Inspection on 20/12/07 for Mayfair Avenue (3)

This is the latest available inspection report for this service, carried out on 20th December 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mayfair Avenue (3) 26/01/06

Mayfair Avenue (3) 09/05/05

Mayfair Avenue (3) 31/01/05

Mayfair Avenue (3) 24/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Mayfair Avenue (3) 3 Mayfair Avenue Ilford Essex IG1 3DJ Lead Inspector Jackie Date Unannounced Inspection 20th December 2007 to 2 January 2008 13:00 nd Mayfair Avenue (3) DS0000025910.V356421.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 Mayfair Avenue (3) DS0000025910.V356421.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. Mayfair Avenue (3) DS0000025910.V356421.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mayfair Avenue (3) Address 3 Mayfair Avenue Ilford Essex IG1 3DJ 020 8518 2839 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) www.mencap.org.uk Royal Mencap Society Care Home 5 Category(ies) of Learning disability (6) registration, with number of places Mayfair Avenue (3) DS0000025910.V356421.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Mild to moderate learning disability. Date of last inspection 1st February 2007 Brief Description of the Service: 3 Mayfair Avenue is one of four homes operated by Mencap in the London Borough of Redbridge. The home is situated in a residential street close to Ilford Town Centre. There is easy access to public transport, shops and leisure activities. The home is a large terraced house with four bedrooms, a bathroom with toilet and a shower room with toilet upstairs. Downstairs there is a large open plan through lounge, kitchen, office, staff sleep-in room, laundry area, toilet and one bedroom. The house is well furnished and decorated. The bedrooms are individually decorated and personalised according to residents likes and interests. There is also a small well-maintained garden. Five adults with learning disabilities live at the home and they all need a lot of assistance and support from the staff team. Two of the residents have little or no verbal communication and have limited ability to make decisions about their lives. The residents are encouraged to be as independent as possible and three have access to day services for all or part of the week. Residents are encouraged to keep in contact with their families and are supported by the home to do this. The scale of charges is between £1000 and £1200 per week. The area service manager provided this information on 4th January 2008. Information about the service provided is contained in the service users guide. Mayfair Avenue (3) DS0000025910.V356421.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 1pm. It took place over four hours that day. A shorter unannounced visit was made on 2nd January 2008 to check some issues raised with the inspector after the initial visit. This was a key inspection and all of the key inspection standards were tested. Staff were asked about the care that residents receive, and were also observed carrying out their duties. Where possible, residents were asked to give their views on the service and their experience of living in the home. All of the shared areas and three of the bedrooms were seen. Staff, care and other records were checked. Relatives, social workers and healthcare professionals were contacted and asked for their opinions of the service. At the time of writing this report feedback had been received from 3 relatives. Any feedback subsequently received will be taken into account for future inspections. Staff supported all of the residents to complete feedback forms and feedback forms were received from four staff. Services are now required to complete an AQAA (Annual Quality Assurance Assessment) and the completed form was received on 21st November 2007. Information provided in this document also formed part of the overall inspection. The registered manager left at the end of November 2007 and the new manager started on 2nd January 2008. In the interim the deputy manager was responsible for the day to day running of the service. The inspector would like to thank the residents and staff for their input during the inspection. What the service does well: A lot of positive feedback was received from relatives and they were complimentary about the staff team and the service provided. For example relatives said: “the home provides a safe family environment for my sister with the right level of supervision without impeding her choice”. “I know that my sister has benefited enormously from the high level of care and conscientiousness”. “I have a good relationship with the staff and am able to discuss any concerns I have with them”. “Teamwork is very important between the staff, residents and families, and I feel that Mayfair Avenue do a lot to keep this going”. The house is homely and comfortable and residents seem very relaxed and at home. Mayfair Avenue (3) DS0000025910.V356421.R01.S.doc Version 5.2 Page 6 Residents are supported to keep in touch with their families and families feel welcomed at the home. 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. Mayfair Avenue (3) DS0000025910.V356421.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 Mayfair Avenue (3) DS0000025910.V356421.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, 3, 4 & 5. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. Information is available to enable the staff team to meet residents’ needs. If a vacancy arose the required information would be gathered on a prospective resident and they and their relatives could spend time in the home to find out what it would be like to live there and to enable the resident to make a choice about living in the home, within their capacity to do so. Residents and their representatives have a written and costed contract/statement of terms and conditions and will therefore be clear about what they are entitled to. EVIDENCE: The residents have lived together for several years. Therefore there have not been any recent new admissions. The organisation has an admissions procedure that includes gathering of information and assessments. It also contains details of how a prospective resident would be introduced to the home. The staff are aware of this and would be able to assess and introduce a new resident to the home if needed. Each