Inspection on 23/01/06 for 2a & 2b Mayfair

This inspection was carried out on 23rd January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

2a & 2b Mayfair 12/02/09

2a & 2b Mayfair 26/04/07

2a & 2b Mayfair 07/11/06

2a & 2b Mayfair 25/04/06

2a & 2b Mayfair 07/06/05

2a & 2b Mayfair 04/11/04

2a & 2b Mayfair 21/04/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Pinta

Kestrel House, St Anne`s Opportunity Centre,

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 2a & 2b Mayfair Tilehurst Reading Berkshire RG30 4QY Lead Inspector Kerry Kingston Unannounced Inspection 23rd February 2006 10:00 2a & 2b Mayfair DS0000011045.V279146.R01.S.doc Version 5.1 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 2a & 2b Mayfair DS0000011045.V279146.R01.S.doc Version 5.1 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. 2a & 2b Mayfair DS0000011045.V279146.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 2a & 2b Mayfair Address Tilehurst Reading Berkshire RG30 4QY 0118 945 3743 / 4 0118 9453743 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) londonroad@tiscali.co.uk Milbury Care Services Limited Care Home 10 Category(ies) of Learning disability (10) registration, with number of places 2a & 2b Mayfair DS0000011045.V279146.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th June 2005 Brief Description of the Service: Mayfair provides twenty-four hour care to ten adults, of both sexes, with learning and associated difficulties. The home is owned, and the care is provided by Milbury Care Services Limited. The house consists of two properties, joined internally via a corridor and has bedroom accommodation on the ground and first floors. The home is in a suburb of Reading approximately fifteen minutes from the town centre. Local shops and facilities are available within walking distance of the home. The home has its own transport and is on public transport is readily available. 2a & 2b Mayfair DS0000011045.V279146.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which took place between 9.45 am and 4.45 pm on the 23rd of February 2006. The home was very busy on the day of inspection with interviews being held and seven of the ten residents were also in their home. The inspector spent time with some residents, generally in observation, as few residents are able to clearly communicate with people they are not familiar with. Some staff were spoken with and observed with residents, records and residents file were also looked at. The manager was available later in the day for discussion and the inspector was able to see some staff records. The home has had some difficulties since the last inspection, it is hoped that the new manager can help the home to overcome some of the problems. The new manager had been in post since the 7th February. The home was found to need improvements in many areas, especially with regard to appropriate staffing and resident well-being. The manager has plans to address these issues as a matter of urgency, he verbally outlined these to the inspector. What the service does well: What has improved since the last inspection? What they could do better: The home could make sure that there are up-to-date written records of what residents need to help them, on a daily basis. 2a & 2b Mayfair DS0000011045.V279146.R01.S.doc Version 5.1 Page 6 Residents could have more activities and do the ones that are written on their weekly activity plans. Residents could be helped to buy nice clothes that they really like. Residents should get all their health needs checked out at least once a year and records should show what happened when residents do see the dentist or doctor. All complaints should be recorded and people should be able to see what happened about them. Staff should be trained to make sure that they can protect, and offer the best care to the residents at all times. Staff should make sure that they help those residents who cannot always behave properly,to do so. The home should be kept looking nice and clean. The structure and make up of the staff team should be able to properly meet the needs of the residents in the home. 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. 2a & 2b Mayfair DS0000011045.V279146.R01.S.doc Version 5.1 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 2a & 2b Mayfair DS0000011045.V279146.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5 There are limited assessments for new residents, on their files. ALL service users have a written contract/statement of terms and conditions. EVIDENCE: The last admissions were of three men in April 05. Their files do not contain detailed assessments of their needs at that time, or how Mayfair could meet them. The inspector was advised that the full assessments were in the organisations head office (in June05), however these assessments were still not on file in the home. One service user needed an O.T. assessment, which was completed six months after he had moved in, this has resulted in him not having access to bathing facilities since his admission. He has a specially designed ground floor disabled bedroom and en-suite but is unable to use the bath safely because he has not been provided with the correct slings and equipment, at this time. There was evidence that this issue is now being addressed, but there may still be some delays. Most service users had a written contract/statement of terms and conditions in their files, these would benefit from a clearer reference to costs and charges and who pays them. 2a & 2b Mayfair DS0000011045.V279146.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Service users had a care plan but these were not reviewed regularly and they were not up-to-date. Residents make some decisions about their day-to-day life. The home has developed robust risk assessments to help residents to be as independent (within the home) as possible. EVIDENCE: Service users have care plans but the quality is not consistent and several do not include behavioural plans, even though aggressive behaviours are noted in risk assessments. Many of the care plans have not been reviewed for over a year and there appeared to be out-of-date information on many of the documents. For example, the use of rectal valium that has not been used for some years and challenging behaviours that have not been in evidence for some time. All service users have an allocated key worker but some of the key workers lacked the skill and knowledge to perform this role, this was demonstrated in some induction work that was seen. The manager is working hard to ensure that all staff have the necessary skill and ability to meet their role responsibilities. There are also several reviews planned within the next few weeks. 