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Inspection on 24/05/07 for Mayfair Care Home

Also see our care home review for Mayfair Care Home for more information

This inspection was carried out on 24th May 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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 Mayfair accommodates people who have long term mental health difficulties. Staff spoken to demonstrated a good knowledge of individuals and were very non judgemental in their interactions with service users. The admissions procedures are good. The newest resident at the home had been able to meet with the managers and visit the home for an extended period of time. There was evidence that other service users were consulted about a new person moving in. The newest service user was pleased with the way in which their move had gone and the information that they received. People are able to choose what time they get up, when they go to bed and how they spend their day. Service users are encouraged to access community facilities and the home is ideally situated to enable people to do this. 90% of service users who completed questionnaires prior to this inspection said that they felt staff listened to them and acted on what they said. All knew how to make a complaint.

What has improved since the last inspection?

A concern was raised about the care of physical health needs in the home. The concern has been used by the home to improve practice and communication. There are now better links with outside professionals. There is now an identified community nurse from the local community mental health team who links with the home and offers advice and support to staff. The home now appear much more aware of the physical needs of service users and have begun to involve outside professionals in assessments of need. Daily records in respect of each service user are much more detailed and there is evidence of GPs being called and consulted with on a range of issues. Service users are being encouraged to take a more active part in the day to day running of the home. At a recent service user meeting residents said they would like to take part in household shopping, this should be facilitated to further develop involvement of service users. 2 senior staff have been appointed from within the existing staff team meaning that there is now always a senior member of staff on duty to offer advice and support to less experienced staff. Various environmental improvements have begun: The shared room has been divided into two meaning that there are now no shared rooms at the home. A new corridor has been created meaning that people no longer have to walk through the kitchen to get to the back of the house. Previously service users were able to smoke at one end of the dining room, this practice has now ceased and a smoking room has been created away from other communal areas. The heating has been fixed to the satisfaction of all service users. A new office space has been created on the ground floor. Health and safety checks are being carried out regularly and records kept up to date.

What the care home could do better:

Although there has been some improvement in care plans these need to be further developed to ensure that they are kept up to date. There needs to be clear evaluation systems in place to ensure that the home is able to monitor the effectiveness of care plans. All prescribed creams and their use should be identified in the care plan. The refurbishment programme in the home needs to continue. Particular regard should be given to the refurbishment of the dining room.The laundry floor needs to be made impermeable to minimise the risk of infection. There needs to be a robust quality assurance system in place to ensure that the home is constantly developing and improving the service offered.