resident has a support plan that contains information about what they can do, their likes and dislikes and what help and support they need. The residents appear to be happy and relaxed in Mayfair Avenue (3) DS0000025910.V356421.R01.S.doc Version 5.2 Page 9 the company of the staff and in the home. Residents that were able to say that they liked living there. The residents have a contract between themselves and provider. These include information about individual financial arrangements. The contracts were available at the home. This means that there is clear information available about the service that will be provided to individual residents. Mayfair Avenue (3) DS0000025910.V356421.R01.S.doc Version 5.2 Page 10 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, 8 & 9. People using the service experience adequate quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. Residents’ are supported by a regular staff team that know them well but support plans need to contain sufficient in depth relevant information to ensure that they are supported effectively and safely. Residents are consulted about what happens in the home as far as they are able. Mayfair Avenue (3) DS0000025910.V356421.R01.S.doc Version 5.2 Page 11 EVIDENCE: All of the residents have plans which give details of how they need/like to be supported. Areas covered included health, personal care, communication and behaviour. The monthly monitoring visit carried out in November on behalf of the organisation concludes that support plans do not give relevant information to support residents effectively and that they need to be in depth and cover the areas for support that each individual needs. A selection of care plans were examined during the visit and confirmed that this was the case. The development of Person Centred Planning has not taken place and recent support plans do not contain as much detail as previous plans. Support plans must contain in depth information that enables staff to effectively support residents and to meet their individual needs and preferences. However the residents are supported by a staff team that know them well and feedback about the quality of care was positive. Records examined also showed that residents have had reviews and that they and their relatives had been involved in these and had therefore had the opportunity to express their views. Daily recordings are made about what each person has done and support that they have been given. These recordings are broken down into various areas including choice, relationships, skills, physical and emotional health and personal care. Therefore there is information about each individual, which can be used as part of the review process and to identify ongoing and changing needs. There are risk assessments in place. These identify risks for the residents’ and indicate ways in which the risks can be reduced to enable the residents’ needs to be met as safely as possible. Risk assessments are also relevant to each person. Risk assessments examined had been reviewed and updated and therefore current information was available. Residents meetings are held each month and a record is kept of these. Three of the residents can and do express their views about what they want to do and what they like. Residents were asked what they wanted to do at Christmas and where they would like to go. Staff spoken to confirmed that residents are encouraged to make choices. For example one residents support plan says “she can tell you if she wants something, i.e. what meals she wants and where she wants to go. She will also say if she does not feel like going out.” On the day of the inspection staff were observed to offer residents a choice of drinks. The residents cannot look after their own finances and staff have to help them. Residents can indicate what they want to buy when given choices in the shop and staff support them to do this. The residents are involved in the running of the home as far as they are able. They are encouraged to make decisions about what happens as far as they are able. Mayfair Avenue (3) DS0000025910.V356421.R01.S.doc Version 5.2 Page 12 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): 11, 12, 13, 14, 15, 16 & 17. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. The residents are encouraged to be as independent as possible, to take part in activities and to be part of the local community. Further development in this area would mean that residents have a more fulfilling lifestyle. Residents are supported to keep in contact with their relatives and visitors are made welcome at the home. Residents are given meals that they like and that meet their needs and individual preferences. EVIDENCE: Residents are encouraged to develop their skills and each person contributes to the tasks in the home in as far as they are able. This may be to help clear the table, wash up or put the rubbish in the bin. Daily notes reflect what residents have done. For example “ cleared the plates”, “got a knife and fork from the Mayfair Avenue (3) DS0000025910.V356421.R01.S.doc Version 5.2 Page 13 drawer”, “emptied the rubbish”, “took clothes to the laundry”. Staff spoken to said that residents are encouraged to do as much as they are able and are offered choice in areas of meals, where to go, when to go out and what to wear. Three of the residents have access to day services. The amount of day services varies from two days to five days per week. The other two residents have “retired” from their day service. This was due to changes in the age range that the day service now caters for. All of the residents need support from the staff team when they go out. They visit local pubs, leisure facilities, shops and cinemas. Residents are asked where they want to go and what they want to do and the staff team also base decisions on their knowledge of individual likes and preferences and how residents respond to new and different activities. Two of the residents enjoy going to the cinema, another likes going to the pub. Three residents went on holiday to Sussex and the others to Kent. The home also has a social connection with a local Baptist Church and residents go there for a coffee afternoon. Two of the residents have been to church but staff and records indicate that this is not a significant need for them. Two residents are Jewish but again records