Inspection on 26/04/07 for 2a & 2b Mayfair

This inspection was carried out on 26th April 2007.

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 no outstanding requirements from the previous inspection report, but made 5 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 07/11/06

2a & 2b Mayfair 25/04/06

2a & 2b Mayfair 23/01/06

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 Stephen Webb Unannounced Inspection 26th April 2007 10:00 2a & 2b Mayfair DS0000011045.V333921.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 2a & 2b Mayfair DS0000011045.V333921.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. 2a & 2b Mayfair DS0000011045.V333921.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 2a & 2b Mayfair Address Tilehurst Reading Berkshire RG30 4QY 0118 945 3743/4 0118 9453743 nick_debourg@hotmail.co.uk londonroad@tiscali.co.uk Milbury Care Services Limited 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) ***Post Vacant*** Care Home 10 Category(ies) of Learning disability (10) registration, with number of places 2a & 2b Mayfair DS0000011045.V333921.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th November 2006 Brief Description of the Service: Mayfair provides twenty-four hour care to ten adults, of both sexes, with learning and associated difficulties, though at present there is only one female resident, who may be moving out. The home is operated by Milbury Care Services Limited. The home consists of two properties, joined internally via a linking 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 public transport is readily available. The fees range from £1,098.16 - £1,442.00. 2a & 2b Mayfair DS0000011045.V333921.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced site visit from 10.00am until 6.15pm on 26th of April 2007. This report also includes reference to documents completed and supplied by the home, and those examined during the course of the site visit. The report also draws from conversation with the manager and some of the staff members on duty. Residents were not able to communicate verbally with the inspector, so some time was spent observing the interactions between staff and residents as they went about their daily activities. The inspector also toured the premises, and ate lunch with the residents in one of the two houses. What the service does well: An appropriate procedure for preadmission assessment was described by the manager, which would be appropriately paced to the needs of the individual. All of the residents’ needs were being reviewed and their care plans updated. Residents are appropriately supported to take risks and a range of individual risk assessments was in place. Residents’ finances are well managed on their behalf, by the service, and individual records are maintained. Contact between residents and their families, is well supported. Residents have opportunities to make some day-to-day decisions about their lives and activities. A healthy diet is provided and necessary adaptations have now been made to meet specific individual’s needs. None of the residents is able to manage their own medication, but an appropriate system is in place to manage this on their behalf, with due regard for their rights. Staff receive an appropriate induction and core training package and additional specialist courses are also made available, to provide necessary skills to meet residents’ needs. Recruitment practice provides protection to residents, though the consistency of the available evidence of the process needs improvement. Systems are in place to promote and protect the health, safety and welfare of residents. 2a & 2b Mayfair DS0000011045.V333921.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Although residents have access to activities, within the unit and the local community, there remains a need for further development to broaden the range of opportunities available to them. At present, residents have limited involvement in day-to-day household tasks, though the manager plans to develop their role. 2a & 2b Mayfair DS0000011045.V333921.R01.S.doc Version 5.2 Page 7 There is a need for written guidelines on how to support one resident who now has a special chair to assist him to eat at the dining table, to ensure that he is supported consistently. Written guidance from the GP or epilepsy consultant, should be obtained in the form of individual protocols for the PRN (as required), administration of emergency epilepsy medication for two of the residents. The senior staff should be reminded of their responsibility to check the medication records/administration at handover. The possible benefits of producing the complaints procedure in an adapted form, to enable the procedure to be explained more readily, to residents, should be evaluated, in consultation with a speech and language therapist. The high proportion of part-time staff, who are currently unable to undertake NVQ, limits the potential levels of NVQ attainment across the unit. The provider needs to consider ways of addressing this issue. The provider must ensure that a complete set of current organisational policies and procedures is provided to the unit. The registration of the current manager also needs to be pursued. The provider needs to ensure that appropriate evidence of the staff recruitment and vetting procedure is available within the unit for inspection. 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. 