Inspection on 21/02/06 for Mayfair Lodge

This inspection was carried out on 21st February 2006.

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

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

Other inspections for this house

Mayfair Lodge 19/02/07

Mayfair Lodge 10/05/06

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 21st February 2006 11.00 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 Mayfair Lodge DS0000019462.V283049.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.V283049.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.V283049.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The category of PD and DE applies only to the named service user and the registration will revert back once the named service user leaves the home. 26th October 2005 Date of last inspection 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; one unit provides 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. Mayfair Lodge DS0000019462.V283049.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection of this inspection year and took place over one day when two inspectors spoke with some of the residents, staff and visitors, examined some of the homes records and made a tour of the building. Information was also obtained from the pre-inspection questionnaire completed by the previous manager during 2005. The statements in this report reflect what was observed by the inspectors on that day. Not all of the standards were examined as they were all inspected during the previous inspection on 26th October 2005 to which reference may be made. Since the last inspection the previous manager appointed in July 2005 left in December 2005. Since then the Deputy Manager has been acting up as Manager until another permanent appointment is made. These frequent changes in management have had a disrupting and demoralizing effect on the staff but they were without exception very supportive of the deputy manager. The requirements made following the last inspection have been met or are in the process of being met. Five requirements are made following this inspection. What the service does well: What has improved since the last inspection? Since the last inspection various works of redecoration and refurbishment have been completed in the home so that it now has a uniform appearance of being well decorated and maintained. As the stability of the team of care staff is gradually improving more attention has been able to be given to delivering a better quality of care to the residents. This has been aided by the recent training that staff are undertaking. Mayfair Lodge DS0000019462.V283049.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.V283049.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.V283049.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): These standards, which were fully met during the last inspection, were not considered during this visit. EVIDENCE: Mayfair Lodge DS0000019462.V283049.R01.S.doc Version 5.1 Page 9 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 and 9. Detailed care plans are compiled for all residents, which were seen to be subject to regular reviews. The home has a robust medication storage and administration system, which was seen to be well maintained by trained staff. EVIDENCE: The residents spoken with all confirmed that they were well cared for. Care giving that was observed during this inspection was seen to be being delivered in a calm and kindly manner by staff who were clearly trying hard to meet the residents needs sensitively and discretely. However on the higher needs units it was observed that the standards of detailed care required for some residents e.g. the care of teeth and hair, the recording of fluid levels and the feeding of residents in an appropriate manner, were not being fully met. Requirements are made. The care plans examined were seen to contain detailed recording of how care needs should be met and since the last inspection better evidence has been recorded concerning the residents wishes for end of life and funeral arrangements. Mayfair Lodge DS0000019462.V283049.R01.S.doc Version 5.1 Page 10 There have been no major changes to the core arrangements for the storage and administration of medication since the last inspection but the manager explained that various changes that the company is to shortly introduce will bring about some major alterations in the system for Mayfair Lodge. One problem with the recording of the administration of PRN medication had necessitated her introducing a change of procedure, which had been introduced only on the day prior to this inspection and so could not be fully inspected. However the advantages and some problems with these new procedures were already being noted by the staff and discussions about adjustments needed were seen to be taking place. The records evidenced that the managers over sight as to the accuracy of the MAR, medication administration records, was regularly carried out. Mayfair Lodge DS0000019462.V283049.R01.S.doc Version 5.1 Page 11 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 and 15 A variety of activities are offered to residents throughout the home. A better variety of more appropriate activities should be offered on the higher needs care units. Visitors are always welcome in the home and several were seen to be visiting on the day of this inspection. Residents were complimentary about their food and the choices offered to them. EVIDENCE: A number of visitors to the home were spoken with during this inspection and they were complimentary about the home and the care delivered. One whose relative had only recently been admitted said “ We have no complaints here at all we were involved from the outset when Mother was in hospital; we visited several homes but liked this home the best. Staff are very approachable and we have been involved with the placement review; we appreciate being able to make ourselves and Mother a cup of tea /coffee whenever we visit. Mother is happy and has settled well, and we feel very relieved “. Mayfair Lodge DS0000019462.V283049.R01.S.doc Version 5.1 Page 12 The in- house activities programme was seen to be advertised around the home as was information concerning the activities organised by the “Friends of Mayfair Lodge”. The manager explained that the recently appointed Activity Organiser, who works for four hours during the five weekdays, has been reviewing the programmes offered to try to ensure that the individual interests and needs of the residents are being met. The residents on several units confirmed that their activity programme meets their wishes and that they were not made to feel compelled to attend if they did not wish to. Several said that they were looking forward to more outings into the countryside and to visit places of interest in the warmer weather. However it could not be evidenced that the activities offered on the higher needs units were always carried out and staff spoken with did not seem to be fully aware of the variety of special activities that might be appropriately offered for the residents on these units. A requirement is made. Residents were without exception complimentary about the food, several commented that there was often too much but said that it was always very tasty and hot dishes were served hot. Since the last inspection food preference sheets are compiled for the residents on a daily basis and this information is given to assist the cook. Mayfair Lodge DS0000019462.V283049.R01.S.doc Version 5.1 Page 13 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 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 complaints nor any incidents concerning Adult Protection since the last inspection. The homes training records evidenced that all staff