Inspection on 10/05/06 for Mayfair Lodge

This inspection was carried out on 10th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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.

Other inspections for this house

Mayfair Lodge 19/02/07

Mayfair Lodge 21/02/06

Mayfair Lodge 26/10/05

Mayfair Lodge 25/01/05

Mayfair Lodge 17/06/04

Mayfair Lodge 11/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Mayfair Lodge The Walk Watkins Rise Potters Bar Hertfordshire EN6 1QN Lead Inspector Mrs Jan Sheppard Unannounced Inspection 10:00 10 and 11th May 2006 th 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 Lodge DS0000019462.V293942.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 Lodge DS0000019462.V293942.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Mayfair Lodge Address The Walk Watkins Rise Potters Bar Hertfordshire EN6 1QN 01707 871800 01707 871861 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) www.quantumcare.co.uk Quantum Care Limited Care Home 62 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (61), Old age, not falling within any other of places category (61), Physical disability (1), Physical disability over 65 years of age (61) Mayfair Lodge DS0000019462.V293942.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: There are none Date of last inspection 21st February 2006 Brief Description of the Service: Mayfair Lodge is a purpose built care home for older people, which is run by Quantum Care Ltd. and was opened in 1998. It offers 62 single bedrooms, 61 have en-suite facilities and one provides wash facilities only. These are grouped in four separate units; two units provide specialist dementia care. The home is well equipped and is wheelchair accessible. It is located close to the town centre of Potters Bar where all the amenities of a high street can be easily accessed. All major public transport is within a short distance. The home offers a secure and homely environment for its service users. The fees which are determined according to the level of care needs range from £495 to £580 per week. Mayfair Lodge DS0000019462.V293942.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and took place over one and a half days when the inspector spoke with residents, relatives and staff, examined records and made a tour of the building. The detail in this report reflects the findings at that time and also takes account of comments made in documentation that is periodically sent to the Commission by the homes Manager. The homes manager post became vacant in December 2005 since when the Deputy has been acting up into the Managers position. Interviews for the replacement manager are to be held on 24th May. Twenty two standards were examined during this inspection. All the requirements made following the last inspection have been met or are in the process of being met. Four requirements are made following this inspection. On the day of this unannounced inspection the home had a calm and happy atmosphere. The staff were seen to be working well together as a team being supportive of each other and towards the management team. Without exception the staff spoke appreciatively of the help and support they receive from the acting manager and several commented, “that the home is much more settled now”. What the service does well: What has improved since the last inspection? The range and frequency of leisure activities has increased since the last inspection. The programme of activities led by specially appointed activity organisers are individually planned to meet residents needs and choices. Many residents commented to the inspector about these recent improvements. Mayfair Lodge DS0000019462.V293942.R01.S.doc Version 5.1 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. Mayfair Lodge DS0000019462.V293942.R01.S.doc Version 5.1 Page 7 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 Lodge DS0000019462.V293942.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The care needs of all prospective service users are fully accessed by one of the homes managers before visits to the home or decisions about admission are taken. Standard 6 is not applicable, as this home does not provide intermediate care. EVIDENCE: The homes pre admission policy and procedures are fully compliant with the requirements of these standards and were seen to have been fully carried out for residents recently admitted to the home. A pack containing the appropriate information including the Homes information sheet, a Schedule of Fees, a copy of the Statement of Purpose and the Service Users Guide, the Complaints procedure and the most recent Inspection Report, is available for prospective residents and their families. Mayfair Lodge DS0000019462.V293942.R01.S.doc Version 5.1 Page 9 One of the homes Managers visits the prospective resident in their own home or other setting to ascertain whether Mayfair Lodge could meet their care needs after which the prospective resident is invited to visit the home and view the room that is available. Where appropriate relatives of the prospective resident are included in these initial visiting arrangements. A number of such introductory visits were seen to be taking place on the days of this inspection when it was observed that staff were accompanying the visitors around the home answering their questions and introducing the prospective resident to some of the existing residents. Mayfair Lodge DS0000019462.V293942.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is, with one exception, adequate. This judgement has been made using available evidence including a visit to the service. Appropriate personal care, which met the residents care needs, was observed being given by kindly and sympathetic staff. The records evidenced that the residents health needs were being met promptly. All the residents care needs are set out in their individual plan of care however some of these were found to be lacking in detail and not to be subject to a regular review. The home has a robust policy and procedures for the storage and administration of medication. EVIDENCE: Personal care was seen to be being delivered in a kindly manner by staff who clearly knew their residents well, understood their care needs and were endeavouring to meet these needs in a manner that retained their dignity and respect. The staff were observed to be working well together as a team. Mayfair Lodge DS0000019462.V293942.R01.S.doc Version 5.1 Page 11 The records evidenced that the residents health care needs were given good attention with prompt referral to the GP or to the paramedic service for advice where an accident or illness occurred. Records kept by the District Nursing service demonstrated the care process for a resident suffering with a pressure area. The appropriate equipment to alleviate this had been provided and the resident confirmed that