2a & 2b Mayfair DS0000011045.V279146.R01.S.doc Version 5.1 Page 10 Staff were observed attempting to give service users some choice about their everyday activities although service users were not very responsive. There were no formal service user meeting minutes or other evidence to suggest that choice is an integral part of the care given. The home has comprehensive and robust risk assessments for each individual with regard to day-to-day risks within the home and community. 2a & 2b Mayfair DS0000011045.V279146.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 The home has developed a weekly activity programme for all service users but these are not followed. EVIDENCE: Each service user has a weekly activity programme in place but on the day of inspection only three of the ten service users appeared to be following the programme. The daily records of the service users evidenced that one service user generally followed her weekly plan, two service users completed some of the plan but the other seven peoples’ activities bore no relationship to the plan. Records were looked at for a period of three weeks. Some of the inhouse activities observed did not appear to hold the interest of the service users and were not planned or structured. The manager advised that there are transport issues in the home and with external day care providers, he is planning to resolve these imminently to release staff to be involved in more constructive activities with service users. 2a & 2b Mayfair DS0000011045.V279146.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Service users personal support needs are included on their care plans but these are not always followed. Service users do not always have regular health checks but the home administers medication safely. EVIDENCE: Service users care plans describe how the individual’s care should be given and their likes and dislikes. They include a cross gender care policy and personal care risk assessments. On the day of inspection the seven male service users seen were dressed in similar clothing, which did not reflect their age, personality or individuality. Some of the clothing looked ‘shabby’ and in need of replacement. No references, in service users daily notes, were found to service users shopping for clothing. There has, for sometime, been an issue with service users having access to their bank accounts, which has recently been resolved. The manager advised the inspector that the staff were to embark on a project to ensure that service users had appropriate clothing, which they are involved in choosing themselves. One service user did not have the necessary specialist equipment provided to ensure he was able to safely access his bathing facilities and had not had a bath for nine months (since admission). This is currently being resolved and the service users made very positive responses when asked if he was looking forward to regular baths. 2a & 2b Mayfair DS0000011045.V279146.R01.S.doc Version 5.1 Page 13 Service users, now, receive support from specialists as necessary but there has been some delay, in the past, in accessing support services. A sample of service users health records showed that some do not have regular health checks and where follow up appointments and/or treatment is required they are not recorded. The last recordings on the weight charts (for those service users with nutritional issues) was in October 05. The G.P surgery had asked that one service user be weighed at the hospital (using the specialist equipment) and this was not recorded as having been done. Health records were not always accurate. The home has a safe medication administration policy and procedure and records seen were generally accurate. There was a shortfall of one pill but it was unclear how this error had occurred. Two staff administer medication, those who do so have been assessed as competent. The home uses the Boots M.D.S. and the pharmacist visits regularly. The manager advised the inspector that he intends to review the medication administration procedure to ensure its’ safety. 2a & 2b Mayfair DS0000011045.V279146.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The home has a comprehensive complaints procedure but do not adhere to it. Staff do not have the knowledge to ensure that they are protective of service users. EVIDENCE: The home has a written complaints procedure and a complaints recording system but these are not always used. The last complaint recorded in the book was in April 05 but the inspector found a reference to a complaint in a service users file dated October 05. This was a complaint about a staff members’ attitude to a service user made by a fellow professional, there was no record of what had been done about it or that he manager was aware of it. The home has a Vulnerable Adults Policy but although there has been one serious Vulnerable Adults incidence since the last inspection there was no reference to this in the complaints book or elsewhere in the home. Training records showed that only six of the 22 staff had received Vulnerable Adults training, much of this several years ago. The manager advised that there had been internal training but we could find no evidence of this event or its’ content. Two staff were spoken to, one confirmed that she had received vulnerable adults training and one said that she had not. There was no written plan of how the provider and manager were going to ensure the safety of all the service users in future following the vulnerable adults incident in October 05. The manager advised that he was going to develop one although he acknowledged that there is a four month delay. On the day of inspection one service user had a face injury (a black eye and swollen face) staff asked did not know how this had occurred. The service user had a Drs appointment later in the day although the injury had occurred the previous day. 2a & 2b Mayfair DS0000011045.V279146.R01.S.doc Version 5.1 Page 15 There was reference to the use of physical restraint for some service users but there were no guidelines in place, most of the staff had not received any training in this area. The manager advised that physical restraint was not used and it was added to care plans ‘in case of emergencies’. This was discussed as unacceptable practice. There was no physical restraint log and no recording of restraint being used on incident report forms. Incident report forms showed that behavioural guidelines, that have been developed for some of the service users who sometimes have difficulty in controlling their behaviour, are not always adhered to by staff members. Five of the service users now have access to their bank accounts and the other five are about to. The finances of the service users were transparent and recording was accurate. The manager had a reasonable knowledge of service users finances and is to request that the provider give receipts for any payments made to them by individuals. 