies of these documents are on display in the front porch for people at the home and visitors to look at. It is recommended that the statement of purpose and service user guide are available in a format appropriate to the people who use the service, their individual capacity and language. The home does offer an audio or pictorial Maple Dene DS0000016913.V369575.R01.S.doc Version 5.2 Page 11 version if so desired but people who use the service and prospective users and their families may not necessarily know this. The admission records were checked and contain the needs assessment as required, pre admission documentation is sound and offers appropriate opportunities for the manager to assess whether Maple Dene can meet the needs of the prospective user. It was evident the manager has assessed the needs of people prior to admission and a subsequent care plan had been developed, this affords staff the information necessary to provide appropriate care. Although the home meets the needs of the people who use the service they should consider further ways in evidencing how they meet all equality and diversity needs. The home operates a key worker system to help individuals feel comfortable in their new surroundings; this system also helps to support people who use the service to ask any questions about life in the home and encourages staff to develop a person centred approach to care. Maple Dene is not registered to provide intermediate care, therefore Standard 6 is not relevant so not assessed. Maple Dene DS0000016913.V369575.R01.S.doc Version 5.2 Page 12 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 good. This judgement has been made using available evidence including a visit to this service. People who use the service can be assured their needs will be met. EVIDENCE: Both plans of care seen contained very detailed information to enable staff to meet people’s needs sensitively. In addition to information about people’s care needs the care plans also contain helpful information about their preferred routines and the order in which they like things done. This is particularly beneficial for people who cannot easily explain what they want so that their wishes can be respected. We liked the way plans of care specifically detailed what the person wished to do for themselves and what support they required from the staff. People’s care plans explain how personal care tasks are to be carried out safely and good work has taken place to cross-reference many aspects of the care plans with risk assessments. The care files contain a range of risk assessments, taking account of people’s personal needs and hazards associated with everyday living. Care plans are being dated and signed by Maple Dene DS0000016913.V369575.R01.S.doc Version 5.2 Page 13 people who use the service to show that the documentation has been reviewed and updated, as necessary. People who use the service had access to a wide range of additional health care services according to their individual need and assessments were in place that looked at peoples tissue viability, nutritional needs, continence needs, hearing and sight. This list is not exhaustive. A visiting professional offered us positive feedback, they felt the home communicated well, always followed their requests, have a very good insight and considered every person who lives at Maple Dene as an individual, with their own needs and wishes. Medication procedures were observed and are sound, people who use the service receive their medication as prescribed and a safe management system is in place. The home needs to ensure that staff do not touch the medication. In most instances we saw staff administer medication into pots without touching but occasionally this did not occur and is not considered good practice as medication may become contaminated. On a couple of occasions staff were seen recording ‘not required’ on the Medication Administration Record chart when the medication was prescribed not ‘as and when required’ This means decisions and judgements are being made by the staff members administering medicines without ensuring if this is in the best interests of the person by discussing it with their General Practitioner. Presently where people who use the service self medicate the policy asks them to sign a Medication Administration Sheet, but this does not occur. Therefore as the home does not require this then in should not be stated in their medication policy. The controlled drugs book and a random sample of drugs were checked and no errors were noted. Each person who uses the service has a medication section within their plan of care with details known allergies and all medication being administered. Staff receive medication training and the manager ensures competency checks are undertaken and recorded. Maple Dene DS0000016913.V369575.R01.S.doc Version 5.2 Page 14 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. People who live in the home experience a meaningful lifestyle that promotes their independence and is reflective of their individual needs. EVIDENCE: People who use the service are able to enjoy a full and stimulating lifestyle with a variety of options to choose from. The home has sought the views of people who use the service (available to read on the notice board near the lounge) and considered their varied interests and abilities when planning and arranging activities. The home has a key worker system where each member of staff has specific tasks to undertake with two or three people who use the service. This promotes closer resident staff relationships where likes, dislikes and needs are shared. Key workers also use their knowledge to plan activities and update information required within risk assessments and daily living. Maple Dene DS0000016913.V369575.R01.S.doc Version 5.2 Page 15 Families, staff and people who use the service confirmed that routines are flexible and people who use the service make choices in all areas of their life. Questionnaires sent by us ask, “ Are there activities arranged in the home you can take part in?” Six questionnaires returned confirmed the following: one said always, four said usually, and one said sometimes. One person recorded; “Seems very hit and miss but it has improved.” The home also arranges seasonal activities and recently turned Maple Dene into Maple Dene on Sea. The local papers visited and people who use the service enjoyed deckchairs in the sand, donkeys, paddling pools, beach huts, Punch and Judy and especially the fish and chips! The manager stated: “ We wanted our residents to do something which encourages them to be outside and enjoy the fresh air.” The home has a computer