Inspection on 07/09/06 for Mayfield

This inspection was carried out on 7th September 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mayfield 05/08/08

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Mayfield 7 Horton Road Gloucester Glos GL1 3PX Lead Inspector Mr Richard Leech Key Unannounced Inspection 12:30 & 7th & 13th September 2006 10:00 Mayfield DS0000067085.V310956.R01.S.doc Version 5.2 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 DS0000067085.V310956.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 Adults 18-65. 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 DS0000067085.V310956.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mayfield Address 7 Horton Road Gloucester Glos GL1 3PX 01452 530004 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.brandontrust.org The Brandon Trust To be appointed Care Home 9 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (2), Sensory impairment (1) of places Mayfield DS0000067085.V310956.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 07/02/06 Brief Description of the Service: Mayfield is a large detached house, which is registered to provide care and accommodation for up to nine adults with learning disabilities. The home is close to the centre of Gloucester. Service users are supported to access local facilities such as the Post Office, shops and the library. The home has transport appropriate for service users needs and is close to bus routes and the railway station. There are two bedrooms on the ground floor as well as a bathroom with an adapted bath. The remaining bedrooms are on the first floor, along with additional bathroom and toilet facilities. The home has a spacious lounge, dining room and kitchen. There is also a large garden. The Brandon Trust runs the home. According to information from the inspection, fees are in the order of £1100 per week. Prospective service users are given information about the home including copies of the Statement of Purpose and Service Users Guide. The latter includes some information about what is covered by fees. Mayfield DS0000067085.V310956.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection began around lunchtime on a Thursday, lasting until early evening. A second visit was made on the following Wednesday from 10.00 to early afternoon. The manager was present throughout the inspection. Most of the service users were met, along with many of the staff team. All communal areas and some bedrooms were looked at. Records were checked including examples of care plans, risk assessments, medication charts, healthcare documents and staffing files. The manager reported that people living in the home appeared happiest with the term ‘householder’. This is therefore used throughout the report. What the service does well: Good systems are in place for care planning and risk management. There is a strong commitment to making information accessible and meaningful to people living in the home. Excellent work takes place around communication and householders are supported and empowered to make meaningful choices. Householders are treated with respect and as individuals. Support is provided for people to access activities in the home and community which reflect their needs and interests. There is also support for people to maintain and develop contact with friends and family. People living in the home have a varied, healthy diet and have control over their own diet. Householders’ personal and healthcare needs are met in a way which is sensitive to their preferences. Total communication principles are put into practice to help establish householders’ choices and wishes and to convey important information, such as about treatment options. The arrangements for handling medication in the home are good. There are safeguards in place to help protect people living in the home from harm and abuse. Householders are valued and listened to and efforts made to help them express their thoughts and views about life at Mayfield. Staff are skilled and caring, and receive training appropriate to meeting householders’ needs. Systems are in place to make the home a safe place to live and work. The home is well run. Mayfield DS0000067085.V310956.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Mayfield DS0000067085.V310956.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mayfield DS0000067085.V310956.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lack of an up to date policy framework and of an assessment tool may compromise a fundamentally sound approach to referrals and admissions. EVIDENCE: The manager described the steps that she would take if there were a vacancy in the home. This included gathering assessment and background material, visiting the person in their home and offering visits to Mayfield. In the last report reference was made to the lack of a formal assessment tool. The manager said that this was pending from Brandon Trust. The admissions policy on file dates from 2000 and an update is expected in the near future. The manager described the support being offered to some people around looking at different accommodation options. This included involving care managers and requesting an up to date assessment, using photographs, offering visits and observing the reactions of the person in different environments. Mayfield DS0000067085.V310956.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Care plans clearly reflect householders’ needs, preferences and choices. Total communication principles are used to involve people in the process, helping householders to know what support they can expect and facilitating real decision-making. Good systems are in place for identifying and managing risk, promoting householders’ safety. EVIDENCE: Care plans for two people were looked at. These covered key areas such as communication, personal care, relationships, activities and eating & drinking. They contained clear guidance and were written in a person-centred way with reference to how the individual expressed their choices and preferences. Care plans and other related documents were seen to be regularly reviewed, including others involved in the person’s care. Mayfield DS0000067085.V310956.R01.S.doc Version 5.2 Page 10 Many care plans were seen to include photographs and symbols to help the householder to be involved in the process and to understand what support they could expect. Daily records included reference to householders being involved in care planning. Staff spoken with had a good understanding of the care planning process and of people’s individual care plans. Some care plans were beginning to need retyping since handwritten entries were affecting the clarity. Throughout the inspection householders were seen being offered choices and these were respected as far as possible. Staff spoken with had a clear understanding of the importance of helping people to make choices, recognising how they communicated these and then following this through with appropriate support. There are coordinators in the home who take the lead for the total communication strategy. Examples were seen of excellent personcentred work involving householders and facilitating communication and decision-making. Pioneering work was taking place around areas such as healthcare and wishes regarding dying and death. Risk assessments viewed covered appropriate areas and provided clear guidance about how the risks were managed/minimised. There was evidence of regular review. As with care plans, some documents would benefit from retyping where the handwritten additions were beginning to make the assessments harder to read and understand. Some simple risk-management measures are in place, such as householders carrying information cards on them when on holiday in case they become lost. Standard 10 was not fully considered. However, there was a discussion about the documents stored in the ground floor office. Sensitive information such as care plans and daily records is accessible on shelves rather than being locked away within the room. In addition, the door between the office and kitchen is often open as well as, at times, the back door leading from the office to the garden. The manager explained that householders liked to walk through the room and this was observed during the inspection. However, it was agreed that the security of information requires review, particularly given that the home has been broken into. Mayfield DS0000067085.V310956.