2a & 2b Mayfair DS0000011045.V333921.R01.S.doc Version 5.2 Page 8 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.V333921.R01.S.doc Version 5.2 Page 9 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): Standard 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ current needs are being reviewed as part of a cycle of care management reviews, and plans have already been made for one resident to transfer to a more appropriate service. Appropriate transition planning is in place and is being paced to reflect the needs of the resident. The pre-admission assessment process as described, was appropriate, though the policy/procedure documents need to be obtained. EVIDENCE: The existing resident group are well established, with the most recent admissions being two years ago, so copies of any original assessments were not examined. Examination of the current files indicated improving systems for the ongoing assessment and review of the needs of individuals. The acting manager was introducing more robust planning, recording and review tools, and a cycle of 2a & 2b Mayfair DS0000011045.V333921.R01.S.doc Version 5.2 Page 10 care management reviews was underway, having been overdue prior to the tenure of the current acting manager. This process will be utilised to review the needs of all residents and ensure they can be met within the service. It was discovered that the policy and procedures documents handed over to the current acting manager were incomplete, and it is suggested a complete new set be provided to ensure they are all up-to-date versions. It was therefore, not possible to locate the current preadmission assessment procedure, though the procedure as described by the acting manager, was thorough and reflected the need for transition planning to be client-led in terms of its pace. The transition plan for one resident who was due to transfer out of the service, appeared to be well thought out and unhurried, to try to ensure the move was a positive experience for the resident, even though their needs presented some challenges to the service at times. 2a & 2b Mayfair DS0000011045.V333921.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The acting manager has introduced new care plan documents and standardised formats to provide more detailed information to staff on how to meet the needs and wishes of residents. There has been improvement in the level of resident consultation and decisionmaking, though it is acknowledged there remains room for further development. Residents’ finances are well managed on their behalf. Residents are appropriately supported to take risks, and relevant individual risk assessments were in place. EVIDENCE: A more comprehensive Person Centred Plan (PCP) format for care plans was being introduced and the previous formats are in the process of conversion, with some files almost completed. 2a & 2b Mayfair DS0000011045.V333921.R01.S.doc Version 5.2 Page 12 The new format includes a range of detailed and relevant documents including comprehensive individual guidelines around specific daily routines, activities, etc. and a “likes and dislikes” sheet, which had yet to be completed, but will contain information on any known preferences, likes and dislikes around activities, food, personal care etc. The new formats were dated recently and supported by staff signature sheets to ensure they are read and understood, and to improve the consistency of approach by the staff, which had previously been identified as an issue. As already noted, a round of care management reviews was under way. There is also a new “daily file” for each resident, which includes examples of the kind of recording expected, and a range of new formats for daily records. It is suggested that information on each resident’s individual communication repertoire and methods, is also included within this file to further support the communication with, and understanding of, residents by all of the staff. Improvements have been made in terms of enabling residents to make day-today decisions and there is now a large picture/image board in each house’s dining room showing the planned activities and outings, to support the making of choices. Pictorial menus have also been prepared together with meal pictures to develop the level of resident involvement in menu planning. Staff described a range of other ways in which they enable residents to make choices and decisions. The care plans and other documents include details of identified resident choices and preferences. The acting manager acknowledged that there was room for further development in these areas, through improvements in staff understanding of the importance of consistency, and of their developmental role in terms of the residents’ skills and life experiences. None of the residents is able to manage their own finances and the unit manages these on their behalf. Records and storage are individualised, and each resident also has a bank account. Appropriate records of expenditure are kept along with the associated receipts or petty cash vouchers, and these are audited throughout the year by the service manager, who was on-site on the day of inspection undertaking this task. Examination of a sample of these financial records indicated expenditure on a range of appropriate items. The manager confirmed that most expenditure was incorporated within the placement fees, leaving the individual’s personal allowance available, as it should be, for items desired by the resident. Appropriate individual risk assessments were present within the care plans of residents covering activities, accessing the community, use of equipment etc. 2a & 2b Mayfair DS0000011045.V333921.