CARE HOMES FOR OLDER PEOPLE Mayfair Care Home 25 The Avenue Minehead Somerset TA24 5AY Lead Inspector Jane Poole Unannounced Inspection 24th May 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Mayfair Care Home DS0000046793.V336227.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Mayfair Care Home DS0000046793.V336227.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mayfair Care Home Address 25 The Avenue Minehead Somerset TA24 5AY 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) 01643 706816 01643 708855 Ms Diane Langdon Post Vacant Care Home 15 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (0) Mayfair Care Home DS0000046793.V336227.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No persons under the age of 55 to be accommodated at the home. The shared room only to accommodate two people who have made a positive choice to share. Date of last inspection Brief Description of the Service: The Mayfair is registered to provide care for up to 15 people over the age of 55 who require care because of mental health difficulties. The home is located in the centre of Minehead, giving service users easy access to shopping and other facilities. The building is a former hotel has been converted by the current owner to provide 15 bedrooms for single occupancy. Service user accommodation is arranged over three floors with a passenger lift between. All communal areas are located on the ground floor. The registered manager/provider is Diane Langdon. Fees at the home range from £350 - £400. Mayfair Care Home DS0000046793.V336227.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over a 7.5 hour period. During this time the inspector was given unrestricted access to all areas of the home. All records requested were made available. During the day the inspector was able to talk with staff, service users and management and observe care practices. 4 health and social care professionals and 10 service users completed questionnaires prior to this inspection. Random inspections were carried out in February and April of this year. Some references to these inspections have been made in this report. Random Inspection reports are not publicly available but copies can be requested from The Commission for Social Care Inspection. What the service does well: What has improved since the last inspection? A concern was raised about the care of physical health needs in the home. The concern has been used by the home to improve practice and communication. There are now better links with outside professionals. There is now an Mayfair Care Home DS0000046793.V336227.R01.S.doc Version 5.2 Page 6 identified community nurse from the local community mental health team who links with the home and offers advice and support to staff. The home now appear much more aware of the physical needs of service users and have begun to involve outside professionals in assessments of need. Daily records in respect of each service user are much more detailed and there is evidence of GPs being called and consulted with on a range of issues. Service users are being encouraged to take a more active part in the day to day running of the home. At a recent service user meeting residents said they would like to take part in household shopping, this should be facilitated to further develop involvement of service users. 2 senior staff have been appointed from within the existing staff team meaning that there is now always a senior member of staff on duty to offer advice and support to less experienced staff. Various environmental improvements have begun: The shared room has been divided into two meaning that there are now no shared rooms at the home. A new corridor has been created meaning that people no longer have to walk through the kitchen to get to the back of the house. Previously service users were able to smoke at one end of the dining room, this practice has now ceased and a smoking room has been created away from other communal areas. The heating has been fixed to the satisfaction of all service users. A new office space has been created on the ground floor. Health and safety checks are being carried out regularly and records kept up to date. What they could do better: Although there has been some improvement in care plans these need to be further developed to ensure that they are kept up to date. There needs to be clear evaluation systems in place to ensure that the home is able to monitor the effectiveness of care plans. All prescribed creams and their use should be identified in the care plan. The refurbishment programme in the home needs to continue. Particular regard should be given to the refurbishment of the dining room. Mayfair Care Home DS0000046793.V336227.R01.S.doc Version 5.2 Page 7 The laundry floor needs to be made impermeable to minimise the risk of infection. There needs to be a robust quality assurance system in place to ensure that the home is constantly developing and improving the service offered. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Mayfair Care Home DS0000046793.V336227.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mayfair Care Home DS0000046793.V336227.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 & 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All prospective service users have opportunities to spend time in the home prior to making a decision to move in. Full assessments are carried out to ensure that staff have the skills to meet the needs of new service users. EVIDENCE: The home has updated their statement of purpose since the last inspection to ensure that it accurately reflects the services and facilities offered by the home. One new service user has moved to the home since the last inspection. There is evidence that the management obtained a full assessment of their needs Mayfair Care Home DS0000046793.V336227.R01.S.doc Version 5.2 Page 10 and were able to visit the service user at their previous placement. The prospective service user spent a day at the Mayfair before deciding to make it their home. There are written records to show that other service users were able to meet with the prospective service user and were consulted on the admission to ensure that the new service user was compatible with the existing group. The inspector was able to speak with the new service user who stated that they were very happy with the information they received about the home and felt that they had been fully involved in the assessment and admission procedure. The initial month is a trial period to ensure that the home is able to meet the needs of the service user and that the person is happy to move in on a permanent basis. An initial care plan had been drawn up in respect of this person to ensure that staff had clear guidelines on how to care for the new resident. The service users preferred daily routine had been documented. Mayfair Care Home DS0000046793.V336227.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has improved their links with outside professionals and is now more aware of the physical healthcare needs of service users. Care plans are not fully reflective of the up to date needs of service users and do not always give clear guidance to staff. EVIDENCE: Random inspections were carried out at the Mayfair in February and April of this year in response to concerns raised about how the home were meeting the physical healthcare needs of service users. The home responded to this concern by working with the CSCI and by improving their liaison with local health care professions. There is now an identified community nurse from the local community mental health team who links with the home and offers advice and support to staff. Mayfair Care Home DS0000046793.V336227.R01.S.doc Version 5.2 Page 12 The home now appear much more aware of the physical needs of service users and have begun to involve outside professionals in assessments of need. Daily records in respect of each service user are much more detailed and there is evidence of GPs being called and consulted with on a range of issues. On the day of the inspection one service user was accompanied to the local hospital for an occupational therapy appointment. All healthcare appointments are recorded. 