CARE HOMES FOR OLDER PEOPLE
Mayfield Mayfield 99 Nursteed Road Devizes Wiltshire SN10 3DU Lead Inspector
Tim Goadby Key Unannounced Inspection 18th & 22nd January 2007 09:20 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 Mayfield DS0000028227.V328037.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. Mayfield DS0000028227.V328037.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Mayfield Address Mayfield 99 Nursteed Road Devizes Wiltshire SN10 3DU 01380 723720 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) Miss Sharon Anne Cooper Tina Jayne Manterfield Care Home 20 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (2), Old age, not falling within any other of places category (17) Mayfield DS0000028227.V328037.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. No more than 20 service users to be accommodated at the home at any one time of which 2 service users may fall within the category DE(E). One named female service user, as detailed in the application dated 26th January 2006, may be accommodated at the home falling within the category DE. 11th October 2005 Date of last inspection Brief Description of the Service: Mayfield provides personal care and accommodation for up to 20 older people. The service first opened in 1983. It is privately owned and the current owner has been in place since 2000. She employs a manager to run the home. The home is a short drive from Devizes town centre. It is a detached Victorian residence with many period features, which has been extended. There is a stair lift to the first floor, which is split level, with one end of the building accessible only by another short flight of steps. Service users’ bedrooms are provided on both floors. Two could be shared rooms, but all are currently occupied as singles. Bedrooms have handbasins but no other en-suite facilities. There are bathrooms and toilets on both floors as well. One ground floor bathroom has an assisted bath. Communal space is on the ground floor, consisting of a dining room and separate lounge. The home also has large gardens surrounding three sides of the property. Part of this, at the side of the home, has a pathway and rails leading to seating. A number of off street parking spaces have been designated at the front of the building. The fees charged for care and accommodation range between £360 and £430 per week. Information about the service is available in a number of ways. The home has produced its own brochure and advertises locally. Copies of its Statement of Purpose and Service User Guide are placed in each bedroom. CSCI inspection reports are kept in the office, and can be seen on request. Mayfield DS0000028227.V328037.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This key inspection was completed in January 2007. It included a review of regulatory contact since the previous main inspection. A random inspection took place in April 2006, following up on requirements of the October 2005 inspection, and responding to concerns raised about practices in the home. The random inspection found that both requirements had been met, and that no Regulations were being breached. Later in 2006 a complaint about practice at Mayfield was made anonymously to the CSCI. This was referred to the home for them to investigate. The service produced a thorough response and the complaints were not upheld. The home supplied some written information as part of the pre-inspection process. Surveys were also distributed for service users. Eleven of these were completed and returned. Two visits then took place to the home. The first of these was unannounced. The second was arranged to conclude the inspection and give feedback. During this fieldwork the inspection process included sampling of records, with case tracking of individual service users; observation of practice; discussion with service users, staff and management; sampling activities; sampling a meal; and a tour of the premises. What the service does well:
Mayfield has a pleasant, homely atmosphere. Service users appear settled and comfortable in their surroundings. Routines of the day are flexible around the needs of individuals. Service users who completed surveys or spoke to the inspector all had positive impressions of the home. They felt that they had received enough information about the service to make a decision about moving in. They were generally happy with the arrangements for activities, meals and support with their care needs. They felt that staff were responsive, and knew how to raise concerns if they had any. Comments included “I’m very happy here” and “Everybody is always very kind.” Friendly interactions amongst staff and service users were observed during the inspection visits. Staff were seen to be available and attentive as required, but to do this unobtrusively. One staff member commented that they see the home as being like an extended family, and spoke about the importance of ensuring that service users feel at home. One relative also commented on the calm and caring environment.