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have access to activities, within the unit and the local community, though there remains a need for further development in these areas to provide a broader range of opportunities. Residents’ family contacts are supported wherever possible, including staff providing transport on occasions. At present, residents have limited involvement in day-to-day household tasks, though the manager plans to develop this further. Residents do have opportunities to make some day-to-day decisions about their lives. Residents are offered a healthy diet and necessary adaptations are made to meet specific needs. However, the staff need written guidelines on how to support one resident who now has a special chair to assist him to eat at the dining table, to ensure a consistent approach. 2a & 2b Mayfair DS0000011045.V333921.R01.S.doc Version 5.2 Page 14 EVIDENCE: Some improvements have been made in the availability of activities and community access, and each house now has a large activity chart on the dining room wall. However, a lot of the activities still relate to walks in the local area, and there remains a need to identify a broader range of possible external activities, which had already been identified by the manager. Staff did indicate that residents have opportunities to access the community most days, though this included access through the day-services provided. Not all residents had a holiday in the past year and the manager identified the provision of appropriate holidays as one of her priorities for the coming year, based on the known likes and preferences of the residents, and in small groups or as individuals, rather than as a larger group. None of the residents has identified needs with regard to visiting places of worship, though one has bible extracts read to him, which he enjoys. Some of the residents have regular family contact, some via visiting, and others through maintaining phone contact. In some cases, family visits are supported by unit staff providing the transport. Two residents have no family contact and one resident’s family live overseas, but keep in touch by letter. It was felt that there had been an inconsistent approach to encouraging the involvement of residents in the day-to-day domestic tasks in the past, with staff sometimes undertaking tasks on behalf of individuals, rather than encouraging and supporting them to do more things for themselves, and the manager was hoping to develop and improve these opportunities. Residents have a limited level of involvement in preparing and cooking the meals, though several have shown enthusiasm for the cake baking and other food-related competitions, which have been set up. A number of photos were evident showing the active involvement of the residents in baking etc. At present, most residents’ involvement revolves around laying/clearing tables. The residents enjoyed their lunch, which consisted of burgers and salad, with yoghurts for pudding. Aids such as plate rims were available where required, as well as ridged plates to assist some residents to eat without help. Each house has its own menu reflecting the identified likes of the residents, who are supported to choose a main meal and a lunch per week each, using 2a & 2b Mayfair DS0000011045.V333921.R01.S.doc Version 5.2 Page 15 photographs of meals and food items. Residents do some food shopping with staff but this is usually for small numbers of items and for short periods. An OT was present to observe and support one resident through the meal, as he has been provided with a special chair to enable him to eat at the table with the other residents. She provided angled cutlery to see if this assisted him in managing his food, and with a little support, he was able to feed himself for the most part. His meal had also been liquidised to meet his needs, and this had been done with appropriate separation of the constituents, to maintain some variety in colour and texture. It was evident that staff were not yet familiar with how to offer the resident appropriate support to get him seated in this chair, and he was wearing ordinary socks, rather than slipper-socks with grip provided, which were also hindering the resident in his efforts to sit upright in the chair, as he could get no purchase on the vinyl flooring. At one point the resident nearly tipped himself out of the chair backwards as its brakes were on, as he pushed against the table. There is a need for a risk assessment and clear written guidelines to be devised on supporting the use of this seat, and the OT agreed to provide some guidance on this. It is suggested that a training session for care staff might also be appropriate. The manager has provided additional guidance to staff on liquidising meals for this resident, including the use of different liquid substrates, depending on the item being liquidised. One resident has a dairy intolerance, and his diet is adjusted appropriately to address his needs. The manager has sought the advice of a dietician, and the home is currently on their waiting list. Staff offered alternatives to the main meal provided, and some support and encouragement was offered to residents during the meal. 2a & 2b Mayfair DS0000011045.V333921.R01.S.doc Version 5.2 Page 16 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): Standards 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The quality of personal support to residents has improved, and there is evidence of increasing documentation of the preferences of individuals, with regard to how they are supported. Residents’ healthcare needs are also being met more effectively, and there was evidence of continuing improvement in some areas. Though none of the residents is able to manage their own medication, an appropriate system is in place to manage this on their behalf, with due regard for their rights. However, there is a need for written guidance from the GP or epilepsy specialist, on the individual protocols for PRN (as required), administration of emergency epilepsy medication for two of the residents, and the senior staff need to be reminded of their responsibility to check the medication records/administration at handover. 