Care Home: Maple House

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What the care home does well Residents` care plans remained detailed outlining their needs on an individual basis. Choice remains a central feature of how care and support is delivered in the home. Residents have access to a range of activities and are supported to integrate into their community. They also have good access to health care facilities. Risk assessments are available for all residents and are designed to promote safety and independence. The environment has been enhanced and residents not only contribute to this, but they seemed very happy with their accommodation. The management and staff maintain a sound level of commitment to the service as a whole. What has improved since the last inspection? Residents have their fee component in their contracts as required by regulation. Drug administration has improved to a good level at which residents are safeguarded with regard to their healthcare management. There have been improvements in the level and quality of training provide by the home. Alternative spaces for locking away staff belongings. The registered informed that plans were in place to carry out an internal audit of the service. What the care home could do better: Obtain a copy of the Local Authority`s Safeguarding Adults Protocol. Provide specific training for staff in Learning Disabilities and Equality and Diversity. Ensure that food storage is appropriate at all times and review each incident and record the actions necessary to prevent reoccurrence. CARE HOME ADULTS 18-65 Maple House 78 Aldborough Road South Seven Kings Ilford Essex IG3 8EX Lead Inspector Stanley Phipps Unannounced Inspection 24th April – 8th May 2008 11:30 Maple House DS0000025909.V362172.R01.S.doc Version 5.2 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 House DS0000025909.V362172.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 Adults 18-65. 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 House DS0000025909.V362172.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Maple House Address 78 Aldborough Road South Seven Kings Ilford Essex IG3 8EX 020 8590 7082 020 8550 0666 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 Alan Philp Mr Brad Holloway Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Maple House DS0000025909.V362172.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 8 7th February 2007 Date of last inspection Brief Description of the Service: Maple Lodge is a residential home for Adults with a Learning Disability, which is staffed on a twenty-four hour basis to ensure that service users needs are met as and when required. The home is situated in a residential road in Seven Kings in the London Borough of Redbridge, with easy access to the local park, shops, places of worship and transport. The nearest shopping facilities are Seven Kings High Road, Ilford Shopping Centre and Newbury Park. Each service user has a single bedroom, individually decorated to a high standard, with personal items that reflects their individual character and interests. Toilets and bathrooms are available on both floors of the building. The home is generally decorated, furnished and maintained to a good standard including the garden, which is accessible to all service users. The home is part of the Alpam Homes organisation, which operates two other similar residential care homes in the London Borough of Redbridge and also has its own day centre (Highview), which service users attend daily. Fees range from £950.00 to £1300.00 and may vary dependent on individual levels of need. They do not cover personal effects. Maple House DS0000025909.V362172.R01.S.doc Version 5.2 Page 5 A statement of purpose is made available to all service users in the home and is kept in the main office. This document is also made available to relatives and stakeholders, who may be involved in referring service users to the home. A service user guide is also given to each service user upon admission to the home. Maple House DS0000025909.V362172.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 the people who use this service experience good quality outcomes. The inspection was unannounced and was carried out over the period 24/4/08 through to the 08/05/07. At the time of the visits the registered manager was available to provide evidence as part of the inspection process. There were seven residents in the home, most of whom looked settled and comfortable in their home environment. Very few of the residents wanted to participate in the inspection process at the time, however written feedback was obtained from them. An assessment of medication practice, menus, policies and procedures, records required by regulation, residents’ care plans and the environment was undertaken. Discussions were held with the registered manager and several members of staff. Formal interviews were also held with two members of staff along with telephone interviews with up to three relatives. The inspection also considered: information provided in the Annual Quality Assurance Assessment (AQAA) provided by the registered person, verbal feedback from external professionals, along with comment cards that were returned from staff and residents. The inspection also looked at the issues raised in a complaint by an exmember of staff in relation to how they affected the health safety and welfare of the residents living in the home. The inspection found no evidence to support the allegations made as such concluded that residents were not adversely affected by the claims made. It also concluded that several areas had improved since the last inspection. However, there are areas required for further development, which are identified in the body of this report. Prior to the inspection an Annual Service Review was undertaken on the service, which looked at the operations of the home by reviewing several document submitted by the registered provider to the Commission. One such document is the Annual Quality Assurance Assessment (AQAA). One of the main findings of the review was that the registered provider was running the service in breach of Regulation by virtue of the company Roselock Limited – not being