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Inspection on 07/06/05 for 2a & 2b Mayfair

Also see our care home review for 2a & 2b Mayfair for more information

This inspection was carried out on 7th June 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home has been redecorated and building work has been finished to make space for ten instead of eight residents. There is lots of room for the residents and there are new conservatories on the sides of the house. The home makes sure that residents keep in contact with their family and friends. Staff do lots of training courses to make sure they can look after the residents properly.

What has improved since the last inspection?

There are more staff who work in the home on a regular basis and who can get to know the residents better. There are now ten residents who live in the home and things are much more settled. The bathrooms and bedrooms are nicely decorated and look smart and all the radiators are safe and not too hot.

What the care home could do better:

The home could make sure that the resident`s contracts are filled in properly. The home could try to provide more activities and help residents to do more things with their time. The staff could have better ways of protecting the residents.

CARE HOME ADULTS 18-65 2a and 2b Mayfair Tilehurst Reading Berks RG30 4QY Lead Inspector Kerry Kingston Unannounced 7 June 2005, 10.00 am 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 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 Stationary 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 and 2b Mayfair H51-H01-S11045-2a2b Mayfair-V229905-070605Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 2a and 2b Mayfair Address 2a and 2b Mayfair, Tilehurst, Reading, Berks, RG30 4QY Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0118 9453743/4 Milbury Care Services Ltd No Registered Manager Care Home (CRH) 10 Category(ies) of Learning disability (LD) registration, with number of places 2a and 2b Mayfair H51-H01-S11045-2a2b Mayfair-V229905-070605Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 04/11/04 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 nand has bedroom accomodation 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 and 2b Mayfair H51-H01-S11045-2a2b Mayfair-V229905-070605Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection, which took place on the 7th June 2005 between the hours of 12 noon and 4 pm. The inspector spoke with the manager, who was available throughout the inspection and met three residents. The inspector looked at some parts of the building and looked at resident files and other records. What the service does well: 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. 2a and 2b Mayfair H51-H01-S11045-2a2b Mayfair-V229905-070605Stage 4.doc Version 1.30 Page 6 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 Standards Statutory Requirements Identified During the Inspection 2a and 2b Mayfair H51-H01-S11045-2a2b Mayfair-V229905-070605Stage 4.doc Version 1.30 Page 7 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 standard(s) 2 and 5 New residents needs were not fully assessed. Contracts/Statements of Terms and Conditions were not complete. EVIDENCE: There have been three new admissions since the last inspection; the new service users all moved from the same home that was shutting down. All three had comprehensive assessments and Care plans from their old home but there was no evidence that an assessment had taken place with regard to the ability of Mayfair to meet their needs. The manager advised the inspector that he had personally assessed the service users and two had had a care management assessment but there was no evidence of this in the home. One residents mother had also visited from the U.S.A. to ensure it was suitable but again there was no record of this visit. There were no recordings of introductory visits or service users views on the home. One of the new service users indicated that he was happy with his home. All residents have a Contract/Statement of terms and conditions, which has been developed since the last inspection, but not all the necessary information was included and they were not signed. 2a and 2b Mayfair H51-H01-S11045-2a2b Mayfair-V229905-070605Stage 4.doc Version 1.30 Page 8 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 standard(s) None of the above standards were assessed at this inspection. EVIDENCE: 2a and 2b Mayfair H51-H01-S11045-2a2b Mayfair-V229905-070605Stage 4.doc Version 1.30 Page 9 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 standard(s) 12,13,14, 15,16 and 17. Service users do not have a varied activity programme and have limited opportunities to access the community. They are helped to have appropriate relationships and are offered a healthy and nutritious diet. EVIDENCE: Service users records showed that their activities consist mainly of going for walks. Only one individual has a full activity programme, which consists of attending the local day centre for four days of the week. The three new service users have no set activities provided externally or internally. Other service users have external activities provided for between one and three days per week. There was little evidence of activities taking place in the evenings or at weekends. The manager is aware of the issues, especially around the new service users and is attempting to develop staff skills and interests to provide appropriate activities and to record those that are participated in. The inspector saw no records, which showed attendance at sports facilities, cinemas or other community outings. The inspector was advised that drivers 2a and 2b Mayfair H51-H01-S11045-2a2b Mayfair-V229905-070605Stage 4.doc Version 1.30 Page 10 for the homes’ transported also impacted on the number of outings that could be organised. Service users families and friends are kept involved in their care and those who do not have families are found advocates. Menus seen were varied and provided well-balanced and nutritious meals. 