Care Home: Maple Leaf Lodge

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What the care home does well It is ensured the home could meet people`s needs and goals before they move in. Anyone wanting to live there can also visit and stay to check if they like it. Each person living at the home has a care plan they help to make. Plans show their needs, wishes and goals and support needed to meet them and manage their behaviours better. Risks are assessed so staff can help keep people safe. People living at the home are encouraged to make decisions about what they do every day and choose their meals. Staff also respect their individuality. Staff support people well with their personal care. They also ensure that their good health is promoted and their medicines are managed safely in the home. Maple Leaf lodge is comfortable, very well furnished and equipped and is kept clean and safe. People can make their own bedrooms nice and personal.Staff have good training to help them understand the special needs of people using the service and know how to support them and keep them safe. Checks are made on staff to ensure they are suitable to care for people. New staff have a good introduction to the home, which helps them do their job well. The home is run well by management with suitable skills and experience. Staff are supported and work together as a team to offer people good quality care. The home has ways of checking the service is right and will keep on improving, as people living there would like it to and to make the home better for them. What has improved since the last inspection? This does not apply because Maple Leaf Lodge is a newly registered home and so this service has not been inspected before. What the care home could do better: Provide information and questionnaires about the service in other ways, such as on tape or video. This is so that people already living at the home, and who may wish to move in, would find it easier to understand and give their views. It will be good when the home has developed the ways that people living there are offered opportunities to make more choices and to lead healthier lifestyles. CARE HOME ADULTS 18-65 Mapleleaf Lodge Ickfield Street Forhill Wythall Worcestershire B38 9EG Lead Inspector Christina Lavelle Key Unannounced Inspection 30 September 2008 11:45am– th Mapleleaf Lodge DS0000071776.V372169.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 Mapleleaf Lodge DS0000071776.V372169.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. Mapleleaf Lodge DS0000071776.V372169.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mapleleaf Lodge Address Ickfield Street Forhill Wythall Worcestershire B38 9EG 01564 824 594 01564 824 594 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) Malvern View (Lydiate) Ltd Mr Joseph John Slack Care Home 13 Category(ies) of Learning disability (13), Mental disorder, registration, with number excluding learning disability or dementia (13) of places Mapleleaf Lodge DS0000071776.V372169.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: Learning Disabilities (LD) 13 Mental Disorder (MD) 13 2. The maximum number of service users to be accommodated is 13. Not Applicable – New Service Date of last inspection Brief Description of the Service: Maple Leaf Lodge was registered in respect of this provider on April 2nd 2008. The home can provide accommodation with personal care for 13 adults. People using this service require care because of learning disabilities and/or due to a mental health disorder. People living at the home may have complex needs and use behaviours that can challenge a care service. The home has a rural location, on the outskirts of Wythall village. This is south of Birmingham within a short drive of Redditch, Bromsgrove and Solihull towns. Maple Leaf Lodge is a large, detached house set in extensive, private grounds. It was formerly a care home for older people that has since been extended and substantially refurbished. The home has ten single bedrooms in the main part of the house, all with en-suite facilities and walk-in showers. There are two ground floor sitting rooms with dining space, a domestic style kitchen, separate laundry, toilets and bathrooms located throughout the home and an office. The home also offers two self-contained flats, one with one bedroom and the other two, which can provide a more independent, supported living environment. Information about the service is provided in a statement of purpose and service users’ guide available from the home. The weekly fee is based on information obtained during the formal assessment process prior to individuals’ admission and as agreed between the provider and their funding authority. This charge is stated to include “the residential placement and a structured programme of day care activities designed around each individual’s needs and interests”. Mapleleaf Lodge DS0000071776.V372169.