indicate that there are not any constraints on their diets and that they do not practice their religion. However one resident does attend some celebrations with his brother. Extra funding has been agreed for activities to be provided to the two residents that retired from day services. However a recent monitoring visit carried out by the service manager concludes that activities are limited and that residents need to be given informed choices about activities. This was supported in feedback from one staff who said that they needed to try to arrange more outdoor activities for the residents such as outdoor education, colleges or afternoon clubs. It is evident that residents do participate in activities via the day centre and staff at the home and also that they do access facilities in the community but it is recommended that this be developed further to ensure that residents have an interesting and fulfilling lifestyle that meets their interests, preferences and cultural needs. Four of the residents have regular contact with their relatives. This is in terms of relatives visiting the house and also residents visiting their relatives. Feedback from one relative was that the family receive a warm welcome when they visit and another said the home provides a safe family environment for my sister with the right level of supervision without impeding her choice. Another relative said that he is not able to get to the home but staff regularly bring his son to see him even though he does not live locally. This relative joined his son at Mayfair Avenue for Christmas dinner and staff picked him up and took him home, even though they were not on duty that day. One of the residents is supported to phone his friend when he wishes. Residents are encouraged and supported to keep in contact with friends and relatives and this exceeds minimum standards. Mayfair Avenue (3) DS0000025910.V356421.R01.S.doc Version 5.2 Page 14 Residents and staff usually eat together. Residents are involved in choosing what they eat and also staff know residents likes and dislikes. Residents said that they had enjoyed their meals. One resident has diabetes and the staff team support him to have an appropriate diet. Records show that residents are offered choices and do have different things to eat. For example different cereals for breakfast. Residents tend to have a take away meal on Fridays and again records show that they make different choices of food and drink for the takeaway. Shortly after the inspection concerns were raised with the Commission that there was not any petty cash to purchase food or cleaning materials. Feedback was that residents had food but choice had become limited especially in relation to fresh items such as fruit. As a result of this a short unannounced visit was made to the home. There was very little in the fridge but there was food in the freezer and this included meat, fish and vegetables. In addition there were no spare toilet rolls or kitchen rolls. This was discussed with staff on duty and they confirmed that some cash had been brought to the home that morning but they were not sure if they should spend the money on shopping as there was a milk bill to pay and also some I.O.U’s owing to staff in the petty cash tin. The area service manager visited the home that day to introduce the new manager and these issues were discussed with her. Due to the fact that the manager had left they had been arranging for new signatories on the petty cash account but she believed that this was resolved. She was clear that there were not any problems with regards to cash for shopping and agreed to arrange for extra cash to be delivered that afternoon. She also advised the staff to do the shopping and said that she would reiterate the petty cash procedures to the staff team for the future. The inspector was satisfied that residents had received appropriate meals and that arrangements to get more shopping that day were satisfactory. Therefore no requirements have been made and this will be monitored during the course of future inspections. Residents are given meals that they like and that meet their needs and individual preferences. Mayfair Avenue (3) DS0000025910.V356421.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): People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. Residents receive personal care that meets their individual needs and preferences and the staff team support them to get the healthcare that they need. Residents are given their prescribed medication safely. EVIDENCE: The residents require support with their personal care and details of the help that they need and how they prefer to be supported are in their individual plans. One resident’s plan states “I like a shower. I can dress and undress but need help with buttons.” Residents are encouraged to choose what to wear and at the time of the visit were all smartly and appropriately dressed. Residents receive personal care that meets their individual needs and preferences. All of the residents go to the local doctor and specialist help is received when needed. Staff take residents to all of their medical appointments. Residents’ files have details of health care issues and show that residents have regular access to health care professionals. Records are kept of medical appointments Mayfair Avenue (3) DS0000025910.V356421.R01.S.doc Version 5.2 Page 16 and these show that residents have checks from the optician, dentist and when needed the chiropodist. Records also show that residents have access to health screening and that they have had drug reviews. Therefore residents’ health care needs are being met. None of the residents are able to self medicate and staff that have received medication training administer medication. The list and specimen signatures of those trained and authorised to administer medication is on file. The medication administration records (MAR) file contains photographs of the resident and details of any allergies. This is good practice as it lessens the chance of medication being given to the wrong person. Medication records had been appropriately completed. The pharmacist had visited recently and found everything in order. Medication is securely stored in a locked metal cabinet in the office and is appropriately administered by the staff team. Mayfair Avenue (3) DS0000025910.V356421.