and printer on the second floor, people who use the service can receive e-mails at no cost to themselves and use the internet again with no charge. Staff are also supporting people to learn new IT skills. It is likely the home will soon purchase a Wii with games that suit the requirements of the people who use the service e.g. bowls, other light sports and exercises. Several people who use the service told us that the quality of the food was good and questionnaires also confirmed this to be so. People also said there was a choice both at lunchtime and at tea. “ The food is fabulous, you can see it and choose exactly what you want.” Questionnaires revealed people who use the service either always or usually enjoyed their meals. We saw menus on the tables, spoke with catering staff, observed a wellmanaged kitchen and understand Maple Dene received a recent 5 star rating from the Environmental Health Officer. The menu is varied with a number of choices including healthy options. It includes a variety of dishes that encourage people who use the service to try new and sometimes unfamiliar food. The meals are balanced and nutritious and cater for the varying cultural and dietary needs of individuals. The staff are sensitive to the needs of those people who find it difficult to eat and give assistance, we saw they were aware of the importance of feeding at the pace of the person, making them feel comfortable and unhurried. Maple Dene DS0000016913.V369575.R01.S.doc Version 5.2 Page 16 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. People who use the service know how to complain and feel able to voice their opinions freely. EVIDENCE: There have been no complaints made to us since the last inspection and the manager reports that a few complaints had been made directly to the home during the same period of time. The complaints log was checked and verifies that complaints have been properly recorded and followed up, indicating that complaints are taken seriously by the home. We are confident that through resident /relative meetings, reviews, staff meetings and the open door approach that people who use the service and their families are confident in the complaints procedure. Opportunities are also available for people to make comments discreetly via a suggestions box. Staff have completed training in the protection of vulnerable adults, which should enable them to safeguard people who live in the home. This was verified in a sample examination of staff training certificates and training records. Staff also confirmed they have seen the adult abuse and Whistleblowing procedures informing them how to report any suspicions of abuse or other concerns about the running of the home, should they need to do so. Maple Dene DS0000016913.V369575.R01.S.doc Version 5.2 Page 17 Systems are in place to safeguard the monies of people living in the home. The recruitment records sampled showed that a robust procedure is followed to protect people living in the home. Maple Dene DS0000016913.V369575.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The high standard of the environment provides the people who live at Maple Dene with an attractive, comfortable and safe home. EVIDENCE: The internal environment is well maintained and suitable for wheelchair users. There is a rolling programme of refurbishment and redecoration in place in order to ensure people who use the service have a safe and comfortable environment in which to live. People can enjoy maximum independence in a discreet non-institutional environment. People who use the service are fully involved in decisions about the décor and any changes in their communal and personal accommodation. Maple Dene DS0000016913.V369575.R01.S.doc Version 5.2 Page 19 The service involves people in decision-making and positively encourages people who use the service to make informed choices where possible. There is ramped access into the garden, this area is attractively laid out with adequate seating areas suitable for everyone. People who use the service have a choice of communal seating areas, a spacious lounge and conservatory. There are small seating areas located throughout the home providing people with a choice of areas in which to relax. A partial tour of the building was undertaken and several people who use the service chose to show us their rooms. Bedrooms reflected personal preferences and are suitably furnished. Bathrooms provide sufficient moving and handling equipment for people who require assistance and support, these will soon be refurbished and redecorated. People who use the service, visitors spoken with, and questionnaires returned confirmed that the home was always clean and tidy. “ It is a lovely spot.” “They are always changing my bed, its marvellous.” “ It is always very clean, never anything to worry about.” The home meet infection control standards, they have a policy and procedure, use soap dispensers, paper towels, protective clothing, uniforms, foot-operated bins, and have a clinical waste collection. Maple Dene DS0000016913.V369575.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Good recruitment procedures are in place to ensure that suitable staff are employed at the home. All staff are receiving appropriate training to equip them for their work. EVIDENCE: The service has plentiful staff available at all times to support the needs, activities and aspirations of the people who use the service in an individualised and person centred way. Two staff files examined demonstrated that a thorough recruitment practice is in place; this includes confirmation that Criminal Record Bureau checks, Protection of Vulnerable Adults first checks (a list of banned staff), and references are taken up prior to people starting work at the home. The application forms cover gaps in employment history and the required identification, certificates and photograph are in place. The home has also removed the date of birth from the application to meet with recent age discrimination legislation. We recommend the home introduces evidence of supervision of staff between a Protection of Vulnerable Adults first check and the receipt of the necessary Criminal Record Bureau disclosure, this will further support the home in Maple Dene DS0000016913.V369575.R01.S.doc Version 5.2 Page 21 showing it has an ongoing procedure to protect the people who use their service. People who use the service can be, and have been involved in the recruitment of staff and receive training and support to do this. People who use the service are very happy with the staff working at Maple Dene they said: “Staff are confidential and discreet”, “ they look after you well” and “the staff are very polite.” The staff group said: “ We all work as a team. ” Staff member questionnaires recorded: “I always feel happy about the care I give and understand those I give it to.” All staff receive relevant training that is focussed on delivering improved outcomes for the people who use the service. We have asked the manager to ensure all training is recorded on their matrix; presently they only record mandatory requirements. The home has put a high level of importance on training, including specialist training, and staff report they are supported to meet the individual needs of people in a person centred way. We are aware staff receive training in equality and diversity and recommend they also follow through with training on the Mental Capacity Act to further demonstrate their ongoing commitment. Maple Dene DS0000016913.V369575.