her wound was improving. A number of Doctors and District Nurses were seen to be visiting residents during the days of this inspection. All spoken with by the inspector talked positively of the home commenting that the staff were alert to any changes in the residents health and called them in without delay. One visiting GP said that she had known the home for seven years and that overall she could only make positive comments. Another District Nurse said “ there is a good awareness of health care issues here and our two services work well together. This home is a pleasure to visit.” All the residents have a care plan and a number were examined during this inspection. Whilst none was found to be inadequate the manner in which they were maintained was found to be variable, some lacked detail as to how identified care needs should be met so as to meet the residents wishes whilst for others a review was overdue. A requirement is made. The homes manager explained that since the last inspection many of the staff had undertaken refresher medication training. The MAR, medication administration record, sheets examined were found to be well recorded. The various checks and systems put in place by the home to ensure accuracy of this recording could be evidenced. Residents and relatives spoken with by the inspector were all positive about the care they receive. One resident said, “Staff are very kind here, I’m very well looked after.” A relative commented “It was such a relief when Mother was admitted here, now the staff seem to know so much about her and can anticipate her care needs”. “Mother is much more contented now and has even started putting on weight”. Mayfair Lodge DS0000019462.V293942.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home provides a range of activities, choices of menu and alternative relaxation areas and encourages participation in the home by the local community. EVIDENCE: Since the last inspection the range of leisure activities provided in the home has increased and the activity choices of many of the residents were seen to be recorded in their care plan. Two activity organisers are now employed in the home and since the last inspection they have been talking individually with the residents to find out what if any activities they would like to participate in. Group and individual activities are catered for. One resident who expressed a wish to go swimming is being accompanied to do this whilst another told the inspector that she has planned a holiday to a Warners Holiday Camp. The activity programmes and future outings and summer events were seen to be advertised around the home. On the first day of this inspection it being very warm and sunny, staff were seen to be helping the residents who wished to settle in the garden. Several of the residents mentioned to the inspector about the recent increase in the range of activities now on offer and said that you did not have to join in if you did not want to. Mayfair Lodge DS0000019462.V293942.R01.S.doc Version 5.1 Page 13 The home has a well established and active “Friends of Mayfair Lodge“ group. The manager explained that a recent Quiz night had raised a considerable sum thanks to the efforts of many of the residents relatives and she also mentioned that one resident, a quiz buff, had been able to fully participate and had particularly enjoyed that evening. A successful coffee morning had been held during the previous week and this had attracted a lot of resident involvement. The home maintains very good relationships with the residents relatives and many were spoken with by the inspector during this inspection. Without exception they all spoke positively about the home and of the care afforded to their relative. The manager said that a Company Director had been asked to give a talk to the relatives and that she was considering arranging a short relatives training course especially to cover the problems encountered when families have a relative suffering from dementia. Several of the residents spoke to the inspector about the way in which the careworkers help them to do as much for themselves as they possible can. “ They encourage me and even though I am so slow they are very patient”, one said. Another relative commented that she understood that staff could not keep everybody under surveillance all of the time,” we understand about risk taking within safe limits”, she said and commented that she wanted this to continue if this gives a better quality of life for her Mother. The homes procedure where a risk assessment identifies a possible risk, which could be safely managed, is to involve the resident, their families and their GP in a meeting to compile an agreed risk assessment. Recent changes in the kitchen staff, the appointment of a new Chef, have been well received by the residents who were without exception very complimentary about the recent improvement in the choice and quality of the food. The chef told the inspector that she tries to speak with the residents at least twice a week and has been encouraged by their responses and that she likes to produce new dishes that they have requested. The particular and changing eating requirements of many of the residents on the Dementia care units were discussed as was the priority being given to ensure that the residents intake of fluids is adequate. It is a requirement that repairs are made to the flaking area of the kitchen ceiling, which could prove a hazard and accidental contamination of foodstuff. Mayfair Lodge DS0000019462.V293942.R01.S.doc Version 5.1 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The home has a robust complaints procedure and follows the Adult protection procedures as set out in the Hertfordshire county council joint Agency Guidelines. EVIDENCE: There have been no formal complaints nor any incidents concerning Adult Protection since the last inspection. The manager showed the Inspector several letters of compliment that had recently been received by the home. A copy of the homes Complaints policy and procedure is given to every resident to their relatives and is available in the entrance hallway of the home along with other information about the home and a copy of the most recent inspection report. The recent changes made by the government to the role of the CSCI when dealing with complaints made against registered providers were discussed with the manager. In the light of these changes it is recommended that the wording of the companies information concerning the dealing of complaints may need to be reconsidered. A recommendation is made. The homes training records evidenced that all staff undertake training concerning adult protection and whistle blowing procedures. Mayfair Lodge DS0000019462.V293942.