2a & 2b Mayfair DS0000011045.V279146.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 Some areas of the home look ‘shabby’ and the carpets look very dirty. EVIDENCE: The home was refurbished in December 04 when new carpets were provided. However at this inspection the carpets looked very dirty and stained. The manager discussed that they have been professionally cleaned and cleaned by staff but there appears to be a problem and they can’t be kept clean. There are certainly strange black patches and stains on the carpets in all the ground floor areas. Areas of the home need some redecoration with much if the paintwork (in the communal areas) in need of refreshment. 2a & 2b Mayfair DS0000011045.V279146.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 The structure and make up of the staff team make it ineffective and staff are not appropriately trained. The homes’ recruitment policies and procedures are safe. EVIDENCE: Staffing ratios remain at the same level as the last inspection but some staff have left and replacements have largely been part time staff. There are 17 part time staff and only five full time staff. Some staff have specific days they are not able to work and this causes issues of consistency and flexibility for the homes’ rota, impacting on the consistency of care for the service users. The inspector observed some poor interaction and a lack of communication between staff and service users at times during the inspection. Of the six staff seen with service users during the course of the day, two appeared to be motivated and displayed good communication skills and interactions with service users. Service users were not seen to be comfortable to approach staff and waited until they were approached. Discussion with the manager confirmed that a predominantly part time work force does not promote consistency, communication or co-operation between staff members and service users have 22 staff members to relate to. A complaint was made in October 05 by a visiting professional about the way a staff member spoke to a service user, there is no evidence that this issue has been dealt with. 2a & 2b Mayfair DS0000011045.V279146.R01.S.doc Version 5.1 Page 18 There is evidence that the manager is working hard to address these issues, a staff meeting showed that the attitude of staff and their interactions with service users was a subject of discussion and concern. The manager has also carried out seven supervisions to discuss individual performances with staff (he has been in post since 7th February). Staff records seen, generally, contained the correct and necessary documentation to ensure the safety of the service users. Only two staff have an N.V.Q. qualification and some of the L.D.A.F. induction work seen was of poor quality. The home manager is, with the help of the providers’ training manager, developing a training profile for the home and for individual staff, he is beginning to set targets for staff and is expecting them to achieve a certain standard of skill and knowledge within a reasonable time frame. 2a & 2b Mayfair DS0000011045.V279146.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 Service users cannot be confident of the quality of care they receive at this time. EVIDENCE: The manager advised that the home has completed an annual quality of care audit and that all the information has been passed to the providers, who supplied the system. There is no evidence of the audit or its’ outcome in the home and the home has not yet formulated its’ annual development plan. 2a & 2b Mayfair DS0000011045.V279146.R01.S.doc Version 5.1 Page 20 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 2 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 1 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 1 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 2 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X X X 2 X X X X 2a & 2b Mayfair DS0000011045.V279146.R01.S.doc Version 5.1 Page 21 Yes 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 YA2 Regulation 14 Requirement To evidence that the home is able to meet the assessed needs of new service users. (01/07/05) To keep the service users plans under review and ensure they are up-to-date. To further review daily activity programmes for service users. (01.01.05,01.08.05) To ensure the service users support needs are met To ensure that the health needs of the service users are met. To ensure that the complaints procedure is adhered to. To ensure that the manager and staff are able to effectively protect service users and produce a plan to evidence this. (01/07/05) To clean carpets and redecorate as necessary. To review the ‘make-up’ of the staff team and to look at the attitudes and competence of staff members. To complete the quality assurance system. Timescale for action 01/04/06 2. 3. 4. 5 6 7 YA6 YA13 YA18 YA19 YA22 YA23 15.2(b) 16.2 (m) (n) 12.2 .3 13.1 22 13.6 01/06/06 01/05/06 01/06/06 01/04/06 01/04/06 01/04/06 8 9 YA24 YA32 23.2(d) 12.5(b) 18.1(a) 24 01/07/06 01/06/06 10 YA39 01/09/06 2a & 2b Mayfair DS0000011045.V279146.R01.S.doc Version 5.1 Page 22 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 2a & 2b Mayfair DS0000011045.V279146.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA National Enquiry Line: 0845 015 0120 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 2a & 2b Mayfair DS0000011045.V279146.R01.S.doc Version 5.1 Page 24 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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