Mayfield DS0000028227.V328037.R01.S.doc Version 5.2 Page 6 Staff also commented positively about working at the home. They confirmed that they receive relevant training and instruction, to help them support service users effectively. They also have confidence in senior staff, so that they feel confident to raise any issues or concerns they might have. They have a good understanding of their duties and responsibilities, and are made aware of all relevant information they need to care for service users safely. Service users can be confident that the home will meet their needs. Systems are being reviewed to make a clear link from initial assessment on to care planning. This helps to define the key need and risk areas for each individual, and to put appropriate guidelines in place. Mayfield liaises closely with other relevant professionals to help deliver the care that each service user needs. The home also acts when necessary to put additional support in place. Activities are provided regularly, in line with the interests and preferences of service users. These include group sessions, and spending one-to-one time with some individuals. A staff member works three days per week leading on this area. Other staff also help wherever possible. A session observed during this inspection was very successful in getting ten service users to participate in and enjoy exercises likely to help their general health and mobility. Service users can be confident that the home takes appropriate action to uphold their safety and welfare if concerns arise about practice. The service has carried out detailed investigation of complaints referred to it, reaching suitable conclusions. It has also promptly reported any issues needing to be addressed under multi-agency adult protection procedures. When the conduct and performance of individual employees has been found wanting, disciplinary procedures have been applied as necessary. What has improved since the last inspection? What they could do better: Mayfield DS0000028227.V328037.R01.S.doc Version 5.2 Page 7 Service users would benefit from a renewed focus on effective practice in all aspects of the management of medication. The home has taken a number of steps to address problems which had occurred, and most of these have proved effective. But several deficits were found at this inspection in a sample of records relating to administration of medication. This means it was not always clear whether or not service users had received prescribed medication at the correct time; and, if not, what the reasons for this were. Such confusion may place service users at risk. The ground floor laundry and a first floor sluice room need attention to ensure they are kept hygienically clean, to minimise any risk of infection. In the laundry, the area around appliances, and particularly behind them, is in need of cleaning. In the sluice room, part of the wall needs redecoration where there is flaking paintwork, to make the surface impermeable. A suitable training plan needs to be documented for the home, to show how future planning for staff development will continue to meet the needs of the service and its users. The service needs to implement a suitable quality assurance system. This must result in an annual quality report and service development plan, based on a range of findings, including the views of service users and others. This will promote continuous improvement. Consideration should also be given to implementing the system in a way that will be most effective for this home, focusing on priority areas at the most regular intervals. Clearer evidence should be kept when staff are instructed in the use of any equipment in the home, such as the stair lift. This applies also to staff working only occasional shifts at Mayfield, such as agency carers. Effective systems for recorded instruction of staff will help to show that the home is taking all necessary steps to minimise any risks to service users. 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. Mayfield DS0000028227.V328037.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 Mayfield DS0000028227.V328037.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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have their needs assessed before they move into the home. Standard 6 is not applicable to this service. EVIDENCE: Mayfield provides short term care. This can be a means of prospective service users getting to know the home over a period of time, before reaching a decision about a long term move. Mayfield DS0000028227.V328037.R01.S.doc Version 5.2 Page 10 The service is clear about the range of needs it can support, and acts appropriately if it can no longer provide for an individual service user. This situation had arisen with one person over the months before this key inspection. As the individual became increasingly difficult to manage, Mayfield liaised with other relevant professionals to provide additional support for a time, whilst another placement was found. Service user records which were checked at this inspection all showed that suitable assessment and life history information had been obtained before the person was admitted. Mayfield DS0000028227.V328037.