registered with the Commission. Consequently, the registered person was instructed to comply without undue delay and despite this instruction an application for registration of Roselock Limited had not been received prior to or up to the date of the first site visit. A more recent check has been made and it was reported by the local area office that an amendment of the certificate had been made. What the service does well: Maple House DS0000025909.V362172.R01.S.doc Version 5.2 Page 7 Residents’ care plans remained detailed outlining their needs on an individual basis. Choice remains a central feature of how care and support is delivered in the home. Residents have access to a range of activities and are supported to integrate into their community. They also have good access to health care facilities. Risk assessments are available for all residents and are designed to promote safety and independence. The environment has been enhanced and residents not only contribute to this, but they seemed very happy with their accommodation. The management and staff maintain a sound level of commitment to the service as a whole. What has improved since the last inspection? What they could do better: Obtain a copy of the Local Authority’s Safeguarding Adults Protocol. Provide specific training for staff in Learning Disabilities and Equality and Diversity. Ensure that food storage is appropriate at all times and review each incident and record the actions necessary to prevent reoccurrence. Maple House DS0000025909.V362172.R01.S.doc Version 5.2 Page 8 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 House DS0000025909.V362172.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Maple House DS0000025909.V362172.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (2,5) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Residents continue to have access to information in making a decision about the suitability of the home. They benefit by having detailed assessments carried out on them and have opportunities to view the service before deciding to live at Maple House. EVIDENCE: There has been an improvement as residents now have access to information regarding their fees placed into their contract. This was not previously available and so residents and/or their relatives did not have access to information that was legally entitled to them under the Care Homes Regulations 2001. At the time of the inspection, there were no additions to the residents living in the home and such the assessment and admission practices were not used. However, random files were selected from the current resident group and it was clear that each individual has a thorough assessment prior to agreeing to live at Maple House. There was also evidence that assessment summaries were obtained from referring authorities. In many respects, there was little room for residents to be move into Maple House without the home being satisfied that they could provide for the needs of the individual. The admissions process is robust and protects prospective residents from being inappropriately placed. Maple House DS0000025909.V362172.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (6,7,9) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Residents benefit from having their needs (including their specialist needs), reflected and reviewed in their individual plan. There was evidence that they take decisions with support, and maintain their safety and independence within a risk management framework. EVIDENCE: From the care plans viewed, it was clear that residents are involved in planning their care, which ensures that they are not only aware, but accept responsibility for their direction. As part of this arrangement, they have the benefit of a key worker who works closely with them in setting up and reviewing their individual plan. Most of the care plans viewed were updated and generally individualised, detailing the specific needs of residents. They were borne out of the assessments carried out initially with them. It was noted that individual profiles for residents were being developed, which would give a more detailed picture of each resident’s background. This is useful as it could be used to look at for e.g. how individuals communicate or even what their a preferred routine is. Maple House DS0000025909.V362172.R01.S.doc Version 5.2 Page 12 The needs of the resident group are quite complex and though they are fairly settled in the home, most needed a high level of support to influence and communicate their needs. Staff play a major role in enabling residents to make decisions about their goals and objectives. An example can be drawn from a case in which one resident deals with a need that could compromise his safety and welfare. Staff along with the resident detailed the alternatives in his care plan that could more effectively achieve a positive outcome for the individual concerned. This is positive. Residents’ meetings are held regularly and they are enabled to participate and contribute to the home’s operations. Information for e.g. complaints and activities are available to them in suitable formats. A system for risk assessment and risk management is in place at Maple House. In all cases they were linked to each resident’s care plan. Staff spoken to understood the importance of risk assessments in ensuring that both the independence and safety of service users are promoted. Linking the risk assessments to their care plans ensure that staff are knowledgeable about the needs, risks and safe management of each individual resident. Both the care plans and risk assessments were updated as a result of being regularly, which is positive. A missing persons procedure in place at the home. Maple House DS0000025909.V362172.