Inspection on 09/08/05 for 45 Mayfield Park North

This inspection was carried out on 9th August 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

45 Mayfield Park North 14/08/07

45 Mayfield Park North 20/09/06

45 Mayfield Park North 28/02/06

45 Mayfield Park North 04/02/05

45 Mayfield Park North 25/05/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOME ADULTS 18-65 45 Mayfield Park North Fishponds Bristol BS16 3NH Lead Inspector Sandra Jones Unannounced 9 August & 2 September 2005 9:30 th nd 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. 45 Mayfield Park North D56_D05_26563_Mayfield Park North_241863_090805_Stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 45 Mayfield Park North Address Fishponds Bristol BS16 3NH 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) 0117 9583869 0117 9709301 Aspects & Milestones Trust Mr Ioan Williams CRH-PC Care Home only 5 Category(ies) of MD Mental Disorder [4] registration, with number MD(E) Mental Disorder -over 65 [1] of places 45 Mayfield Park North D56_D05_26563_Mayfield Park North_241863_090805_Stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate up to 4 persons aged 19 - 64 years May accommodate 1 person aged 65 years and over Date of last inspection 4th. Feb.2005 Brief Description of the Service: Mayfield Park North is a care home for five adults with mental health care needs. It is operated by Aspects and Milestone Trust and managed by Ioan Williams. The property has the appearance of a domestic dwelling, which blends well with its immediate environment. It is close to shops, ameneties and bus routes. Arranged over three floors, with shared space on the ground floor and bedrooms on the lower ground floor and first floor. There is selfcontained accommodation on the basement that is used by a resident that is with living skills. 45 Mayfield Park North D56_D05_26563_Mayfield Park North_241863_090805_Stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted over two days. On the first visit records were examined and a tour of the premises took place. On the second visit residents’ feedback was sought. Two residents at the home during the second visit gave feedback on the standards of care. Since the last inspection, two staff have resigned leaving the home with one permanent staff member along with the manager. The home is relying on regular bank staff to cover vacant hours. The permanent member of staff was involved in the inspection and was clearly aware of the day to day system needed to manage a care home. What the service does well: What has improved since the last inspection? The requirements made at the last inspection have been implemented. The one member of staff has completed NVQ level 3 and the manager is undertaking the Registered Managers Award (RMA). 45 Mayfield Park North D56_D05_26563_Mayfield Park North_241863_090805_Stage4.doc Version 1.40 Page 6 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. 45 Mayfield Park North D56_D05_26563_Mayfield Park North_241863_090805_Stage4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 45 Mayfield Park North D56_D05_26563_Mayfield Park North_241863_090805_Stage4.doc Version 1.40 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 standard(s) 1 The Statement of Purpose contains sufficient information for residents to make a choice about living at the home. EVIDENCE: The prepared Statement of Purpose describes the full, intended range of facilities and services that the law requires and the National Minimum Standards expect. Along with the policies and procedures, establishes the approach for meeting residents’ needs. 45 Mayfield Park North D56_D05_26563_Mayfield Park North_241863_090805_Stage4.doc Version 1.40 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 standard(s) 6, 7 & 8 Care plans must be reviewed to ensure changing needs are met. A person centred approach towards care planning must be developed. Residents are enabled to make decisions about all aspects of their lives. Residents have input into the day-to-day running of the home. EVIDENCE: Case records examined contained personal profiles and care guidelines, which detail all aspects of their lives including needs. There are also risk assessments for activities that may involve an element of risk - for example, smoking, staying at home unaccompanied and relationships. A requirement to develop a person centred approach to meeting assessed needs was previously made. The person’s likes, dislikes and preferred routines were required to be added to the action plans. The care plan for one resident included information about the “inspector requiring that residents likes be incorporated into the care plan and the resident not having any particular likes.” Legislation requires that “for the purpose of providing care to service users, and making proper provision for their health and welfare, so far as practicable ascertain and take into account their wishes and feelings.” 45 Mayfield Park North D56_D05_26563_Mayfield Park North_241863_090805_Stage4.doc Version 1.40 Page 10 Additionally the “White Paper” based on rights as citizens, inclusion in the local community, choice, daily lives and real choices to be independent endorses a person centred approach to meeting needs. Care plans must be therefore developed using a person centred approach to meeting residents assessed needs. It was also evident that care plans must be reviewed. There is a keyworker system in operation and residents consulted described the role of their keyworker. Keyworkers spend 1:1 time with their key residents and support to pursue hobbies, interest and assist with purchases and accompany residents where requested. Other documentation held within case records included agreements from two residents in respect of sharing bedrooms. Records also evidenced that input from outside agencies is sought. Risk assessments in place evidence that residents can make decisions on, for example, intimate relationships. There was evidence that discussions and suggestions made by staff take place and residents can make decisions about acting upon the suggestions made. The cooker is disconnected and kettle is removed at night to safeguard the group from one person. It was understood from a member of staff that although hot drinks are not available at night, residents can have cold drinks at any time. Monthly house meetings take place with residents and staff chairing the meeting. From the records of the meetings, residents have opportunities to make suggestions. Residents giving feedback reported that house meetings take place and are supported by the residents. As the home relies on bank staff to cover vacant hours, residents are asked to comment on their satisfaction with the care provided. This is seen as good practice. It was understood from the member of staff on duty that potential staff are invited to an informal meeting during the recruitment process. This enables residents to meet candidates and make observations about them. Residents complete surveys annually which are based on the standards of care, lifestyles, choice, support and complaints. From the analysis of the responses, judgements are made about the provision of care at the home. 45 Mayfield Park North D56_D05_26563_Mayfield Park North_241863_090805_Stage4.doc Version 1.40 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 standard(s) 11 Residents have opportunities to learn practical skills which they use at the home. EVIDENCE: Two residents agreed to give feedback on the standards of care at the home. They reported that depending on the individual’s abilities, members of staff support them to use practical skills. Comments made by the residents indicated that opportunities exist for personal development. The residents at the home stated that annual holidays are arranged by their keyworkers. The destination for the two residents with staff was to be Tenby and they would be travelling by train. 