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 good. This judgement has been made using available evidence including a visit to this service. Service users have their abilities, needs and goals reflected in their individual plans. Service users have their health care needs met effectively. Service users are placed at risk by some deficits in the management of medication in the home. Service users are treated with respect and have their privacy upheld. EVIDENCE: Mayfield DS0000028227.V328037.R01.S.doc Version 5.2 Page 12 The service is reviewing its care plans. The new format links initial assessment to support guidance for each area identified as relevant to a service user. Plans were at various stages of completion at the time of this inspection, so examples were seen of information in both new and old formats. Three sets of service user records were checked in detail. All had an appropriate range of information about assessed needs and risks, and the steps being taken in response. Topics covered included physical and mental health needs, activities and social contact, and any issues of concern around behaviour. There was clear guidance about potentially sensitive subjects. The home uses a number of assessment forms to cover various health needs. These include pressure areas, diet and nutrition, and mobility. If an individual is identified as being at risk, a suitable care plan is then put in place. Other relevant professionals, such as district nurses, are also involved where necessary. For instance, they assess service users who may need particular pieces of equipment, and attend to change dressings. No service users were managing their own medication at the time of this inspection. Staff were responsible for all medicines at the home. Issues of concern relating to the management of medication arose at Mayfield in February 2006. The home took appropriate action in reporting these to other agencies, and ensuring that a full investigation took place. Systems in the home have also been changed as a result, with more regular checking of practice. One senior carer oversees this area. Administration of medication to service users was observed over a lunchtime round on one of these inspection visits, and was carried out appropriately. Arrangements for the storage of medication were also seen to be suitable. All care staff receive training in medication. This covers both in house instruction and a distance learning package. Each staff member is observed and assessed for their competency before they finally go on to administer medication independently. Several deficits were found in medication records. There were examples where a prescribed dose had not been signed for on the chart, nor had a code been used to show any reason for the service user not taking it. In another case, a dose for the day after the chart was being checked had already been signed for as taken by the service user. These examples were raised with the manager during the inspection. She indicated that she would take further steps to reinforce with all staff the importance of effective recording and checking. Observations during the inspection showed that all service users were treated respectfully. Staff interacted appropriately with them. Any personal care was given in private. The permission of service users was obtained before inviting
Mayfield DS0000028227.V328037.R01.S.doc Version 5.2 Page 13 inspection of their rooms. Feedback from service users and one relative also confirmed that residents are always well treated and have their dignity upheld. Mayfield DS0000028227.V328037.R01.S.doc Version 5.2 Page 14 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 provided with opportunities to undertake activities in line with their preferences and abilities. Service users are able to maintain contact with family and friends. Daily lives for service users have an appropriate balance between necessary routines, and individual choice. Service users are offered healthy, nutritious and enjoyable meals, in line with individual needs and preferences. EVIDENCE: Mayfield DS0000028227.V328037.R01.S.doc Version 5.2 Page 15 Mayfield provides a regular programme of activities spanning all seven days of the week. One member of staff is employed part-time to lead on this area. Other staff help to offer sessions at other times. The programme is displayed on a noticeboard. It includes games, quizzes, reminiscence, gardening, knitting, films and radio programmes. An activity session was observed taking place in the lounge on the afternoon of the second inspection visit. This included ten service users taking part in a gentle exercise session to music, and a series of ball games which also encouraged movement and co-ordination. The session was conducted to ensure that all service users took part, and there were obvious signs of concentration and enjoyment. Special events are arranged occasionally, such as live music at the home. Birthday parties are held for service users. Religious services also take place at Mayfield. A carol service was held at the home in the run up to Christmas. Records are kept of all the activity sessions, including a note of who takes part. Care is taken to