2a & 2b Mayfair DS0000011045.V333921.R01.S.doc Version 5.2 Page 17 EVIDENCE: As noted earlier the new care plan formats include some details of residents’ preferences and choices about their care but the completion of the new “likes and dislikes” formats will further improve this aspect. In conversation staff did indicate awareness of some individual preferences, but until these are systematically recorded, the possibility of inconsistency of approach remains higher. The detailed new guidelines around specific routines, activities and times of day also allow for the inclusion of relevant details to indicate appropriate and effective approaches with each individual. The “special notes” daily recording format provides a place to record newly observed or expressed preferences as they become apparent, to enable their subsequent discussion and inclusion in the guidelines. As already noted, it would be beneficial to include details of each individual resident’s communication repertoire within a standard format as part of their daily care records, to maximise staff awareness. Given that all of the residents have previously demonstrated behaviours which challenge the service, the presence of only one incident report since the start of 2007, is perhaps some indication of the improving stability within the service, and of the improvement in the effectiveness of the staff, in meeting residents’ needs, under the new acting manager’s leadership. Behaviour management plans, drawn up by the in-house behavioural specialist, were now also in place to improve the consistency of management of specific behaviours, by staff. The manager gave examples of how simple changes in the order of events and routines, had helped to maintain calmness in the residents, by avoiding unnecessary waiting around, for example ahead of meals being served. She had identified it as a priority, to enable staff to understand the benefits of this pro-active approach rather than working reactively. The need for detailed support guidance for supporting the identified resident in the use of his new chair at meal-times, is a good opportunity to foster this approach, through seeking ideas from the staff to develop the guidance. Staff have also received training in some relevant areas to support improvements in their understanding. 2a & 2b Mayfair DS0000011045.V333921.R01.S.doc Version 5.2 Page 18 Examination of a sample of the healthcare records indicated individual recording of appointments and formats to record more detail with regard to how the process was supported and what was more or less effective in supporting the individual. Records also showed recent or regular appointments where appropriate. Specialist bathing equipment required to enable one resident to use the adapted bath provided for him, had now also been obtained, in order to properly address his needs, rather than waiting for decisions on who would fund its purchase. The home has an appropriate system in place for the management of residents’ medication, since none are able to manage this for themselves. The system provides an audit trail for the medication. Medication is administered with regard to the preferences and rights of residents, and where it is taken with a spoon of jam, this is prepared in front of the individual. However, examination of a sample of medication administration record, (MAR) sheets, indicates a number of gaps in recording. The manager confirmed that in all cases the medication had been given, but the staff member had omitted to initial the MAR sheet as required to confirm this. The manager suggested that the senior coming on duty should be checking the medication records at handover to identify any issues and seek timely clarification. The senior staff should be reminded of their responsibility to ensure these records are fully completed. Though the staff who administer medication have received training in this specialist area, there is a need for individual written PRN guidelines for the administration of emergency medication in the event of seizures, for two residents, in order to ensure an appropriate and consistent approach. 2a & 2b Mayfair DS0000011045.V333921.R01.S.doc Version 5.2 Page 19 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): Standards 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although a complaints procedure is in place, there is a need to evaluate the benefits of producing it in adapted form, to enable the procedure to be explained more readily, to residents. Residents are protected more effectively from abuse by the improvements in behaviour management planning, incident recording and monitoring which are being introduced. EVIDENCE: The home has a complaints procedure in place, but there are no versions in other formats which might help to support a resident who was unhappy, to raise an issue. Although all of the residents are essentially non-verbal, they are able to convey their feelings and anxieties in other ways, and would thus depend on the advocacy of staff or others to raise issues on their behalf. It is suggested that the manager seek advice from a speech and language therapist regarding the possible benefits of alternative versions of this procedure. The manager said that she planned to address this issue, and it had also been identified in the 2006 “Outcome of Annual Service Review and Development Plan” document for the unit. The complaints log had no recorded complaints since 2005, so it was not possible to evaluate the procedure in action. 