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (12,13,15,16,17) People who use the service experience god quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Residents are encouraged to participate in their community, in appropriate activities and are able to maintain and develop social and personal networks of their choosing. Most times residents are supported to exercise their rights, which are respected and promoted by staff in the home. Maple House provides meals that are reflective of service users’ choice and nutritional requirements. EVIDENCE: There was evidence that service users were supported to develop and maintain their living skills however restricted they might be. This is true despite having varied and complex levels of needs, and motivation. This presents a challenge for the staff team and from observation they were aware of the challenges in providing care and support to the resident group. Residents have an individual programme of activity, which is specific to their choice and interests and all staff were expected to work in accordance with this. From speaking with relatives, they were satisfied with how the staff supported their loved ones with regard to the range and level of activities that is provided to them. Maple House DS0000025909.V362172.R01.S.doc Version 5.2 Page 14 Residents continue to make use of the community facilities such as the cinema, the day centres, shopping arrears, and the local parks. Most of them were familiar with the community facilities and so make good use of them and again the staff are very instrumental in enabling this. Residents receive support in a flexible manner to enable them to enjoy accessing and using the community resources. It was clear that residents were engaging with their community in an effective manner. This conclusion is supported from views of external professionals, relatives and the records viewed. This is positive. From assessing residents’ records, talking to the staff, relatives and community professionals, it was noted that residents are encouraged to develop and maintain relationships with their friends and families. Relatives are also invited to and in some cases attend social events in the home such as birthday events. Some residents also go to their relatives on short periods of leave and this is usually done in conjunction with each relative and remains a positive feature of the service. During the course of the inspection staffing interactions with residents were appropriate and more importantly respectful. Residents were addressed by their preferred names and staff were observed checking with them their preferences around food and personal support. Advocacy information is made available to residents and the key worker system is used as a means of ensuring that the rights and needs of residents are respected and provided for. During the course of the inspection menus were available and lunch was observed on the first day. Lunch consisted of baked beans, sausage and mash and residents seemed to enjoy their meals, as they were unrushed. This dish was a particular favourite of one of the residents – but it was clear that they could all have their preferences prepared. Some ate more independently than others, but even so support was provided to individuals in a dignified manner. From observation there were healthy options available and the staff at hand showed an awareness of the residents’ specialist dietary needs. Checks carried out indicated that there was a good supply of food and drink, which is accessible to all residents. Service users could eat where they preferred, and the mealtimes were flexible. Maple House DS0000025909.V362172.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (18,19,20) People who use the service experience god quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Residents enjoy personal support in a manner that is generally suited to them. Arrangements are in place to provide for their physical and emotional health needs, as staff continued to maintain effective links with external professionals in achieving this outcome. This is enhanced by the improved practices by staff in the handling of medication. EVIDENCE: Feedback received from relatives was positive with regard to how residents received personal support, which is coordinated through the key-worker system used in the home. For many they are unable to independently manage their personal care. Staff were observed throughout the course of the inspection providing personal support to residents and this was carried out in a safe and dignified manner. It was also clear that the staff had a system for determining individuals’ preferences and dislikes, which made the relationship between them – a positive one. Residents have their individual style of dress, which was consistent with their choice, culture and personality, and this was promoted in the home. Residents are given good support to ensure that their health needs are provided for. They were all registered with a GP and records assessed indicated Maple House DS0000025909.V362172.R01.S.doc Version 5.2 Page 16 that arrangements are in place for them to see other health professionals such as the dentist, chiropodist and the opticians. They also have the benefit of getting support to attend their outpatients’ appointment should they require this. Feedback received from external professionals was positive about the staffing awareness of residents’ needs. Records bore evidence that all community appointments were documented as they occurred. Good support is provided in relation to the healthcare needs of residents at Maple House. At the time of the visit, all residents were receiving support with medication, as they were unable to independently manage this task. A medication policy was in place to guide staff in the safe handling of medication in the home. The safety is enhanced by: ensuring that staff receive training in drug administration prior to supporting residents in this area and although not required one staff member witnesses the medication administration procedure. This practice acts as a safeguard in ensuring that mistakes/errors are kept minimal. Medication storage in the home is was good. There was evidence from the recording systems in the home to confirm that drugs stocks are appropriately recorded and monitored at Maple House. Residents are therefore assured that their health care support needs are well-provided for. Maple House DS0000025909.V362172.