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 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An experienced manager manages the home and offers leadership. The home is run in the best interests of the people who use the service. EVIDENCE: The manager Leisha Cooper is registered with the commission and has the required qualifications and experience necessary to run the home. She has a clear understanding of the key principles and focus of the service, based on organisational values and priorities. The manager is able to describe a clear vision of the home based on the organisations values and corporate priorities. The manager communicates a clear sense of direction, is able to evidence a sound understanding and Maple Dene DS0000016913.V369575.R01.S.doc Version 5.2 Page 23 application of ‘best practice’ particularly in relation to continuous improvement, customer satisfaction, and quality assurance. Equality and diversity, human rights and person centred thinking are given priority by the manager who is able to demonstrate a high level of understanding and demonstrate best practice in all areas. On speaking with staff and analysing returned questionnaires we feel the manager promotes equal opportunities, has good people skills and understands the importance of person centred care and effective outcomes for people who use the service. Comments included: “We all work as a team, we all focus on what is best for the individual and we get support in doing so” “ My manager always chats to me to make sure I am happy and my work is ok.” “ The management, care and kitchen staff are very good and work well as a team.” Staff also confirm they are supervised and have an annual appraisal, a member of staff told us their induction “was very informative and even though I had not done care work before I knew what to expect.” Records were also seen to confirm staff receive formal supervision. There is a feeling of warmth and openness in the home and overall staff deliver good care. All the working practices in the home are safe and there are good monitoring and record keeping systems. The home has a comprehensive range of policies and procedures to promote and protect people who use the service and employees’ health and safety. There is full and clearly written record of all safety checks and accidents, including analysis, and there is no evidence of a failure to comply with statutory reporting requirements and other relevant legislation. The home proactively monitors its health and safety performance and consults other experts and specialist agencies about health and safety issues as required. There is evidence of organisational monitoring by corporate providers. People who were spoken to were happy with the manager and staff team and felt they were approachable. The home has a statement of purpose that sets out the aims and objectives of the service. Maple Dene DS0000016913.V369575.R01.S.doc Version 5.2 Page 24 The annual quality assurance assessment (AQAA) is a legal document that all services have to complete on a yearly basis. All sections of the Annual Quality Assurance Assessment were completed and the information gave us a picture of the situation within the service. The evidence to support the comments made is good, although there are areas where more supporting evidence would have been useful to illustrate what the service has done or how it is planning to improve. The Annual Quality Assurance Assessment also verified that all necessary servicing and checks required within the home were undertaken and in date. If they wish and are able to, people who use the service are helped to take responsibility for managing their own money and are provided with facilities to keep their valuables and money safe. Where the home is responsible for peoples money it works to a rigorous system and maintains very clear records. Staff have received fire training including regular fire drills. The manager has undertaken individual fire evacuation procedures for each person who uses the service to make sure they are fully assessed should a fire occur. Maple Dene DS0000016913.V369575.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 3 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 4 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 4 Maple Dene DS0000016913.V369575.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 It is recommended that information is made available to confirm that the Statement of Purpose and Service User Guide are available in a format appropriate to the people who use the service, individual capacity and language. The home should amend their policy where people who use the service self medicate if they do not require them to sign to say they have administered their medication. The home should ensure they follow their own policy which asks people who use the service sign to say they have received their medication as prescribed. Staff should not touch any medications to fully comply with infection control measures and ensure medication is not compromised in any way. The home should ensure it can demonstrate staff are appropriately supervised between a Protection of Vulnerable Adults first and a Criminal Record Bureau disclosure, this means the home can demonstrate they DS0000016913.V369575.R01.S.doc Version 5.2 Page 27 2 3 4 5 OP9 OP9 OP9 OP29 Maple Dene 6 OP30 continue to protect people who use the service. The home should ensure it records all training offered to staff on their training matrix to show there is a good skill mix within the home. Maple Dene DS0000016913.V369575.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Maple Dene DS0000016913.V369575.R01.S.doc Version 5.2 Page 29 - 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. 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