Inspection on 19/02/07 for Mayfair Lodge

This inspection was carried out on 19th February 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 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 10/05/06

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 Key Unannounced Inspection 19th February 2007 10:00 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 DS0000019462.V332900.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. DS0000019462.V332900.R01.S.doc Version 5.2 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 Karen Sweetman (registration applied for) 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) DS0000019462.V332900.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th May 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. Information about the home is included in the Statement of Purpose and Service User Guide, these and the most recent CSCI Inspection Report and the Complaints Procedure are available in the entrance foyer along with facilities seeking the views and comments of visitors and friends. The fees, which are determined according to the level of care needs, range from £495 to £580 per week. DS0000019462.V332900.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over one day 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 on that day and also takes account of information sent periodically to the Commission by the homes Manager as well as information received from residents and relatives during the past year., Since the last inspection a new manager has commenced her duties. Her application for registration by the Commission is currently in process. The requirements made at the last inspection have been met. Good practice recommendations are made following this inspection. On the day of this inspection the atmosphere within the home was peaceful and homely. Staff were observed to be interacting closely with the residents and to be meeting their care needs in a calm manner. What the service does well: What has improved since the last inspection? Since the last inspection an Activities organiser has been appointed who will work specifically on the dementia care units providing activities and occupations planned to meet the particular needs of this group of residents. The routine works of maintenance and refurbishment of the home have continued so that on this occasion the home presented with a very well kept appearance. DS0000019462.V332900.R01.S.doc Version 5.2 Page 6 A new and improved medication storage and administration system has been successfully introduced in the home. The home now has a permanent manager in post and other posts in the management team have been filled, this giving management stability to Mayfair Lodge that has been lacking for some time. 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. DS0000019462.V332900.R01.S.doc Version 5.2 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 DS0000019462.V332900.R01.S.doc Version 5.2 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. Standard 6 is not applicable, as this home does not offer intermediate care. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Admissions to the home are not agreed until a full needs assessment has been carried out and the home is satisfied that it can meet these needs. Sufficient information is provided for prospective residents and their families to enable them to make an informed choice about admission. EVIDENCE: The manager said that she makes a home assessment visit to all new residents referred to the home and that if possible a care worker from the unit where there is a vacancy will also attend. Care is taken where prospective residents have not had the benefit of a social services assessment to ensure that all care need details and adequate medical information is available so that an accurate DS0000019462.V332900.R01.S.doc Version 5.2 Page 9 assessment can be made before they are asked to visit the home to have a trial run for the day. The paper work pertaining to recent admissions evidenced that the properly admissions policies and procedures and followed. Residents spoken with said that they were happy in the home. One said, “they (the staff) were very good when I came in they helped me settle and this made my daughter very happy too”. Other comments made to the inspector evidenced that staff do have an understanding of the big culture change that residents experience when they enter the home for the first time and that they work at minimizing the effects of this. DS0000019462.V332900.R01.S.doc Version 5.2 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. People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to the service. Good quality care plans are maintained for each resident. Residents have prompt access to medical services whenever these are needed. Residents are given encouragement to make decisions about their own lives where it is safely possible for them to do this. The home has a robust medication storage and administration system, which gives protection to the service users. EVIDENCE: The health and personal care needs of the residents are met following an assessment of their individual needs and with due reference to retaining their dignity and respect. The new format of the care plans which have been developed since the last inspection, were found to be being well maintained with very clear and more explicit detail of how particular care needs should be DS0000019462.V332900.R01.S.doc Version 5.2 Page 11 met. Care plans examined were found to give good detail to be clearly set out with reviews and risk assessments in place. Not every care plan seen contained the residents’ photograph. Better detail should be recorded concerning each doctors visit to a resident why they were called, what was determined and what further actions the doctor recommended if any. It would be advantageous and more adequately meet their current needs if a Spanish speaker could be found to talk with the resident who does not now have the ability to communicate in English. New