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 using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. The complaints procedure is in a pictorial format to help residents understand how to complain. Staff have received adult protection training to ensure that they are clear about what constitutes abuse and what to do if abuse is seen or suspected. This gives residents a greater protection from abuse. Residents’ finances are adequately managed and monitored and this lessens the risk of financial abuse. EVIDENCE: There is an organisational complaints procedure and the staff team have developed a version with photographs for the residents. This includes photos of the manager, service manager and the inspector and is displayed in the home. Due to the degree of their disability it is unlikely that most of the residents would be able to make a complaint without support. However residents are able to demonstrate if they are unhappy with anything through facial expressions, or behaviour changes. There was one recorded complaint from a relative and the service manager appropriately addressed this. The Commission has not received any complaints about the service since the last inspection Mayfair Avenue (3) DS0000025910.V356421.R01.S.doc Version 5.2 Page 18 Mencap has produced a detailed adult protection policy that tells staff the actions to take in the event of abuse/suspected abuse being discovered. Staff have attended a course on protecting residents from abuse and are aware of their responsibility to residents. Feedback from relatives was that they were very happy with the care provided and also that their relatives were happy living at Mayfair Avenue. All of the residents need help with their finances and have limited capacity to understand about the concept of spending or saving money, other than that money is exchanged for goods. Each resident has a building society or bank account and they now go with staff to withdraw cash. Records are kept of financial transactions. Checks had been made by the manager or deputy to ensure that these were correct. In addition the service manager checks residents’ finances as part of her monitoring visits. Evidence of this was seen on finance records. The cash held for two residents was checked at the time of the inspection and was correct. Appropriate receipts were on file. However it was noted that in November at least two residents shared the cost of buying a hi-fi unit for the lounge. This was discussed with the service manager who said that she had not authorised this and that it was not appropriate or in line with Mencap’s policy. She also said that the November finance sheets would have been checked as part of her next monitoring visits and that she would have identified this. The service manager was clear that residents would be reimbursed for this and that she would reiterate Mencap’s finance policies with the new manager and the staff team. The new manager subsequently confirmed that she had requested cheques to reimburse residents. Therefore a requirement has not been made and this will be monitored during the course of future visits. Mayfair Avenue (3) DS0000025910.V356421.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, 25, 26, 27, 2, 29 & 30. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. The residents live in a clean and comfortable home that is suitable for their needs. EVIDENCE: Mayfair Avenue (3) DS0000025910.V356421.R01.S.doc Version 5.2 Page 20 The house is in Ilford and is near to the local shops, bus routes and train station. The home is clean and well maintained. The lounge and dining area are combined and the kitchen is open plan. The building is non-smoking. None of the residents smoke. The office and staff sleeping-in room are on the ground floor. There is no separate visitors room but residents can meet visitors in the office if they wish. There is a small well-maintained garden that is used by the residents. There is a toilet on the ground floor and a shower room with toilet plus a bathroom with toilet upstairs. There is a separate utility area with laundry facilities Each resident has a single bedroom. These are decorated and furnished to meet individual needs and likes. On the day of the visit three of the residents showed the inspector their bedrooms and these were personalised to suit the resident. There is also one bedroom on the ground floor, which could be used for someone with reduced mobility but as previously stated the shower and bathing facilities are upstairs. At present none of the residents need any specific adaptations. During the visit the home was clean and free from offensive odours. Since the last inspection the stair carpet has been replaced. The house is very comfortable and homely and suitable for the needs of the residents. Mayfair Avenue (3) DS0000025910.V356421.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): 31, 32, 33, 34, 35 & 36. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. Staffing levels are sufficient, and staff receive the necessary training, informal supervision and support, in order to meet residents’ current needs and provide an appropriate service for them. Regular formal supervision would give staff more opportunities to discuss issues and receive feedback and guidance on their work practice. Residents are supported and protected by the organisations recruitment practice. EVIDENCE: Since the last inspection a new deputy has been recruited and there is a full staff team. There was some long term staff sickness and this was covered with regular relief staff. Therefore sufficient staff are employed to provide a consistent service to residents. A minimum of two staff are on duty at peak times. In addition extra funding has been secured to support residents for activities. This is particularly for the residents that ‘retired’ from day services. Mayfair Avenue (3) DS0000025910.V356421.R01.S.doc Version 5.2 Page 22 Feedback from staff was that this was sufficient to meet residents’ needs. A relative said “the home provides a safe family environment for my sister with the right level of supervision without impeding her choice.” At night there is only one member of staff sleeping in, but with access to support in the event of an emergency. Feedback from staff was that this was a satisfactory arrangement, as residents rarely needed support