45 Mayfield Park North D56_D05_26563_Mayfield Park North_241863_090805_Stage4.doc Version 1.40 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 standard(s) 20 Safe medication practices exist at the home. EVIDENCE: The residents currently accommodated have full control of their prescribed medications. Analgesics are administered when required from a stock supply and the records of administration were consistent with the medication held. Individual drug profiles that describe the purpose of the medication, their side effects and compatibility with homely remedies are in place. Information leaflets provided by the pharmacist are appended onto the profiles for additional information. Residents giving feedback confirmed that they self medicate and take responsibilities for ordering their medications. 45 Mayfield Park North D56_D05_26563_Mayfield Park North_241863_090805_Stage4.doc Version 1.40 Page 13 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 Residents confirmed that their views are sought and acted upon. EVIDENCE: Residents confirmed that their views are sought during house meetings and 1:1’s. Records of house meetings indicate that group issues are discussed during these forums. There were no complaints received at the home for investigation since 6/5/02. 45 Mayfield Park North D56_D05_26563_Mayfield Park North_241863_090805_Stage4.doc Version 1.40 Page 14 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) These standards were examined at the previous inspections and timescale for requirements from the previous inspection have not yet expired. EVIDENCE: Since the last inspection appliances were replaced and there is new carpet in the corridors. 45 Mayfield Park North D56_D05_26563_Mayfield Park North_241863_090805_Stage4.doc Version 1.40 Page 15 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, 35 & 36 Bank staff are used to maintain staffing levels while recruitment for two parttime staff takes place. Individual supervision must take place with the staff as other systems that achieve consistency are not used so that residents benefit from well supported and supervised staff. The sole permanent member of staff has achieved NVQ level 3 and the manager is undertaking the Registered Managers’ Award (RMA). EVIDENCE: Two permanent staff have resigned from the home, leaving one member of staff and manager. One person is generally rostered to work throughout the day, with one person sleeping at night. For this reason the home relies on bank staff to cover vacant hours and every effort is made to use regular bank staff to provide consistency of care. It was understood from the member of staff on duty that at present there is an internal recruitment drive for two parttime staff. 45 Mayfield Park North D56_D05_26563_Mayfield Park North_241863_090805_Stage4.doc Version 1.40 Page 16 As there is one permanent member of staff and the manager, staff meetings have not occurred. It was understood from the member of staff that consistency is achieved through the communications book, by passing information between staff. An induction folder is in place for bank staff about the home’s background, staffing needs, fire safety and personal profiles, providing essential information. Monthly visits from the external manager are conducted and the CSCI office receives a copy of the visits. Individual supervision between the manager and member of staff last occurred on the 23/11/04. Members of staff must have individual supervision to ensure performance is monitored and personal development is discussed. The member of staff has completed NVQ level 3 and the manager is currently undertaking the Registered Managers’ Award (RMA). 45 Mayfield Park North D56_D05_26563_Mayfield Park North_241863_090805_Stage4.doc Version 1.40 Page 17 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) 41 & 42 Records of cash and valuables are accurate and up to date. There is a record of professional visits to the home. To properly safeguard residents rights, records of fees must detail the sources that contribute towards the fees. Otherwise, the home’s record keeping polices and practices do safeguard these rights. Residents’ safety is promoted. EVIDENCE: Facilities for the safekeeping of cash and valuables exist at the home and currently two residents have cash held in safekeeping. Records indicate that the cash is handed to the person for personal use and is signed by the person. Records of fees charged at the home no longer details the sources that contribute towards the fees. 45 Mayfield Park North D56_D05_26563_Mayfield Park North_241863_090805_Stage4.doc Version 1.40 Page 18 Visitors book indicates professional visits take place from other agencies, Trust staff and outside contractors. The records that relate to fire safety policies, procedures, checks and practices were examined. From the records it is evident that system checks and practices are conducted at the stipulated frequencies. 45 Mayfield Park North D56_D05_26563_Mayfield Park North_241863_090805_Stage4.doc Version 1.40 Page 19 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 3 x x x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 3 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 3 x x x x x x Standard No 31 32 33 34 35 36 Score x 3 2 x x 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 45 Mayfield Park North Score x x 3 x Standard No 37 38 39 40 41 42 43 Score x x x x 3 3 x D56_D05_26563_Mayfield Park North_241863_090805_Stage4.doc Version 1.40 Page 20 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. 2. 3. 4. Standard Standard 6 Standard 6 Standard 36 Standard 42 Regulation Requirement Timescale for action 30.01.06 30.01.06 30.11.05 30.11.05 Regulation Care plans must be developed 12(3) using a person centerd approach to meeting needs. Regulation Care plans must be reviewed to 14 (2) ensure residents changing needs can be met. Regulation The manager must have regular 18 (2) 1:1 supervision with staff at the home. Regulation Records of fees charged at the 17 (2) home must include the sources that contribute towards the fees. 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 Good Practice Recommendations 45 Mayfield Park North D56_D05_26563_Mayfield Park North_241863_090805_Stage4.doc Version 1.40 Page 21 Commission for Social Care Inspection 300 Aztec West Almondsbury South Gloucestershire BS32 4RG 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 45 Mayfield Park North D56_D05_26563_Mayfield Park North_241863_090805_Stage4.doc Version 1.40 Page 22 - 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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