Medication storage arrangements have been introduced since the last inspection. Staff who administer medication have been trained to do so. The managers monitoring system for the accuracy of the medication administration record sheets (MAR) could be evidenced. Spot checks made of these records evidenced that they were satisfactory. It was noted that an error in recording found on a MAR sheet had been identified by the manager and this matter had been dealt with promptly. DS0000019462.V332900.R01.S.doc Version 5.2 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. People who use this service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to the service. The diverse social and activity needs of the residents are supported via the range of activities that are provided. The residents receive a healthy diet of freshly prepared good quality food. More awareness is needed of the specific dietary requirements of some residents on the dementia care units. EVIDENCE: Since the last inspection an activities organiser with set hours especially devoted to provide for activities that meet the needs of the residents on the dementia care units has commenced duties. She is an experienced care worker as well as having undertaken special needs activity training. Her plans to gradually expand the activities programmes for this group and to target activities to more specifically meet individuals’ changing needs are gradually being developed. The manager explained that changes are being planned for the better use of the activities room. Several residents mentioned to the DS0000019462.V332900.R01.S.doc Version 5.2 Page 13 inspector about planned outings they hoped to make in the summer and also with the finer weather, the possibility of spending more time in the gardens. A nutritious and varied diet is available for all the service users. Those consulted all expressed their appreciation of the variety of tasty food available and one mentioned the very good efforts that the cooks make to provide special food to celebrate birthdays and other occasions; one told the inspector about the beautiful birthday cake that had recently been provided for her. The manager discussed with the inspector the need to ensure that the residents on the dementia care units actually consume a sufficient and balanced diet and spoke of her intention to further improve the meals for these residents for whom finger food is already constantly provided (and where staff regularly encourage the residents to eat when ever they wish not just at set meal times). One visiting relative who spoke with the inspector mentioned very positively the staff efforts to encourage her mother to eat “They have to supervise and encourage every mouthful she said otherwise my Mother would just look at the food and eat nothing.” DS0000019462.V332900.R01.S.doc Version 5.2 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 People who use this service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to the service. There is a good understanding of the policies and procedures concerning Adult protection and Whistle Blowing and how these give protection to the residents. There are clear policies and procedures concerning complaints in place, which are freely available. EVIDENCE: A comprehensive complaints policy and procedure is in place and is well publicised to both residents and to those responsible for them. A complaint received by the home since the last inspection was properly investigated. Residents questioned confirmed that they knew about the complaints procedure but most indicated that they would first speak to their key worker or the manager who they felt sure would sort things out. A number of complimentary letters have recently been received by the home. DS0000019462.V332900.R01.S.doc Version 5.2 Page 15 Staff receive training in issues and procedures around the protection of vulnerable adults. Since the last inspection there has been one incident concerning adult protection, which is currently the subject of joint agency investigation. Copies of the Hertfordshire Joint Agency Adult Protection procedures were seen to be freely available for all staff. Staff questioned had a good awareness of these procedures. The manager said that since her appointment she had attended refresher Adult Protection training in Hertfordshire so that she had a sound understanding of the locally agreed procedures, and she could evidence that she had followed these concerning the recent and on going investigation. DS0000019462.V332900.R01.S.doc Version 5.2 Page 16 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. People who use this service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to this service. The service offers a good environment that is well appointed and subject to regular maintenance that meets the needs of the residents. However, improvements could be made to the short stay room to make it more homely and storage in bathrooms should be discouraged for the benefit of the people who use the service. EVIDENCE: The home, which was purpose built within the last ten years, provides for its residents single bed sitting rooms all with en-suite facilities. The accommodation is divided into small units each with their own lounge dining room, small kitchen and bathrooms. All, except one, of the bedrooms were DS0000019462.V332900.R01.S.doc Version 5.2 Page 17 found to be well decorated and furnished in a homely and comfortable manner with a style chosen by the residents that reflected their own tastes and interests. Bedroom 61 is used for short stays and has not the same homely feel as the other bedrooms. Any required individual equipment is provided following an individual needs assessment. Many of the communal areas, lounges dining rooms and corridors have been redecorated since the last inspection and the whole home has a bright cheerful and well-decorated appearance. The home was found to be generally clean and tidy with no malodours. Evidence of routine maintenance works completed since the