2a & 2b Mayfair DS0000011045.V333921.R01.S.doc Version 5.2 Page 20 Staff receive POVA (Protection of Vulnerable Adults) training as part of the core training, and the provider has an ongoing cycle of refresher training. Staff confirmed receipt of this training in conversation, and the manager said that almost all of the staff had received the POVA training. There have been no reported POVA issues since the last inspection. Since then, improvements have also been made in behaviour management planning, and incident recording systems, which are being rolled out, to ensure appropriate management monitoring of any issues that arise. Appropriate systems are in place to protect residents from financial abuse, and examination of a sample of records of residents’ funds expenditure raised no issues of concern. 2a & 2b Mayfair DS0000011045.V333921.R01.S.doc Version 5.2 Page 21 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): Standards 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with an appropriate environment, and equipment, necessary to meet individual needs, has now been provided. The level of homeliness is also improving. The home provides a clean and hygienic environment. EVIDENCE: The unit is comprised of two adjacent houses, which are linked by a corridor, but usually separated by a closed door, secured on a keypad, in order to manage the two separate groups effectively. Each unit has its own lounge and dining room, and has a separate area of enclosed garden, though there is a gate between, which can be opened when appropriate. At present the bedrooms in one house are kept locked, with the keys readily available outside on hooks, to protect the privacy of residents from one of their 2a & 2b Mayfair DS0000011045.V333921.R01.S.doc Version 5.2 Page 22 number, who will enter other people’s rooms without permission. The bedrooms in the other house are not kept locked, though the doors are fitted with locks should a resident be admitted who can manage a key. Each house has its own kitchen facilities and caters for the residents therein, and each has a dedicated team of staff, though some swapping does occur to maximise cover or provide an appropriate gender mix at times. The houses were decorated and furnished in a homely style, and some new soft furnishings had been provided. However, the provision of decorative borders had proved less successful and these may be replaced with stencils. One resident has an adapted en suite bathroom, with a hoist bath and overhead tracking to enable a hoist to be used to provide support. An additional necessary piece of equipment has now been provided, after some delay, to enable him to use the bath. The ground floor and communal areas of the unit are accessible to one resident, who tends to move about the floor or use a wheelchair. The gardens also have level paved areas and lawns. One has a swing provided. In the gardens are pots of flowers planted up by the residents with support, for a competition for the best pot. There are also plans for a sunflower growing competition. One resident’s bedroom, which had previously been rather bare, owing to his past destructive behaviour, was now successfully equipped with curtains on a rail and a shoe storage unit, as well as some pictures, and he also had a new bed. There were plans to try, over time, to further develop his tolerance of furnishings and other items. Standards of hygiene were good, and the home had appropriate laundry facilities to meet needs. 2a & 2b Mayfair DS0000011045.V333921.R01.S.doc Version 5.2 Page 23 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): Standards 32, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is evidence of some positive improvements in the consistency of staff approach, and in their awareness of their role, to support and encourage the development of residents’ skills and abilities; though it remains to be seen whether this can be sustained and built upon over an extended period. The limitations in terms of access to NVQ are of some concern in this regard, owing to the high proportion of part-time staff, who are currently unable to undertake NVQ. Staff do receive an appropriate induction and core training package and additional specialist courses are also made available, to provide necessary skills to meet residents’ needs. Recruitment practice provides protection to residents, though the consistency of the available evidence of the process needs improvement. 2a & 2b Mayfair DS0000011045.V333921.R01.S.doc Version 5.2 Page 24 EVIDENCE: The service provides an appropriate core training package to staff, which covers the required areas, including NVCI training to provide staff with consistent skills to manage difficult and challenging behaviour. The manager had produced individual records of staff training, which included copies of certificates, but had yet to produce an overall spreadsheet to enable ease of monitoring. She undertook to produce an overall record of training. This made it hard to establish how recently staff had received the core training and any necessary updates. The manager was able to assure the inspector that all staff received the POVA training and that ten had recently attended the medication training, leaving only the two most recent recruits without this. The acting manager is an accredited manual-handling trainer and will provide this input to staff as required. Specialist training has also been provided in emergency epilepsy medication and autism. All staff also undertake the LDAF foundation but at the time of inspection the level of NVQ attainment was