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 2 Star. This means that the people using the service experience good quality outcomes. This is a key inspection of the service provided at Maple Leaf Lodge. This means all the Standards that can be most important to people living in care homes are assessed. As part of the inspection we, the Commission, visited the home without telling staff or people using the service beforehand. We spoke with one person who lives at the home about their experience of the service and their lifestyle. Two support workers were interviewed about their role, training and support. The way the home is run and plans to develop the service were discussed with the home’s deputy manager and two team leaders. Surveys were sent to the home for people living there and all the staff. Also to two care professionals, who are involved with the home, asking them all for their views of the service. Eight surveys were completed and the feedback from them and discussions during our visit are referred to in this report. The manager had completed an Annual Quality Assurance Assessment (AQAA) before our visit. This asks managers to say what their service does well and could do better and about their plans to improve the service. Relevant records including the care plans of people living at the home and relating to staff were checked and the building looked around. All other information received by the Commission about the home since it was registered is also considered. What the service does well: It is ensured the home could meet people’s needs and goals before they move in. Anyone wanting to live there can also visit and stay to check if they like it. Each person living at the home has a care plan they help to make. Plans show their needs, wishes and goals and support needed to meet them and manage their behaviours better. Risks are assessed so staff can help keep people safe. People living at the home are encouraged to make decisions about what they do every day and choose their meals. Staff also respect their individuality. Staff support people well with their personal care. They also ensure that their good health is promoted and their medicines are managed safely in the home. Maple Leaf lodge is comfortable, very well furnished and equipped and is kept clean and safe. People can make their own bedrooms nice and personal. Mapleleaf Lodge DS0000071776.V372169.R01.S.doc Version 5.2 Page 6 Staff have good training to help them understand the special needs of people using the service and know how to support them and keep them safe. Checks are made on staff to ensure they are suitable to care for people. New staff have a good introduction to the home, which helps them do their job well. The home is run well by management with suitable skills and experience. Staff are supported and work together as a team to offer people good quality care. The home has ways of checking the service is right and will keep on improving, as people living there would like it to and to make the home better for them. 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. Mapleleaf Lodge DS0000071776.V372169.R01.S.doc Version 5.2 Page 7 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 Mapleleaf Lodge DS0000071776.V372169.R01.S.doc Version 5.2 Page 8 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who may wish to use this service can be confident the home would be able to support them. This is because a comprehensive assessment is made of their needs and staff would know their wishes and goals from involving them and/or their representatives in their needs assessment and admission. EVIDENCE: It is evident from discussion with the home’s senior staff and care records of people now living at the home that no one would be admitted until a thorough assessment of their needs has been undertaken. Initial care plans and risk management plans are set up based on the assessment information. Support workers also confirm they have always received enough information about the needs of people wishing to use the service. One comments that “I think the assessment and information given to our staff about service users is excellent”. The AQAA states “prospective service users are provided with full information and support prior to moving into the home”. One person living there confirms he was asked about moving in and says “I was told a lot of things about the home”. Admission procedures include people who might want to live at the home being invited to make several introductory visits, including overnight and weekends, followed by a trial stay. Reviews follow their trial when contracts are agreed and signed by all involved parties before placements are confirmed. Mapleleaf Lodge DS0000071776.V372169.R01.S.doc Version 5.2 Page 9 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home all have a care plan, they and/or their representatives are involved in making and reviewing. Plans show their needs and goals and how they can be met, with any risks assessed so they can be minimised. Staff promote individuality and enable people to make decisions about their lives. EVIDENCE: People using the service all have a care plan drawn up that highlights their needs, preferences, aspirations and support they require. The home has adopted an appropriately “person centred” approach to care planning so individuals are involved in planning their care and enabled to make decisions about their lives. Plans cover all relevant aspects of their life, their history and things that are important to them. They are agreed with them and/or their representatives and reviewed regularly. One person confirms he takes a very active role in his care planning and is also clear about counselling and psychological support he receives. As part of a person centred approach Mapleleaf Lodge DS0000071776.V372169.R01.S.doc Version 5.2 Page 10 individual forensic counselling sessions, which follow a treatment pathway also take place and are recorded. There is a key worker system operated, whereby support workers are allocated to certain people living at the home. The key workers give the people some individual support and also take an active part in reviewing and updating their care plans. People meet with their key workers monthly to review their needs and plans. Staff are clear about their key worker role and confirm in surveys that they are always given up to date information about people’s needs. One comments that “our home