last inspection and on going now was seen. One kitchen unit was being refitted. Decorations had been carried out in some corridors bedrooms and dining rooms and a bid for funds has been made to refurbish the garden and enlarge the patios so that more of the residents can use these facilities in the summer months. However, it was noted that several of the bathrooms were untidy and, because they were being used to store inappropriate equipment, had an institutional feel to them. Whilst the requirement made at the last inspection concerning the redecoration of the kitchen ceiling had been completed it was noted that the cleaning (deep cleaning) of the extractor hoods and of the fly screens needs to be more frequent. DS0000019462.V332900.R01.S.doc Version 5.2 Page 18 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. People who use this service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to the service. There are sufficient numbers of trained and skilled staff at Mayfair Lodge to support the people who use the service and to ensure the smooth running of the home. EVIDENCE: On the day of this unannounced inspection, the Manager told the inspector that the management team for the home was now fully staffed and that interviews were to take place the following week to fill the remaining four care worker posts. She commented that she was pleased both with the number and the calibre of the applicants. In addition, all of the five new care staff who commenced their duties in November 2006 had NVQ level 2 qualifications and were experienced carers. They had made a very positive impact on the other staff in the home. The home continues to meet and to exceed the minimum standard of fifty percent of its carers holding NVQ qualification at level 2. DS0000019462.V332900.R01.S.doc Version 5.2 Page 19 The recruitment records examined for staff recently appointed evidenced that the correct procedures and checks were followed to ensure the protection and safety of the residents. Staff consulted during this inspection were all positive about the training and regular supervision and support that they receive from their managers. One commented on the friendly helpful attitude amongst the staff team, “this allows us to have a more relaxed approach to the residents”, she said. Several of the residents spoken with complimented the staff for their kindness and helpfulness to them. One said, “The manager comes to talk with us every day we can easily talk with her”. DS0000019462.V332900.R01.S.doc Version 5.2 Page 20 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, 37 and 38. People who use this service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to the service. People using this service are safe guarded by a sound management approach led by an experienced and trained manager whose open approach encourages residents’ independence and choices. There is a well developed system of quality assurance monitoring. EVIDENCE: The new Manager, who at the time of this inspection had been in post for just under three months, has many years experience working in the management team of residential services for older people and holds the NVQ level4 DS0000019462.V332900.R01.S.doc Version 5.2 Page 21 Registered Managers Award qualification. She told the inspector that she was being well supported by the Quantum Care Managers who were endeavouring to assist her to quickly learn the company systems and that she had also been greatly assisted by the initial hand-over period when she had worked alongside the previous manager and had thereby been able to gain a better understanding of the workings of this large and busy home. She has applied for registration with the Commission. The homes records evidenced that staff receive regular supervision and staff consulted confirmed that they are well supported by their managers. The openness of the homes management style was evidenced during this inspection. The staff said that their views are regularly sought at their regular unit and large home staff meetings and confirmed that their views and ideas are listened to. The open approach of the new manager was positively commented on. During this unannounced inspection, the inspector witnessed several occasions when staff approached her with a query or comment. During the period of this inspection it was seen that residents also often seemed to call into her office as they passed and happily made their comments and greetings. The home has clear health and safety policies and evidence of the regular management checks of these was seen. Random checks by the inspector during this inspection (of water temperatures, fire testing and accident recording) evidenced that checks are routinely carried out and well recorded. Overall the maintenance of the homes records is well done with good detail and consistency, this safe guarding the service users rights and interests. DS0000019462.V332900.R01.S.doc Version 5.2 Page 22 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 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 3 X X X X X X 2 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 3 3 3 DS0000019462.V332900.R01.S.doc Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP7 OP8 OP26 OP26 Good Practice Recommendations Individual care plans should contain better recording of the reasons for GP visits with more detail of why and what and with any recommended actions. It is recommended that a Spanish speaking care worker is found to talk with the resident who is now not able to communicate in English. The bedroom used for short stay residents should be appropriately furnished and well decorated so as to give a homely appearance. A good level of cleanliness should be continually maintained for the kitchen equipment, which should be cleaned according to need and not just to follow an annual pattern. DS0000019462.V332900.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 DS0000019462.V332900.R01.S.doc Version 5.2 Page 25 - 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!