4 health and social care professionals completed questionnaires prior to this inspection; all answered YES to the question ‘If you give any specialist advice is it always incorporated into the care plan?’ and all stated that they were satisfied with the overall care provided to service users. One professional commented ‘ There is an overall improvement in the staff’s approach to residents, they are listening more and liaising more.’ 10 service users completed questionnaires prior to the inspection; to the question ‘Do you receive the medical support you need?’ 7 people answered ALWAYS, 2 answered USUALLY and 1 person said SOMETIMES. The inspector viewed the care plans of three people living at the home. These continue to improve but still do not fully reflect the up to date needs of the service users. Although each service user has a personal file, stored in the office, for the staff convenience, information is being recorded daily in a communal file. This leads to confusion and repetition. There is evidence that the home is consulting with service users about their care plans. Peoples’ likes, dislikes and preferences are being recorded. The home uses a monitored dosage system for medication. The inspector viewed the Medication Administration Records (MARS) and found them to be correctly signed when tablets were administered or refused. There needs to be care plans in place when creams or lotions are prescribed to ensure that the effectiveness of these treatments can be monitored (this includes where service users apply their own creams.) There are adequate storage facilities for medication including items that require refrigeration. All service users have single rooms with en suites where personal care can be assisted with in private. The inspector noted that staff knocked on doors before entering and addressed service users in a respectful manner. Mayfair Care Home DS0000046793.V336227.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are able to choose how they spend their day and staff assist people to access community facilities where appropriate. Visitors are welcome at anytime and people are encouraged to keep in touch with friends and family. EVIDENCE: Everyone living at the Mayfair has a long term mental health difficulty therefore activities are arranged on an individual basis depending on the health of the person at the time. Service users are encouraged to participate in the day to day running of the home. People have access to facilities to make hot and cold drinks and snacks throughout the day and everyone makes their own breakfast, meaning that they are able to get up at whatever time they choose. Service users spoken to stated that they choose how they spend their day and many go shopping on a daily basis. Some shop for their own requirements, Mayfair Care Home DS0000046793.V336227.R01.S.doc Version 5.2 Page 14 and others for household items. Many people are able to access the community without staff supervision and on the day of the inspection it was observed that several people went out of the home with and without staff. In the afternoon a member of staff and three service users were in the garden weeding and enjoying the sunshine. Some service users stated that they preferred to occupy themselves, knitting, visiting friends or watching TV. Two people at the home have befrienders from voluntary groups who assist them to access community facilities. Some people attend clubs outside the home and further education classes in cookery have been accessed in the past. Due to peoples fluctuating health it is sometimes difficult for people to attend courses on a regular basis and the possibility of running an in house cookery course was discussed with the manager. At a recent service user meeting people stated that they would like to be more involved in household shopping and have more trips out. Service users are encouraged to make choices about their day to day lives and many examples of this were seen on the day of the inspection. Friends and family are always made welcome and people are able to see visitors in private if they wish to. Cordless phones are available, which can be taken to personal rooms to enable service users to keep in touch with friends and relatives. The main meal of the day is at lunch-time and there is always a choice of two main courses. Service users spoken to stated that if they did not wish to have either then the cook is always happy to make an alternative. A lighter meal is provided at tea time and as previously stated drinks and snacks are always available. Everybody spoken to during the inspection was happy with the food in the home. Mayfair Care Home DS0000046793.V336227.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are appropriate systems in place to minimise the risks of abuse to service users whilst enabling people to maintain independence. All service users know how to make a complaint. EVIDENCE: A random inspection was carried out in February of this year in response to concerns raised by outside professionals. It was apparent at this inspection that the home had used the concern to improve practice and communication. The home has received no complaints since the last inspection. The home uses the ‘Red Crier’ training pack and the majority of staff have now completed the course on the protection of vulnerable adults. The complaints and whistle blowing procedure are both displayed in the home together with the Somerset interagency policy on the Protection Of Vulnerable Adults. Mayfair Care Home DS0000046793.V336227.R01.S.doc Version 5.2 Page 16 All service users who completed questionnaires prior to this inspection answered YES to the question ‘Do you know how to make a complaint?’ 90 of people said that they felt the staff listened to them and acted on what they said. All those spoken to said that they would be comfortable to raise any concerns with a member of staff. The inspector observed that people were free to access all communal rooms, and their personal rooms, throughout the day. Risk assessments are completed for people who access the community to ensure that they are able to maintain independence whilst minimising risks. As with care plans, the home need to ensure that these are fully up to date. Mayfair Care Home DS0000046793.V336227.