tailor approaches in ways which give all service users a chance to participate. This includes one-to-one input to some people, in addition to the group sessions. Activities usually take place in communal areas, but service users will also be visited in their own rooms if they prefer. Staff can also support service users outside the home if necessary. For instance, they may accompany them to appointments. In another recent example, one service user was helped to go and visit a relative in hospital, for which they were very grateful. Service users are able to maintain contact with their families and friends. Staff will provide help with letter writing or making phone calls, if necessary. One relative who was visiting during the inspection confirmed that they are able to visit at any time, and that they are kept informed of any relevant developments. They also felt able to raise any issues or questions with any of the staff, including the manager. The relative was aware of who the allocated staff keyworker was for their own family member. Daily routines in the home are kept flexible. Service users can choose where they wish to spend their time. Some like to remain in their own rooms, whilst others make use of communal areas. Menus run over a four week cycle. Choice is available at all meals. There are always two main options, with other alternatives possible on request. Menus are shown in the dining room. During the morning staff also go round to check with each service user what they would like to have for their midday meal. Mayfield DS0000028227.V328037.R01.S.doc Version 5.2 Page 16 Mayfield employs its own cooks, who work between 9 a.m. and 2.30 p.m. to cover the main hot meal. Care staff serve other meals, and regular drinks and snacks are on offer throughout the day. All food is prepared on site. The home is able to cater for special dietary needs, although no service users had particular requirements at the time of this inspection. A note is kept of the known likes and dislikes of each service user. Advice is also obtained from a dietician whenever necessary. The inspector joined service users in the dining room for the midday meal on the first of these inspection visits. Most service users choose to dine here, although meals can also be served in individual rooms if people prefer. Food was of good quality and served at appropriate temperatures. Service users’ preferences regarding what to eat, and portion sizes, were respected. Each person was given time to eat their meal at their own pace. On the first day of the inspection visit, some service users were also observed finishing their breakfasts, up until around 10 a.m. Again, it was clear that they were able to do so at their own pace, and to enjoy a start to the day in line with their own wishes. Mayfield DS0000028227.V328037.R01.S.doc Version 5.2 Page 17 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. Service users are safeguarded by the home’s policies and procedures for complaints and protection. EVIDENCE: There are clear procedures in place for complaints and protection. Copies of complaints information are placed in each service users’ own room. Relatives have been given copies of the Wiltshire ‘No Secrets’ leaflet, with information about how to raise adult protection concerns. The home also has a suggestions box which any visitor could place comments into. An anonymous complaint about a number of aspects of practice at Mayfield was received by the CSCI in June 2006. This was referred to the home for their investigation and response. A detailed process was carried out, and all of the concerns raised were concluded to be unfounded. When issues of concern have arisen about the practice of any staff members, the service has acted appropriately in referring these to the multi-agency adult protection process. This has enabled issues to be addressed effectively. When
Mayfield DS0000028227.V328037.R01.S.doc Version 5.2 Page 18 necessary the home has applied its disciplinary procedures, including the dismissal of one employee. Staff have received training about adult protection and the prevention of abuse. They also state that they feel confident in raising any concerns they may have. There is a whistle blowing policy in place. If service users present possible risks to themselves and others, due to aspects of their behaviour, this is recognised and clearly addressed in their individual plans. There is clear guidance for staff about the issues, and how to minimise risk. Other professionals, such as those specialising in mental health, are involved in developing safe systems of support. Mayfield DS0000028227.V328037.R01.S.doc Version 5.2 Page 19 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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a comfortable environment, suitable to their needs. Service users are placed at risk by factors affecting the cleanliness and hygiene of some parts of the building, which may produce increased infection hazards. EVIDENCE: Mayfield stands in its own grounds, set back from one of the main routes into Devizes. The property is towards the outskirts of the town, but within a residential area, and just a short drive from all local amenities.