unsatisfactory, with only four staff having NVQ level 2, and one more soon due to complete this. The manager explained that one of the difficulties was the number of students employed by the service who were limited to working twenty hours per week, which made it difficult for them to complete an NVQ as well as their other studies. The provider needs to consider how to address this issue, as it is also likely to be a factor in its other units. The government expectation is for at least 50 of the team to have achieved NVQ Level 2. There is a stable core team, some of whom have been in the unit for three years or more, although a lot of part-time students, whose working hours are legally limited, have also been recruited, who currently make up about a third of the team. This was seen as necessary in order to staff the unit with “permanent staff”, to avoid the need for agency staff, though it has led to the unit having a staffing complement of around thirty staff, which produces a lot of changes of personnel, for residents to relate to. Observation of staff during the inspection indicated varying levels of confidence in their interactions with residents, and some inconsistencies of approach and a lack of awareness were evident at times. Nevertheless, residents were offered some choices, and encouragement around the lunchtime meal, and some staff showed good insight regarding the improvements being made. 2a & 2b Mayfair DS0000011045.V333921.R01.S.doc Version 5.2 Page 25 Examination of a sample of recent recruitment records indicated that appropriate checks were undertaken for the most part, though there was no confirmation that a POVA check had been requested as well as the CRB. The accompanying checklist was incomplete, and not always filled in. It is understood that the provider is planning to relocate recruitment records to head office. In order for this to meet requirements, the records must remain accessible to CSCI on request, at head office, and a complete checklist of the required records, ideally signed off by an appropriate representative, must be available in the unit for inspection. The staff spoken to confirmed they had received a good induction and core training, as well as specific training on some of the communication methods used by residents. Staff referred positively to the leadership of the new manager, who was clearly felt to have been a stabilising factor, and to have introduced improvements in various systems and records, and in the consistency of staff approach to residents. Standard staffing levels are three staff throughout the waking day in each house, with one staff member sleeping-in, within each house at night. This may need to be reviewed in the future, to ensure that there are sufficient staff available, to support further improvements in residents’ access to a broader range of community activities. 2a & 2b Mayfair DS0000011045.V333921.R01.S.doc Version 5.2 Page 26 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): Standards 37, 39, 40 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents now benefit from a well run home, and the new manager has clearly identified her priorities for future improvements to the service. The views of residents and relevant others have been sought as part of a quality review of the service, though a more suitable summary report should be developed and made available to those who took part in the review. The provider has an appropriate set of organisational polices and procedures in place, but needs to ensure that a complete set of these are provided to the unit. Systems are in place to promote and protect the health, safety and welfare of residents. 2a & 2b Mayfair DS0000011045.V333921.R01.S.doc Version 5.2 Page 27 EVIDENCE: Following an unsettled period of management, the unit is now more effectively and consistently managed, and the manager has made improvements to systems, procedures and planning, in order to develop a greater consistency of approach and greater understanding of their role, by the care staff. The acting manager is appropriately experienced, having been a manager for over ten years elsewhere, and has attained her NVQ level 4 and Registered Manager’s Award, and is also an accredited manual handling trainer. The provider should ensure that the necessary steps are taken to pursue the manager’s registration with respect to this unit. The staff spoken to, were generally enthusiastic about the improvements made, and complimentary about the manager’s approach, noting how they had seen residents benefit from the changes made. The provider had undertaken an annual service review in 2006, under the previous manager, which had included seeking the views of residents, relatives, care managers and external healthcare professionals, and an outcome report and development plan were available. This identified some of the significant shortfalls, which are now being addressed, though as a summary report, is not in an accessible nor easily read format, and is not really suitable for providing to review participants. Consideration should be given to developing a more appropriate summary format for this purpose, which details what specific actions are planned in response to identified shortfalls. It was reported that the provider is engaged in a “quality drive”, and as part of this, a series of garden and cooking competitions, with prizes, had been set up across the provider’s services, to engage residents and staff in these activities, and there was also a drive to broaden the range of social activities which residents could access. The provider has monitoring systems in place including audits of residents’ funds, and monthly Regulation 26 monitoring