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is ideally situated to enable service users to access local amenities and facilities. Some areas of the home are in need of refurbishment to ensure that it provides a comfortable home for service users. EVIDENCE: The home is located in a central position in Minehead, which enables service users to easily access shops, the sea front and other local amenities. Service user accommodation is arranged over three floors with a passenger lift giving access to all floors. Mayfair Care Home DS0000046793.V336227.R01.S.doc Version 5.2 Page 18 On the ground floor there is a large lounge and dining room. There is a toilet located close to the communal areas. Aids and adaptations have been fitted in the home to assist people to maintain their independence. The home has experienced some problems with the heating system, which have now been rectified to the satisfaction of all service users. During random inspections carried out over the winter months the inspector noted that all areas of the home are now adequately heated. Since the last inspection the one double room has been converted to two singles. At the time of this inspection the home were in the process of fitting an en suite into one of these rooms. Once this work is complete all service user accommodation will be for single occupancy and all will have en suite facilities ranging from a toilet and wash-hand basin to full bathrooms. In addition to en suites there is a bathroom and shower room for communal use. Other environmental improvements are under way in the home. The kitchen has been made smaller and is no longer a thoroughfare to the back of the house. This has also created a small office area where information can be safely stored. Previously service users were able to smoke at one end of the dining room, this practice has now ceased and a smoking room has been created away from other communal areas. Service users are able to personalise their private rooms, which gives them a very homely feel. Service users spoken to were very happy with their accommodation but some felt that communal areas would benefit from re decoration. The inspector noted that the dining room looked particularly shabby and requires refurbishment. With the exception of one area, that the home is aware of, the home was clean and fresh on the day of the inspection. The laundry is located at the rear of the home and is adequate to meet the needs of the service users. The floor in the laundry needs to be replaced to ensure that it is impermeable to reduce the risk of infection. Mayfair Care Home DS0000046793.V336227.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff demonstrated a good understanding of the needs of service users. Training opportunities for staff are continually improving leading to a more competent workforce. EVIDENCE: The home employs 11 care staff and two ancillary staff. With the exception of 4 people all staff are currently working towards National Vocational Qualifications(NVQ) in care. In addition to this staff have undertaken training in working with aggression, care of people who have a dementia, health and safety issues including first aid, food hygiene, fire safety and moving and handling. A training session in the care of people with diabetes had been arranged for the day after the inspection. Since the last inspection two senior staff have been appointed from within the existing staff team to ensure that there is always a senior person on duty at the home. This is clearly marked on the duty rota. Mayfair Care Home DS0000046793.V336227.R01.S.doc Version 5.2 Page 20 Staff and service users felt that the home was adequately staffed. Currently all care staff are female meaning that service users do not have a choice of the gender of the person who assists them with their care. No new staff have been recruited since the last inspection therefore this standard was not inspected on this occasion as no concerns were raised at the previous inspection. Staff spoken to during the inspection appeared competent and confident in their roles, they were able to demonstrate a good knowledge of individuals needs. Throughout the day there was constant interaction between staff and service users. Mayfair Care Home DS0000046793.V336227.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed in the interests of the service users. Appropriate systems are in place to ensure the health and safety of service users and staff. EVIDENCE: The registered manager/provider is Diane Langdon who is a qualified psychiatric nurse and holds a National Vocational Qualification in management at level 4. Mayfair Care Home DS0000046793.V336227.R01.S.doc Version 5.2 Page 22 In addition to the registered manager there is a home manager who is in charge of the day to day running of the home. As mentioned previously two new senior positions have been created to ensure that there is always a shift leader on duty to advise and support less experienced staff. There is also an on call rota to contact a member of the senior management team if required. Currently the home manager is responsible for the formal supervision of all staff. Due to the number of staff, formal supervision sessions are not occurring as frequently as the manager would wish. It is strongly recommended that the new senior carers undertake a training course in supervision skills to enable them to supervise other staff members. There are regular staff and service user meetings in the home to enable people to make suggestions about the running of the home. To ensure that service users feel able to express their views freely an outside facilitator chairs the service user meetings. The home holds small amounts of money for service users. Records seen correlated with monies held. The home manager is developing a quality assurance programme for the home. Measures are in place to maintain health and safety in the home. A fire detection system is fitted which is tested regularly by a nominated member of staff. Records seen were up to date. All accidents are recorded and give clear details of the accident and the action taken. The lift is regularly serviced by outside contractors. Portable electrical appliances were tested in November 2006. The landlords gas safety certificate was no available at this inspection. A copy of this should be forwarded to the CSCI. The certificate of insurance was not displayed at the time of this inspection but the manager was able to show evidence that suitable insurance was in place. The certificate of registration is displayed in the main entrance. Mayfair Care Home DS0000046793.V336227.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 3 3 X 3 3 2 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 3 X 3 Mayfair Care Home DS0000046793.V336227.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? yes 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 OP7 OP8 Regulation 15(2) 12 (3) Requirement Timescale for action 30/06/07 2 OP19 23 (2) [b][d] 13 (3) 3 OP26 4 OP33 24 (1) a All care plans must accurately reflect the needs and wishes of the service user and give clear guidance for staff. (Previous timescale 04/04/07 not met) The registered manager must 31/08/07 ensure that all areas of the home are kept in a good state of repair and reasonably decorated. The registered person must 31/08/07 ensure that floor and wall surfaces in the laundry are impermeable to minimise the risks of infection. The registered person must 30/06/07 ensure that there is a system for seeking the views of interested parties and improving the quality of care in the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000046793.V336227.R01.S.doc Version 5.2 Page 25 Mayfair Care Home 1 2 Standard OP15 OP28 Service users should be involved in household shopping to enable them to make choices about the food coming into the home. 50 of care staff should have a National Vocational Qualification in care at level 2 or above. (Recommendation carried over from previous inspection) Senior staff in the home should undertake training in supervision skills. 3 OP36 Mayfair Care Home DS0000046793.V336227.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mayfair Care Home DS0000046793.V336227.R01.S.doc Version 5.2 Page 27 - 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!