Mayfield DS0000028227.V328037.R01.S.doc Version 5.2 Page 20 The original part of the home dates from Victorian times, and retains some attractive period features. There is a more modern two storey extension at the rear. Service user accommodation is provided on both floors. The property presents as generally well maintained. There are some areas of décor in need of attention, as would be expected from a property of this size which is used for this purpose. There is an ongoing programme to address these. The home employs its own handyman, who can attend to many of the jobs which need doing. There is a stairlift fitted on one of the home’s staircases. However, the first floor is on two levels, with rooms at the front of the house only accessible via another short flight of steps. These rooms are therefore only suitable for more mobile service users. All current service users have single bedrooms. Two rooms could be shared, but this would only be done if people chose. Some bedrooms were seen during this inspection, by the invitation of their residents. Each was attractively decorated and furnished to reflect the tastes of its occupant. Service users can bring in their personal items to help them feel more at home. Bedrooms have handbasins but no other en-suite facilities. Bathrooms and toilets are provided on both floors, within easy reach of bedrooms and communal areas. One ground floor bathroom has an assisted bath, and is therefore the most regularly used. A ground floor toilet has a bidet which is never used, and which is positioned awkwardly in the room, restricting easy access to the toilet. It would be sensible to remove this to make the room better fit the needs of service users. The second floor of the building is not used as part of service user accommodation. It was previously used as a room by staff sleeping in overnight. The home has now changed to having waking night staff, so this area was being converted for use as a larger staff office. Communal space is on the ground floor. There is a dining room and a separate lounge. There are connecting doors between these two areas, which can be opened or closed depending on how the space is being used at different times. The home is also planning to add a conservatory at the rear of the building. This will create additional communal space, and will be particularly useful in creating another area where activities could be offered. Concern had been raised previously about heating levels in some parts of the home. However, these were found to be comfortable throughout during this key inspection, which took place during a spell of severe winter weather. Mayfield DS0000028227.V328037.R01.S.doc Version 5.2 Page 21 Cleanliness and hygiene were generally seen to be of a good standard. The kitchen and food storage areas were all appropriately maintained. Logs were being kept of fridge and freezer temperatures, and of the temperature at which hot food was served. The home’s laundry room is on the ground floor. All laundry is done on site by the care staff. There are appropriate appliances and systems in place to minimise any risk of infection. However, the laundry room was in need of cleaning around the appliances, and especially behind them. Furthermore, a sluice room on the first floor has a large area of peeling paintwork, due to the tumble drier having previously been sited there. This wall surface needs to be made good to ensure that it can be kept hygienically clean. Mayfield DS0000028227.V328037.R01.S.doc Version 5.2 Page 22 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, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by suitable numbers of appropriately trained staff. But more evidence is needed of how the service will ensure that service users continue to benefit from the support of staff who have gained appropriate knowledge and skills. Service users are protected by effective recruitment practices. EVIDENCE: Mayfield has gone through a period of staff turnover, but this now appears to be stabilising. There was only one vacant post at the time of this inspection. The manager is supported by three senior carers. They help to oversee various aspects of the daily running of the home. The home is also encouraging all staff to take on a range of roles and responsibilities. Mayfield DS0000028227.V328037.R01.S.doc Version 5.2 Page 23 There are always at least two care staff on duty for all daytime shifts, one of whom is a senior. In addition to this the manager is usually present on all weekdays. A cook works in the kitchen in the mornings. The activities coordinator is on duty three days each week. A cleaner was also about to start work shortly after this inspection. Night cover is now provided by two waking staff. Service users commented that they find the staff very caring and helpful. One said that you only have to ask and they will help with anything. The home recently took the decision to introduce staff uniforms, with different colours depending on the different roles people have. Service users were consulted about the decision, and were in favour of the step. They also helped to choose the colours. Staff confirmed that they are working towards National Vocational Qualifications (NVQs) in care. Some have already achieved the award at Level 2. Although the service was below the 50 target for care staff with this qualification at the time of the inspection, due to turnover, there was a clear plan in place to remedy this. Staff also spoke about the other training they have undertaken. This has included medication, abuse, and health and safety. The home has purchased distance learning packages on some of these. There are also weekly in house sessions on topics like the introduction of new care plans. Staff also confirmed that they get training on specific techniques relevant to their work with service users, such as pressure area care and supporting people with continence. Training in supporting people with dementia was due to take place shortly. Records are kept of the training which staff have had, from induction onwards. The service also needs to produce a training plan, which will show what is needed for the year ahead, and how this will be provided. Three sets of staff records were