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (22,23) People who use the service experience god quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. A satisfactory complaints procedure is in place and widely available to all residents and staff. Safeguarding adults’ practices within the home generally protects residents from abuse, although this could be enhanced through the acquisition of an updated copy of the Local Authority’s Safeguarding Protocol. EVIDENCE: A satisfactory complaints procedure is in place at the home and is made widely available in appropriate formats (in most cases) to all residents. From discussions held with staff and relatives, they generally felt able to raise issues of concern, should they feel the need to. The complaints record was analysed and in the main, complaints were logged and dealt with in line with the home’s complaints’ procedure. Prior to the inspection, an ex-member of staff raised concerns about the management practices in the home, which allegedly compromised residents’ safety and disempowered staff. The ex-member of staff remembered that when interviewed previously about the management practices in the home that – the individual now raising the concerns reported the management practices as being very good at that time. The staff raising the concern invited the Commission to speak with current staff and relatives to verify the experiences described in the allegation. This was done along with, assessing the comment cards returned by every member of staff (seven in total), assessing the complaints records and closely examining the case files of at least thirty-three per cent of the residents living there. From the evidence gathered, the conclusion was that the claims made Maple House DS0000025909.V362172.R01.S.doc Version 5.2 Page 18 were unsubstantiated i.e. there was no evidence that residents’ safety was compromised by the practices of the manager neither was there any evidence to indicate that staff were disempowered or bullied. As a matter of fact one of the staff comments was: “the manager is very supportive”. The Commission in its work would continue to seek out and identify any such malpractice/s where they are discovered and would take appropriate action wherever necessary to ensure the safety and well-being of residents and staff alike. There was evidence that staff had safeguarding training and that a policy was in place to direct them on safeguarding issues. There were no safeguarding issues in the home, although on one occasion since the last inspection following an incident – a safeguarding referral should have been made to the local authority. This was done only following the intervention and direction of the Commission. The registered manager was strongly advised to adhere to safeguarding guidelines and when unsure, to check with the local area office. This is to ensure safer practice rather than having regrets of the consequences of failing to act. The registered manager must obtain an updated safeguarding adults protocol from the local authority, as the one he currently holds dated 2003 is woefully outdated. Maple House DS0000025909.V362172.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (24,28,30) People who use the service experience god quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Residents live in a clean, purpose built and suitably designed home that matches their needs and lifestyles. They enjoy using their facilities, which are homely and personal, including their shared spaces. The home is clean and hygienic and fit for its purpose. EVIDENCE: Although the inspection was unannounced, the home was clean bright and airy on both visits. There was also decorative works done to enhance the homely feel to the environment and residents seemed quite happy with it. Feedback from relatives indicated that they were pleased with the quality of the environmental facilities provided at Maple House. Residents were observed negotiating their way was around the home with relative ease. It was noted that residents had options of where to go dependent on what they wished to do e.g. watch television, relax or engage with an activity of their choice. The shared spaces were more than adequate to meet the residents, needs and there was an improvement in that staff were no longer using the kitchen cupboards to store their personal belongings. Maple House DS0000025909.V362172.R01.S.doc Version 5.2 Page 20 The laundry facilities were designed to promote the service users’ independence as far as possible. It was also designed to ensure that service users could develop their skills in this area. An infection control policy is in place and service users and staff are encouraged to work within this e.g. handwashing. The laundry equipment is designed to cater for soiled linen and appropriate arrangements were in place for maintaining them. The layout of the home is such that foul linen is well away from food preparation and so the risk of the spread of infection is minimised. The services and facilities do comply with the Water Supply Regulations 1999. It must be noted that the feedback received service users and from relatives was quite positive about the cleanliness and quality of the environment Maple House DS0000025909.V362172.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (32,34,35) People who use the service experience god quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Residents receive care and support from a staff team that is motivated to work with them. Their welfare and best interests are promoted by ensuring that generally staffing levels do reflect their needs, However, staff would benefit from having further specialist training to carry out their duties more safely. Improvements in staffing recruitment practices means that residents are protected from coming into contact with individuals not suited to work with them. EVIDENCE: In observing practice staff demonstrated their ability to positively engage and interact with residents. It is fair to say that even at times when a service user became anxious, staffing interventions were generally appropriate. From the records viewed, staff were able to make appropriate referrals to external professionals e.g. the GP and generally able to act when emergencies occur. One weakness however is the ability to review incidents and review actions to prevent the risk of reoccurrence - although this would