provides consistent care and support for service users” and another says staff “understand the needs of individual service users on a day-to-day basis”. Risk assessments are carried out covering all relevant areas, resulting in plans to reduce possible safety risks. There are also detailed individual management plans in place for aggressive and other challenging behaviours. They include interventions staff could use, for example diversion and diffusion, as well as how to use physical restraint as a last resort. All staff have undertaken a five day training course on these techniques. The moods and behaviours of people living at the home are closely monitored and all incidents are fully recorded. They are then analysed and reviewed with their Psychologist and Psychiatrist. Any decisions or action that can limit choices and/or freedom of people using the service are appropriately agreed with multi-disciplinary teams. Individuals are also supported to make appropriate informed decisions based on their treatment pathways and care plans. The AQAA states that this approach helps people to address offending or extreme forms of challenging behaviours and is recorded in their plan, risk assessment and daily records. It is good that staff have received instruction about the implications of the Mental Capacity Act. Mapleleaf Lodge DS0000071776.V372169.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home are supported to take part in activities, to mix in the community and to maintain links with their family and significant other people. Staff respond to people’s diverse needs appropriately and they are treated as an individual. Their independence is also encouraged and dignity respected. Food provided is healthy and meets people’s needs and preferences. EVIDENCE: Each person living at the home has a record sheet listing activities they enjoy. One person’s only includes household tasks, golf, meeting a friend and says he can go out when he wants to. It is recognised that it might be difficult for people to take up educational or work related activities and/or to take part in activities within the community, due to their complex needs. It is positive however the AQAA states that one improvement planned is to offer people opportunities to make more choices in their life and to lead a healthier lifestyle. Mapleleaf Lodge DS0000071776.V372169.R01.S.doc Version 5.2 Page 12 Staff encourage people’s involvement in the domestic tasks and day-to-day running of their home. They choose their own daily routines and one person says he enjoys washing up, cleaning his room and doing his own washing. He comments “I enjoy the weekends most because I have a lie in and we have a takeaway every Saturday for our tea”. Individuals are also assessed in respect of managing their own money and medication. It is apparent from observation during our visit and staff interviews that the individuality and rights of people living at the home are respected. One person comments that “the staff always treat me very well and with respect and they do listen at all times”. An example was also given in the AQAA about how the home had ensured that one person’s specific cultural needs had been met by providing them with the opportunity to follow their faith. Information had also been gathered for staff to read to help them to understand this faith. People living at the home are supported to keep in touch with their family, friends and significant other people and it is good that staff are trying to find an independent advocate for one person. Regarding food provided by the home weekly menus reflect varied and healthy meals that people like. Recipes are available so that meals can be consistent. Staff say that although people can choose their own meals they give advice and offer them a good balanced diet. No one needs a special diet but guidance has been sought from a Dietician about healthy eating in general. It was noted people buy their own weekly takeaway meal. It is advised the home should pay for this as it is in lieu of a main meal the home would normally provide. Mapleleaf Lodge DS0000071776.V372169.R01.S.doc Version 5.2 Page 13 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home receive personal care in ways they need and prefer. Their physical and emotional health care needs are also met because the home has procedures in place that staff follow. If people take medicines they are not able to manage themselves then staff manage them safely on their behalf. EVIDENCE: Plans of people living at the home include an assessment of their personal care needs and their plans and staff confirm that self-care is always encouraged. Daily care records detail the support offered to each person in respect of their personal care. The AQAA provides evidence that individuals’ preferences and any diverse needs are also ascertained and met, such as gender of their carer. Each person has a health action plan that includes key information about their medical condition, health and an assessment of other relevant health related aspects, such as diet, mobility and communication. Staff ensure that people receive routine, and have preventative, health care checks such as well person clinics, which team leaders oversee and management closely monitor. Records are kept of physical health care checks such as weight. It is positive the home plans to encourage people to take the lead in managing their own health care. Mapleleaf Lodge DS0000071776.V372169.R01.S.doc Version 5.2 Page 14 Specialist health care support is provided for people at the home, with regular input from Psychologists and Psychiatrists. Their behaviour management and treatment plans are closely