during the night. From discussions with staff it was evident that the staff team have been receiving training that enables them to carry out their duties and to meet residents’ needs. For example, Protection of Vulnerable Adults, infection control and food hygiene. Four staff have achieved NVQ qualifications at level 2 and/or 3. The staff team all have a lot of experience of working with people with learning disabilities. Therefore an appropriately trained and experienced staff team supports the residents. The organisation operates an appropriate recruitment procedure. Jobs are advertised, application forms completed and interviews held. The necessary checks are undertaken prior to staff commencing employment. It was not possible to check staff records on this occasion as staff on duty did not have access to these. However at previous inspections random samples of staff records held in the home were checked and contained the necessary information and confirmation that appropriate checks had been made. Since the last inspectioopn there has only been one new appointment and that is the deputy who had previously worked at the home permanently and had continued as a relief staff. In November the service manager had highlighted that this file was not in the home and the new manager will address this. Therefore the recruitment process offers safeguards to residents. Staff meetings are being held regularly but staff have not been receiving regular formal supervision. However feedback from staff was that they had received very good informal support from the previous manager and that she worked alongside them. They also said that they could raise any concerns with her and that they had the opportunity to discuss these. It is important that in addition to informal supervision staff also receive formal supervision. This gives the opportunity for staff to individually and privately discuss any concerns or issues and also receive feedback and advice on work practice. It is therefore recommended that staff have regular recorded supervision meetings at least six times a year with their senior/manager in addition to regular contact on day to day practice. Mayfair Avenue (3) DS0000025910.V356421.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 using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. Appropriate management arrangements are in place but some work is needed to ensure that issues between staff and senior management do not adversely affect the development of the service provided to residents. The registered provider monitors the service to check the quality of the service provided to residents. The residents are living in a safe environment. Mayfair Avenue (3) DS0000025910.V356421.R01.S.doc Version 5.2 Page 24 EVIDENCE: The registered manager resigned and had left the service approximately 3 weeks before this inspection. Feedback from staff was that the manager was supportive and approachable. Feedback from relatives was also very positive. One relative commented “I feel that the managers leaving will be a huge loss. I know that my sister has benefited enormously from the high level of care and conscientiousness”. Another said “I can say without contradiction, that Mrs Hegarty was the finest manager the home has ever had and we are more than sorry to see her go”. A new manager has been appointed and started work on 2nd January 2008. In the interim the deputy manager took responsibility for the day to day running of the home. Therefore appropriate arrangements have been in place for the management of the home. From feedback received from staff it is evident that there have been issues between staff and ‘senior management’ of Mencap. However, the organisation are aware of this and a senior officer has visited the service to meet and interview staff and another meeting is scheduled in January. Therefore appropriate action is being taken to address the problem. A representative of the organisation, the area service manager, carries out monthly unannounced monitoring visits to the home and a report on this visit is left at the home and a summary of this sent to the Commission. The reports cover the necessary areas and indicate any action that is needed. Previous sections of this report give information about areas that the service manager has highlighted for action/improvement. For example, support plans and activities, and this also confirms that the monitoring is robust. Therefore the quality of the service provided to the residents is monitored by the organisation. The staff team carries all of the necessary health and safety checks out regularly. For example fire call points are tested weekly, as are hot water temperatures. Fridge and freezer temperatures are tested daily. Regular fire drills take place and these are recorded. Monthly health and safety audits are carried out. The working practices in the home are safe and there have not been any preventable accidents. Records show that there are very few accidents at all and staff confirmed this. A safe environment is provided for the residents. Mayfair Avenue (3) DS0000025910.V356421.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 3 4 3 5 3 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Mayfair Avenue (3) DS0000025910.V356421.R01.S.doc Version 5.2 Page 26 NO 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 YA6 Regulation 15 Requirement Support plans must contain in depth information that enables staff to effectively support residents and to meet their individual needs and preferences. Timescale for action 31/03/08 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 YA12 Good Practice Recommendations It is recommended that activities be developed further to ensure that residents have an interesting and fulfilling lifestyle that meets their interests, preferences and cultural needs. This recommendation also relates to standards 13 & 14. It is recommended that staff have regular recorded supervision meetings at least six times a year with their senior/manager in addition to regular contact on day to day practice. 2. YA36 Mayfair Avenue (3) DS0000025910.V356421.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 Mayfair Avenue (3) DS0000025910.V356421.R01.S.doc Version 5.2 Page 28 - 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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