2a and 2b Mayfair H51-H01-S11045-2a2b Mayfair-V229905-070605Stage 4.doc Version 1.30 Page 11 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 standard(s) None of the above standards were assessed at this inspection. EVIDENCE: 2a and 2b Mayfair H51-H01-S11045-2a2b Mayfair-V229905-070605Stage 4.doc Version 1.30 Page 12 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 standard(s) 22 and 23 Service users have access to a comprehensive complaints procedure. Service users are not fully protected form abuse. EVIDENCE: There is a comprehensive complaints procedure, in place. This has been produced a service user-friendly format and each individual is provided with a copy. The complaints book is up-to-date but may benefit from more detail, with regard to the response to the complaint and the manager identifying what is appropriate to record. During a Vulnerable Adult complaint in February of this year the joint agency Vulnerable Adults procedure was not adhered to in the initial stages of the investigation. Staff have now all been trained in the Protection of Vulnerable Adults and the manager is confident that he would respond appropriately, in the future. Service users finances are not clear and they, currently, have no access to their own bank accounts. They are borrowing money from the provider until the problem is sorted out; this appears to be taking a long time. The manager has no real knowledge of the service users finances and would be unable to protect them form abuse. Service users cash deposits showed inaccuracies. 2a and 2b Mayfair H51-H01-S11045-2a2b Mayfair-V229905-070605Stage 4.doc Version 1.30 Page 13 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 standard(s) 24,27 and 30 The home is homely, comfortable, clean and hygienic and bathing/toileting facilities are of a good standard. EVIDENCE: The home has recently been refurbished to a good standard and the home was clean and hygienic, on the day of inspection. 2a and 2b Mayfair H51-H01-S11045-2a2b Mayfair-V229905-070605Stage 4.doc Version 1.30 Page 14 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 35 Service users are supported by a generally, well trained effective staff team. EVIDENCE: The home has had a major staff recruitment drive and staffing ratios have been increased to reflect the extra service users in residence. There is limited use of agency and staff rotas reflected a minimum of six staff per shift plus the manager during the day. There are two waking night staff and a sleeping-in person during night time hours. Staff were observed interacting appropriately with service users and staff meeting minutes recorded useful discussion amongst the staff team. There are some communication issues and more training is needed with regard to staff attitudes to daily activities for service users (see standard 13). Communication issues were reflected in the staff meeting minutes and the manager is aware of some team problems, which he is attempting to address. The manager may also be assisted to keep communication records up-dated (with regard to service users needs) if he had access to I.T equipment. 2a and 2b Mayfair H51-H01-S11045-2a2b Mayfair-V229905-070605Stage 4.doc Version 1.30 Page 15 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 The home has very high standards with regard to the Health and Safety of staff and Service users. EVIDENCE: All Health and Safety maintenance records and staff training were up-to-date. Safe working practice risk assessments are comprehensive and accidents and incidents are recorded carefully. All radiators are now covered and operating at safe temperatures. 2a and 2b Mayfair H51-H01-S11045-2a2b Mayfair-V229905-070605Stage 4.doc Version 1.30 Page 16 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 1 x x 2 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x x x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 3 x x 3 Standard No 11 12 13 14 15 16 17 x 2 2 2 3 3 3 Standard No 31 32 33 34 35 36 Score x x 3 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 2a and 2b Mayfair Score x x x x Standard No 37 38 39 40 41 42 43 Score x x x x x x 3 H51-H01-S11045-2a2b Mayfair-V229905-070605Stage 4.doc Version 1.30 Page 17 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 5 Regulation 5.1(b) Requirement To provide a statement of terms and conditions/contract which includes al the necessary information. (previous timescale 01.02.05) To further review daily activity programmes for service users. (previous timescale 01.01.05) To ensure that the manager is able to effectively protect service users. To evidence that the home is able to meet the assessed needs of new service users. Timescale for action 01.09.05 2. 3. 4. 13 23 2 16.2 (m) (n) 13.6 14 01.08.05 01.07.05 01.07.05 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 33 Good Practice Recommendations To provide the manager with I.T.equipment to aid communication and record keeping. 2a and 2b Mayfair H51-H01-S11045-2a2b Mayfair-V229905-070605Stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection 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 and 2b Mayfair H51-H01-S11045-2a2b Mayfair-V229905-070605Stage 4.doc Version 1.30 Page 19 - 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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