followed and monitored with very detailed records kept by staff. The home’s management team and the multi-disciplinary team review this information and people’s needs and condition on a monthly basis. When necessary other specialist advice is also sought such as from a Dietician. Regarding medicines prescribed for people living at the home, the home has a comprehensive policy and procedures in place to ensure its safe management. They include protocols for medication that can be administered as and when required if people are anxious and/or use aggressive behaviours. Each person is assessed and supported to manage their own medicines if capable. Staff are currently responsible for managing most medicines in the home and staff so designated have received appropriate training. Samples of staff signatures are kept and records checked of medicines administered were being maintained appropriately. Suitably secure storage is provided for medicines in the home. Daily and weekly audits of medication are undertaken to ensure good stock control and a community Pharmacist visits regularly to check the system. Mapleleaf Lodge DS0000071776.V372169.R01.S.doc Version 5.2 Page 15 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are enabled to express their views and if they have concerns about the home they know how to complain and are confident they will be listened to and dealt with. The home safeguards them from abuse, neglect and self-harm. EVIDENCE: The home provides a suitable complaints procedure in written and pictorial formats for people living at the home and their representatives to use if they need to. A compliments and complaints book is also available at the home for all visitors to use if they wish. Procedures describe how complaints will be handled with timescales and action taken. The AQAA states complaints received would be fully investigated and a report produced. The home also has a whistle blowing policy that can be used by people using the service, staff or others to offer individuals protection. The Commission has not received any complaints, and no referrals have been made under safeguarding adults procedures, since the home opened. One resident says he feels able to discuss concerns with the manager and staff and that the manager resolved one complaint he had made. He says “I would speak to the staff or manager because they are all here to help me”. Staff also confirm they would know what to do if anyone raises concerns about the home with them. One commented that “we have a very comprehensive complaints procedure, which due to our level of service provision has not been utilised”. The AQQA states that staff and people using the service both have access to the inter-agency procedures for safeguarding adults. Staff receive training on Mapleleaf Lodge DS0000071776.V372169.R01.S.doc Version 5.2 Page 16 abuse and protection and how to use these procedures during their induction in addition to their training on how and when to use physical interventions. Mapleleaf Lodge DS0000071776.V372169.R01.S.doc Version 5.2 Page 17 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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People at Maple Leaf Lodge have the benefit of living in a safe and very wellmaintained home that is comfortable, clean, pleasant and hygienic. EVIDENCE: Maple Leaf Lodge has a rural, and although not isolated, private location that provides secure accommodation for the people living there. Several big towns are within a few miles and the home has a vehicle to provide transport. The property was extended and substantially improved and refurbished before being re-registered as a care home. The main house and separate flats have very good quality decor, furnishings and fittings. The overall impression of the environment is comfortable and it is good that people living there are being supported to choose the colour of decor and furnishings etc, in their bedrooms to personalise them. The plan is also for them to be involved in making the communal areas of the house more homely as and when more people move in. Mapleleaf Lodge DS0000071776.V372169.R01.S.doc Version 5.2 Page 18 We visited most areas of the building and found them to be warm, fresh, clean and tidy. There are suitable laundry facilities and the home has provided a comprehensive infection control policy and staff cover this topic as part of their induction. The home follows required food safety regulations and provides equipment such as disposable gloves and aprons. There are also appropriate arrangements in place for the disposal of soiled waste and for the control of substances hazardous to health (COSHH). Mapleleaf Lodge DS0000071776.V372169.R01.S.doc Version 5.2 Page 19 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, 33, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home are receive appropriate support because there are sufficient, well trained and supported staff. People can also have confidence in staff because checks have been carried out to make sure they are suitable. EVIDENCE: The home has gradually recruited a stable staff team, which has a wide age range and gender mix. Staff confirm there is always enough staff on duty. The home has robust recruitment policies and procedures that are followed in practice. It is confirmed staff have an enhanced CRB (criminal records bureau) check and written references taken up before they can start work at the home. The AQAA states that the home has obtained satisfactory checks for all their staff and staff records sampled contained all required documents and checks. The deputy manager was advised however that applications must include staff members’ full employment