be covered under the management section (YA42) of this report. Despite the fact that staff received training, including structured induction training, and have the minimum NVQ level 2 in Care, there remains outstanding for them to acquire Learning Disability Award Framework training. Maple House DS0000025909.V362172.R01.S.doc Version 5.2 Page 22 Although it is accepted that some staff may go to complete an NVQ Level 3 in Care, until such time the deficiency would remain, hence the risk of the compromised quality standards of care remain. There is also a lack of equality and diversity training for staff, despite the fact that they have a diverse resident and staff group. This needs to improve. The recruitment file of the most recently recruited staff was examined and an improvement was noted in the robustness in the recruitment practices undertaken by the registered manager. All checks required by regulation were undertaken prior to staff taking up duty at Maple House. Residents are now assured that all staff are thoroughly screened prior to engaging with them. They are therefore more protected from the risk of coming to harm, which is a positive outcome for them. A training and development plan is in place for the staff. However, there was a lack of training in relation to the specialist needs of residents with learning disabilities, which must be addressed (See Standard 32 above). It must be said that service users currently living there do have a range of complex needs and appropriate training must be provided to ensure that staff are equipped to provide the best possible care to residents living at Maple House. Maple House DS0000025909.V362172.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (37,39,42) People who use the service experience god quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Management systems are in place to provide a quality service at maple House. Good quality assurance systems are implemented to enhance this. Health and safety practices within the home generally protect residents, except in the area of food storage and reviewing incidents to reduce the risk of reoccurrence. EVIDENCE: The registered manager has been managing the service for a number of years and has developed a good level of expertise in management. He has also completed the Registered Managers Award in 2007 and has done some training updates in restraint. He claims to have sound professional relations with the GP and external professionals. Staff interviewed as well as staff that submitted comment cards spoke positively of their experience with him. From observation he held good levels of interaction with residents. From discussions held with him he has some understanding of the specific needs of the resident group. Maple House DS0000025909.V362172.R01.S.doc Version 5.2 Page 24 It was observed that there were limited opportunities for him to pursue further training to enhance his skills and knowledge, particularly in relation to learning disability. However, he has provided evidence of training he has undertaken since the visit as well as training he intends to go on. They included; the Mental Capacity Act, Communication with People with Dementia and Food Nutrition Advice (completed). There was evidence that quality assurance systems were implemented with the view to improving the service. This included; an internal audit of the service, regular monthly monitoring visits as required by Regulation 26 of the Care Homes Regulations 2001, residents’ surveys and surveys conducted with relatives. The 2008 residents surveys are nit yet done, but plans were in place to so do. Residents have reviews regularly internally and on average a yearly review with external professionals. Residents are therefore assured that the registered persons would take steps to develop the service. The health and safety file was assessed and all records on; appliance safety, fire safety and electrical safety were in order. There was evidence that staff have as part of their induction, appropriate training in health and safety. Safety signs were also appropriately displayed throughout the home and all areas of the home were safely accessible to the residents. Risk assessments were in place for all residents to ensure their safety and independence, however it was observed that when incidents occur, there is very little or no action to prevent a reoccurrence of the incident that is reported under Regulation 37 of the Care Homes Regulations 2001. This needs to improve. Residents safety was also compromised through the inappropriate storage of food by staff in the home. This also needs to improve. Maple House DS0000025909.V362172.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 Adults 18-65 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 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 3 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 2 x Maple House DS0000025909.V362172.R01.S.doc Version 5.2 Page 26 N0 Are there any outstanding requirements from the last inspection? 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 YA23 Regulation 13 Requirement Timescale for action 08/07/08 2. YA35 3. YA42 The registered manager must obtain an updated version of the Local Authority’s Safeguarding Protocol. This is to ensure that current practices are followed in keeping residents safer. 18(1)(c)(i) The registered persons are 09/08/08 required to provide appropriate training for staff to ensure that residents get the best standard of care possible. This includes: Learning Disability Award Framework Training or its equivalent, and equality and diversity training. 13(4)(b)(c) The registered persons must 08/07/08 ensure that appropriate arrangements are made for the storage of food in the home at all times, and to determine and record a plan of action to prevent incidents from reoccurring – when they occur. This is to ensure the safety of residents. Maple House DS0000025909.V362172.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Maple House DS0000025909.V362172.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 House DS0000025909.V362172.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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