visits, though a number of the resulting reports were not available in the unit. The manager confirmed that the visits had taken place, but without the reports being sent to the manager, it is hard for her to address any issues identified. The provider must ensure that copies of these reports are provided to the unit. 2a & 2b Mayfair DS0000011045.V333921.R01.S.doc Version 5.2 Page 28 In discussion, it emerged that although the unit has a computer, there is currently no email link to head office, which would seem to be an omission, in terms of the effective dissemination of information. As noted earlier, some of the required policies and procedures could not be located, and it appeared the new manager had not been handed-over a complete set of these. The provider should supply a complete set of current polices and procedures to the manager, to ensure that staff have access to all relevant documents. The manager and staff reported a noticeable reduction in the level of incidents, and this was borne out by the incident records, which showed only one recorded incident this year. Incident records go onto the relevant individual’s case record. Accident records were also sampled. Two accidents relating to one individual falling whilst unattended, waiting for his lunch, had been reviewed by the manager, who had instigated a change in care practice for this individual so that he was not brought to the table too early, to await meals, and left unattended while staff supported others to the table. This is a good example of how the manager has made a difference, and some of the staff have responded positively to this, recognising the potential for improvements in their practice. Accident records are held collectively, enabling effective management monitoring, but copies should also be filed on the relevant case record as part of the care history, and also to enable ready monitoring by the keyworker. Examination of a sample of health and safety-related service certification indicated that the majority of servicing was up-to-date, though the annual testing of portable electrical appliances was several months overdue. The manager agreed to pursue this and report the date this is undertaken. The unit had a fire risk assessment in place, which had been reviewed in October 2006. Staff receive fire safety training on an annual cycle. The most recent fire drill took place in March and all residents successfully evacuated in three minutes. The manager said she had started to compile individual evacuation plans for the residents and these would be completed in the light of evidence from a series of drills. 2a & 2b Mayfair DS0000011045.V333921.R01.S.doc Version 5.2 Page 29 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 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 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 2 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 2 X 3 X 2a & 2b Mayfair DS0000011045.V333921.R01.S.doc Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA12 Regulation 16(2)(m) & (n) Requirement The manager must ensure that the level of activities and community participation are developed further, in order to broaden the life-enriching opportunities of residents. The manager must ensure that staff have appropriate guidelines and training to enable them to meet effectively, the meal-time support needs of the identified resident. The manager must seek individual PRN protocols for the administration of emergency epilepsy medication for residents where this is prescribed. The provider must pursue the registration of the current manager with respect to this unit. The provider must supply a complete set of current policies and procedures to the unit, to ensure these are available, and familiar to staff, to support them in carrying out their duties. Timescale for action 28/07/07 2. YA17 18 28/05/07 3. YA20 17(1)(a) & Sched. 3.3(m) 8 28/05/07 4. YA37 28/06/07 5. YA40 12 & Appendix 2 28/05/07 2a & 2b Mayfair DS0000011045.V333921.R01.S.doc Version 5.2 Page 31 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. 2. 3. Refer to Standard YA2 YA16 YA20 Good Practice Recommendations The manager should obtain copies of the current assessment and admissions policy/procedure, so that staff can refer to these. The manager should ensure that residents have improved opportunities and encouragement of their involvement in day-to-day household tasks. The manager should remind senior staff of their responsibility for checking and monitoring the correct administration and recording of medication, to ensure that residents’ medication is effectively managed. The manager should review the possible benefits of providing the complaints procedure in adapted formats, to better support its explanation to residents. The provider should consider how to address the limitations on NVQ attainment, arising from the high proportion of part-time staff, in order to maximise the competence and skills of staff in meeting residents’ needs. The provider should ensure that appropriate evidence of the staff recruitment and vetting procedure, remains available on-site, so that the process can be verified to assess how well it protects residents. Consideration should be given, by the provider, to the development of a more accessible format for the summary report of the findings of quality assurance surveys, in order to make the information more readily available to residents and other parties. 4. 5. YA22 YA32 6. YA34 7. YA39 2a & 2b Mayfair DS0000011045.V333921.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 2a & 2b Mayfair DS0000011045.V333921.R01.S.doc Version 5.2 Page 33 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!