histories, with any gaps explored and explained. It is good that the home plans to involve people living at the home in staff recruitment. This means they will show prospective staff around the home and be involved in the interview process and selection of staff from the applicants. Mapleleaf Lodge DS0000071776.V372169.R01.S.doc Version 5.2 Page 20 The company has a comprehensive induction programme for its new staff. They also require all staff to attend a five day forensic and a five day training courses on positive interventions for management of challenging behaviours. Staff surveys confirm their induction to the home covered everything very well. Their comments include “I had excellent support and guidance throughout my induction” and “the induction programme is first class and very informative”. New staff have the benefit of the manager or deputy manager being a mentor and have to work a probationary period before their employment is confirmed. Staff feel they receive training relevant to their role. One comments that the home “gives staff the training and tools to do their job correctly”. They are all expected to achieve a social care qualification. Although only two staff have an NVQ (National Vocational Qualification) another five are currently working towards it. Staff confirm communication is good within the staff team and they work well together to provide good consistent care. Regular staff meetings are arranged and they often meet their manager to give them support and discuss how they are working. One support worker says “if there are times I feel I need support there is a well structured support team to help me”. Mapleleaf Lodge DS0000071776.V372169.R01.S.doc Version 5.2 Page 21 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can have confidence in the service because it is well managed. There are ways to ensure the service continues to improve and people’s views should inform how it is reviewed and develops. The environment is safe for people at the home because good health and safety practices are carried out. EVIDENCE: The home’s manager has a background in care, first working with children with disabilities and then adults with learning disabilities. Mr Slack has 17 years management experience and has been a registered care manager previously in several homes. He qualified as a nurse and retains his professional status and is soon to complete the Registered Manager’s Award course. Mr Slack has also undertaken extensive training relating to both management and care practices, including management of challenging behaviours, introduction to mental health and legislation, risk and mental health and self-harming behaviours. Mapleleaf Lodge DS0000071776.V372169.R01.S.doc Version 5.2 Page 22 It is evident that management have a clear understanding of the key principles and focus of this care service and plan to continually improve it to promote the quality of life and provide people living at the home with good individualised care. They are supported by a well-motivated staff team who also endorse the principles of person centred care. Staff feel that management is approachable and it is evident there is an open and positive management approach. The AQAA is clear and detailed and gives good evidence about what the home does well and how this results in good outcomes for people using the service. As a new service it is also positive that the manager has recognised and plans are in place, to improve aspects for the continual development of the service. This is part of an effective system for monitoring and assuring service quality. An independent person also makes the required monthly monitoring visits to the home with written reportS made following each visit on its conduct. In respect of quality assurance and monitoring processes the AQAA states “we will continue to listen to the people who use our service and make necessary changes to improve the home’s quality of care. This is to be undertaken using service users’ meetings, monthly surveys and a stakeholder’s comment book. This is then reflected in monthly action plans and annual development plans”. Regarding promotion of health and safety in the home, staff are trained in the mandatory areas including fire safety, first aid and food hygiene. It was confirmed during the service’s registration process that the property had been approved by a Fire Safety Officer and there is a fire risk assessment and a gas and electrical certification. It was also confirmed that safe working practice documentation is complete, current and complies with current legislation. The AQAA confirms that appropriate risk assessments are in place and that fire and other safety checks and tests are being carried out as required. Mapleleaf Lodge DS0000071776.V372169.R01.S.doc Version 5.2 Page 23 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 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 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 4 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Mapleleaf Lodge DS0000071776.V372169.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NA STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered persons meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered provider 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 providers to consider carrying out. No. Refer to Standard Good Practice Recommendations Mapleleaf Lodge DS0000071776.V372169.R01.S.doc Version 5.2 Page 25 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 Mapleleaf Lodge DS0000071776.V372169.R01.S.doc Version 5.2 Page 26 - 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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