checked, relating to employees who had been recruited within the previous six months. All showed that the required recruitment checks had been carried out before new staff commenced working with vulnerable people. New starters go through a documented induction process. They are given copies of various relevant information, including the national codes of conduct for staff working in social care. Mayfield DS0000028227.V328037.R01.S.doc Version 5.2 Page 24 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 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager is suitably qualified, competent and experienced, so that service users benefit from a well run home. Quality assurance measures need to be implemented, to ensure the home is conducted and developed in line with service users’ needs and preferences. Service users have their financial interests safeguarded. Service users are protected by effective systems for upholding their health and safety. Mayfield DS0000028227.V328037.R01.S.doc Version 5.2 Page 25 EVIDENCE: The registered manager for Mayfield is Mrs Tina Manterfield. She has been in post for around 18 months and her registration was approved by the CSCI since the home’s last main inspection. Mrs Manterfield is working towards the necessary management qualifications she must obtain, and expects to complete these by the summer of 2007. The owner is Miss Sharon Cooper, who is regularly present at the home. Staff expressed confidence in both the owner and the manager, and said that they always felt able to raise any issues or concerns with them. They were confident that suitable action would be taken in response. The service has not yet implemented a quality assurance system. This is becoming an increasingly important issue, as under recent changes in care homes regulation, it will now be a statutory requirement for each home to provide an annual quality assurance assessment. Mayfield has purchased a quality assurance tool from a company which provides such materials to the care sector. These systems are usually set up to run over an annual cycle. It was discussed during the inspection that it may be more suitable for this home, given its size, to phase the overall system over a longer period. Key topics can still be audited more regularly, based on the home’s own assessment of which areas are most relevant. As well as auditing its own performance, it will be important for the service’s quality assurance to include getting the views of others, including service users. Residents’ meetings take place every six weeks, and these will form one useful source of feedback. The home has also recently implemented a suggestions box, which should generate comments from other visitors. Suitable systems are in place for the management of any service user money which the home holds in safekeeping. This is stored securely, and only senior staff have access to it. Records are kept of all transactions, with two signatures each time. Receipts are also retained. The home does not hold any appointeeships for service users. Some service users still retain a degree of control over their own finances. An incident in December 2006 involved a service user sustaining injuries after falling whilst being assisted to use the home’s stairlift. This event was reported to all appropriate authorities. During the inspection, the possible training implications around the use of equipment were discussed. The home provides instruction for all staff working at the home, including any agency
Mayfield DS0000028227.V328037.R01.S.doc Version 5.2 Page 26 employees who help to cover certain shifts. However, there could be clearer evidence kept of this. A programme for the covering of all hot surfaces has been implemented since the last main inspection, and much of this work is now complete. The rest is being addressed in order of priority, based on documented risk assessments. Risk assessments are also in place for a range of other health and safety topics, including infection control and food handling. Fire safety information is all up to date. The property’s fire risk assessment was reviewed in May and June 2006. Mayfield DS0000028227.V328037.R01.S.doc Version 5.2 Page 27 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 3 8 3 9 2 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 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Mayfield DS0000028227.V328037.R01.S.doc Version 5.2 Page 28 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 OP9 Regulation 13-2 17-1a Sch3-3i 16-2j 23-2b,d Requirement From now on, records relating to the administration of medication for service users must be maintained fully and accurately. Floor and wall surfaces in laundry and sluice rooms must be kept clean and in good condition to enable effective hygiene to be maintained. Timescale for action 22/01/07 2 OP26 31/03/07 3 OP30 17-2 Sch4-6g 18-1c There must be a staff training 31/03/07 and development plan to ensure that all staff receive training to meet the aims of the home and the needs of service users. This must include a minimum of three paid days training per year for all staff. The persons registered must devise and implement an effective quality assurance system, which results in an annual service development plan. COMMENT: The timescale relates to evidence of an initial 31/03/07 4 OP33 24 Mayfield DS0000028227.V328037.R01.S.doc Version 5.2 Page 29 development plan, which could include further implementation of the quality assurance system as one of its targets. 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 Refer to Standard OP19 OP33 Good Practice Recommendations The unused bidet in the ground floor toilet should be removed, to improve access for service users. Implementation of a quality assurance system should be phased over a cycle that is suited to the scale of this service. The home should ensure that there is clear evidence that all staff working at Mayfield receive full instructions in the use of all equipment. This includes any agency workers who help to maintain cover. 3 OP38 Mayfield DS0000028227.V328037.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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
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