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Mayfair Lodge, which was a purpose, designed and built home some eight years ago, provides its residents with a clean and comfortable environment, which has an attractive homely ambience. The home is generally safe but one minor exception was noted which could render the residents at risk. EVIDENCE: The home is well maintained and since the last inspection a number of works of redecoration and areas of new carpeting have further improved its appearance. Residents spoken with all expressed their satisfaction with their rooms and the furnishings and equipment provided and many were seen to have personalised their rooms. The home carried out regular checks maintains all the required records to ensure the safety of the residents. Mayfair Lodge DS0000019462.V293942.R01.S.doc Version 5.1 Page 16 However checks made during this inspection revealed the hot water temperature in one area to be above the recommended level. This area was immediately put out of bound to the residents warning notices were placed to alert the staff and urgent repairs arranged. A requirement is made. Mayfair Lodge DS0000019462.V293942.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home is adequately staffed with experienced and qualified carers who seemed to be very positive about their work and to work well together as a team. The home has robust policies and procedures for the recruitment of staff, which ensure the proper protection for the service users. EVIDENCE: Staff were seen to be working well together as a team and to be providing support for the residents in a kindly unhurried manner this allowing them to do as much for themselves as it was safely possible for them to do only intervening in a sensitive manner. Staff were found to be familiar with the needs of the residents and a good rapport was seen to exist between them. Staff spoke positively about the support they receive from their managers and also of the training opportunities that are available for to them. Since the last inspection the percentage of staff holding an NVQ qualification has increased by some ten percent and more staff are studying for this qualification. In addition the homes training records evidenced that a number of other training courses have been attended since the last inspection. All staff have a training needs profile and from these an annual training plan for the whole home is compiled. Mayfair Lodge DS0000019462.V293942.R01.S.doc Version 5.1 Page 18 The records examined for recently recruited staff evidenced that the proper checks are being made including CRB and POVA investigations. The manager confirmed that the homes recent recruitment drive had been very successful with several applications received from experienced and well qualified applicants. The home is now virtually fully staffed and the staffing team now seems to have settled somewhat. Staff retention is now considered to be a priority by this manager. Mayfair Lodge DS0000019462.V293942.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The deputy manager, who has been the Acting Manager of this home for the past five months, and who will continue until a new permanent manager appointment is made, is a well qualified and experienced professional who has had many years managed residential homes for older people. She is assisted by a stable experienced and well qualified management team who have been working well together to ensure that the needs of the residents are fully met. Questionnaires are used to gather feedback from resident’s relatives and professional stakeholders in the home concerning the quality of service being provided. The homes financial policies and procedures ensure that the residents financial interests are safeguarded. Mayfair Lodge DS0000019462.V293942.R01.S.doc Version 5.1 Page 20 The health and safety of the residents is promoted by the homes good maintenance of its safety checks and procedures. EVIDENCE: Without exception the residents, relatives and visiting professionals interviewed during this inspection confirmed that the manager and her team were always very approachable and make every effort to sort out any problems quickly. Several commented that following the disruption last year caused by the sudden departure of the previous manager the home had settled very well under the stewardship of the acting manager and the harmony and smooth running that had previously characterised the home had returned. Staff spoken with all confirmed that they felt themselves to be well supported by their managers. Arrangements are in place for all staff to receive regular supervision and an annual appraisal but the records did not evidence that these meetings were happening consistently for all staff at least six times a year. A requirement is made. No changes have been made since the last inspection, to the homes procedures for the safe keeping of residents monies. Residents are able to deposit small amounts of money for safekeeping with the records that are kept of the detail of these monies paid in and out being countersigned and receipts kept for cross checking. The accounts that were checked at random during this inspection found that the amounts all tallied. Staff spoken with were found to have a good awareness of health and safety issues relating to the care of the residents. The maintenance of the homes safety checking procedures and records examined relating to fire and accidents and to risk assessments further evidenced this. The manager described the ways in which the homes fire safety procedures had been effective in preventing the spread of a fire that had recently occurred at night in the home, following which further fire training was undertaken by all staff and issues relating to fire safety were also discussed with the residents. Mayfair Lodge DS0000019462.V293942.R01.S.doc Version 5.1 Page 21 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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 2 x 3 Mayfair Lodge DS0000019462.V293942.R01.S.doc Version 5.1 Page 22 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 OP7 Regulation 15(2) Requirement Care plans must contain better detail as to the residents care needs and must be regularly reviewed. All water temperature must be maintained within the prescribed limits this to protect the residents from danger. It is a requirement that the flaking ceiling in the kitchen food preparation area, which could prove a safety hazard, is repaired. It is a requirement that all staff receive adequate and regular supervision. Timescale for action 31/07/06 2. OP19 13(4)(a) 31/05/06 3. OP15 23(2)(b)& (d) 31/07/06 4. OP36 18 (2) 31/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Mayfair Lodge DS0000019462.V293942.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 Mayfair Lodge DS0000019462.V293942.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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