have received training concerning adult protection and that refresher training is also undertaken. Mayfair Lodge DS0000019462.V283049.R01.S.doc Version 5.1 Page 14 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 25 and 26 The home meets the space and environmental requirements for these standards. It provides a pleasant comfortable and homely environment for its residents. Requirements are made concerning the areas where the safety of this environment was found to be compromised. All areas of the home visited were found to be clean and tidy and had no offensive odours. Although the home is generally well maintained and follows a routine maintenance programme a number of small items needing attention were noted during this inspection. Requirements are made. EVIDENCE: A tour of the home revealed it to be clean, well decorated, with well appointed bedrooms that were warm and had a homely appearance. Without exception all the residents said that they were happy with their rooms and confirmed that they had every facility that they needed. The request of one resident for a higher watt lighting bulb so that she could read more easily was immediately attended to by a member of the house keeping staff. Mayfair Lodge DS0000019462.V283049.R01.S.doc Version 5.1 Page 15 All the residents consulted said that they were happy with the laundry services provided by the home. Items are returned quickly well laundered and ironed and only rarely do items go missing. The manager explained that since the last inspection new arrangements to ensure that all residents clothing is clearly marked have been successful in reducing mislaid items and had improved the efficiency of the service. The requirements made during the last inspection have been partially met but new trolleys have not yet been provided. The laundry staff commented that they would be glad when they arrived, as the present equipment was difficult and heavy for them to manoeuvre. It was noted that filters in the drying machines need to be replaced. Requirements are made. The home is generally well maintained but attention needs to be given to the following maintenance items; On Byron Unit, a soap dispenser is needed by the sink in the bathroom where a replacement nail brushes is also required. To prevent risk to the residents, a cover is needed for the soap dispenser in the WC opposite to room 9 and the loose raised toilet seat needs to be tightened in the shower room opposite to room 11. Further precautions need to be taken to restrict the accessibility of the kettle in that Units kitchen/dining room which was seen during the inspection to be freely accessible for the residents many of whom do wander freely and for whom, because of their mental state, an accessible kettle could easily poise a risk. Mayfair Lodge DS0000019462.V283049.R01.S.doc Version 5.1 Page 16 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): 27,29 and 30 The home appeared to have staff on duty that tallied with the planned duty rota. All staff undertake regular training and many are experienced carers. The employment procedures and records seen for new staff were found to be in line with the homes recruitment policies and procedures. EVIDENCE: Mayfair Lodge is fortunate in that since the last inspection the staffing group has remained stable and new staff appointed have been both experienced and well qualified. The staff were observed to be working well together with good team co-operation and several told the inspector that they liked their work. All spoke very appreciatively of the support and help that they receive from the homes deputy manager, (currently acting up as manager), and they confirmed that they receive regular supervision. The home currently has several day care staff posts vacant, advertising for these is ongoing and shortfalls are made up by the employment of agency staff. However in the management team the vacant manager hours caused by the acting up of the deputy manager, now for a period exceeding two months, have not been compensated for. The acting manager said that it was encouraging that recent applicants for vacant posts had included some staff who are experienced carers and who already hold NVQ qualifications. The recruitment records and procedures evidenced that these were correctly carried out with CRB and POVA checks made as required. Mayfair Lodge DS0000019462.V283049.R01.S.doc Version 5.1 Page 17 The homes records evidenced that training plans for all staff have been made for the forthcoming year. Staff spoke appreciatively of the training opportunities afforded to them. All staff are to attend a refresher Dementia Care training course next month and two further staff have commenced the one years Dementia Care course run by Quantum Care. Training and retraining courses on Medication have also been arranged for all staff during the spring. Mayfair Lodge DS0000019462.V283049.R01.S.doc Version 5.1 Page 18 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): 31,36, 37 and 38. The home is currently being managed by the deputy manager who is an experienced carer and manager and who is well respected by the staff team. The residents interests and safety are supported by the good maintenance of the homes records and the following of procedures concerning risk and safety. One safety requirement concerning the locking of a kitchen door on one higher needs unit is made as this could put the safety of the residents at risk. See comments in standard 19. EVIDENCE: The staff were seen to be working well together as a team and although several who spoke to the inspectors mentioned the disruption and lowering of morale caused by the sudden changes in the management team over the past few months, all staff appeared to be putting the needs of the residents first and to be giving their full support to the present acting manager. Mayfair Lodge DS0000019462.V283049.R01.S.doc Version 5.1 Page 19 Staff confirmed that they are well supported by their managers and that new arrangements for staff supervision had been discussed with them and were beginning to work well. Residents spoke positively of their carers and of the managers, one said, “the manager often walks around and talks with us, she is very caring“. Mayfair Lodge DS0000019462.V283049.R01.S.doc Version 5.1 Page 20 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 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x 2 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x x x x 3 3 2 Mayfair Lodge DS0000019462.V283049.R01.S.doc Version 5.1 Page 21 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 OP12 Regulation 16(2)(m) & (n) Requirement Activities offered in the higher needs care units must be increased and should be planned to more appropriately meet the special needs of these residents. Extra precautions are needed on the Byron Unit kitchen, concerning the kettle, to ensure the safety for the residents at all times. The clothes trolleys used in the laundry needs to be refurbished or replaced. New filters are needed in the dryers. More attention to the detail of care delivered to residents on the higher needs units is required. See the text in standard 8 for full details of this requirement. Timescale for action 31/03/06 2. OP19 13(4)(c) 31/03/06 3. OP26 23(2)(c) 31/03/06 4. OP8 12(1)(a) 31/03/06 Mayfair Lodge DS0000019462.V283049.R01.S.doc Version 5.1 Page 22 5. OP25 23(2)(a)& (b) A number of small maintenance items are required on Byron Unit. See text for this standard for full details of what works are required. 31/03/06 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.V283049.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.V283049.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. 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