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the 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, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Householders are support to access activities which reflect their needs and interests on an individual basis, promoting their quality of life. Appropriate support is offered for people to maintain and develop contact with important people in their lives. Householders are support to exercise their rights and to take control of their lives, helping them to feel empowered, respected and valued. A varied and healthy diet is offered which responds to people’s dietary needs and preferences, promoting their wellbeing. EVIDENCE: Householders had care plans about their needs and preferences around activities. Daily records and discussion with staff provided evidence that people were treated as individuals and supported to take part in a range of activities Mayfield DS0000067085.V310956.R01.S.doc Version 5.2 Page 12 in the home and community. These included walks and drives, helping in the home, music and art sessions, relaxing with CDs, TV and books, attending parties/other social events and going shopping. Some people also chose to attend day centres. It was suggested that daily records could include more information about activities, such as the duration and destination of a walk/drive and whether the person appeared to enjoy the experience. Care plans and other documents included reference to family relationships and contact. Daily records and discussion with staff provided evidence of how this contact was facilitated as far as possible. Householders were seen accessing different areas of the home freely, and using facilities in the kitchen when they chose to. Staff provided discreet supervision and support as appropriate. People were also seen helping out in the home. The manager and staff described it as the householders’ home, and observation throughout the inspection provided evidence that people living at Mayfield do have the sense that it is their home. People’s preferences and choices around routines were seen to be respected, such as around times for getting up, choices about drinks and snacks and also where people chose to have refreshments. Care plans included important points such as people’s preferred form of address. They also placed a strong emphasis on acknowledging people’s strengths and promoting independence. Staff spoken with gave examples of how they encouraged people to do things for themselves as much as possible. Householders have individual food cupboards. They are supported to shop for the things they like and to access food when they wish. Menus provided evidence of variety and balance in people’s diets. The manager and staff confirmed that, whilst a lunchtime meal is offered, people can elect to have something different if they prefer. This was observed during the inspection. People are also offered choice about what they would like for breakfast and tea. Care plans around eating and drinking were seen, along with weight charts where appropriate. Records are also kept of the food that people choose to eat day by day. People were seen to eat at different times and in various locations of their choice. Mealtimes appeared relaxed and pleasant, with householders seeming to enjoy their food. Fresh fruit was available in the kitchen. Fresh vegetables were seen being prepared as part of a main meal. Mayfield DS0000067085.V310956.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care support is offered in a way which responds to people’s needs and preferences, promoting people’s dignity. Creative and innovative work is taking place in health action planning to make information meaningful and to support people to make choices. Robust systems are in place for the handling of medication, enhancing people’s safety and wellbeing. EVIDENCE: Care plans included clear guidance about people’s needs and preferences around personal care. Staff spoken with described how they offered this support in an enabling and sensitive way. They demonstrated awareness of the importance of maintaining people’s privacy and dignity. Throughout the visit staff were observed offering appropriate support to people in a discreet manner. Records along with discussion with the manager and staff provided evidence of the team working very closely with a variety of external healthcare Mayfield DS0000067085.V310956.R01.S.doc Version 5.2 Page 14 professionals. This included consultation over difficult issues related to ethics and care delivery, as well as to best-interests work. Healthcare records were seen, along with health action plans. The team is very advanced with health action planning and some staff have become facilitators having undertaken training. As with other aspects of care planning, total communication principles were seen to be adopted in healthcare support. Excellent work had taken place on involving householders in decisions about their health and in making information accessible and meaningful. The team intend to make accessible healthcare plans for all householders, putting copies in their rooms of they wish. There was a discussion with the manager about whether it might be possible to explore different options for promoting the oral and visual health of some people who found it difficult to attend routine healthcare appointments. This could be done in consultation with relevant healthcare professionals. Records indicated that it had not been possible to check these aspects of some people’s care for several years. Medication storage and records appeared to be in order. Some changes have been made to local procedures in response to observations by the pharmacist inspector during a specialist inspection. Staff carry out regular audits of medication to check stock and to establish whether any errors have been made. A robust system is in place for following up on any issues identified. One person is being supported to take more control of their medication, with total communication techniques being used to facilitate this. It was recommended that where there is a handwritten entry on the medication administration record a second person should sign this having verified that it is correct. The Trust’s medication policy dated from 2000 and was listed as pending an update. The policy was out of date, for example referring to 1984 legislation about care homes. This should be reviewed, updated and distributed as soon as possible. Mayfield DS0000067085.V310956.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good systems are in place for supporting people to express dissatisfaction, helping householders to feel listened to. Appropriate safeguards are in place which help protect householders from the risk of harm and abuse. EVIDENCE: The Trust has a complaints procedure. Whilst efforts have been made to improve the accessibility of the document, the manager understood that further changes were planned. In the meantime aspects of an older procedure are still being used as householders are more familiar with the format and find it easier to understand. Records were seen of a complaint made a householder. This provided evidence that the person had been appropriately supported throughout and that the issue had been thoroughly investigated. Staff spoken with demonstrated knowledge of how different individuals expressed dissatisfaction, and described how they responded to this. The Trust has policies covering adult protection and whistle blowing. The latter dated from 2000 and was marked as due for review. Staff spoken with stated that they would raise any concerns that they had and were generally aware of the whistle blowing policy (though some were not). They expressed confidence Mayfield DS0000067085.V310956.R01.S.doc Version 5.2 Page 16 in systems for investigating and dealing with concerns. The manager includes whistle-blowing procedures in the induction process. Various other information was held on file including copies of local adult protection procedures and documents about the PoVA scheme. Selected records of householders’ finances appeared to be in order. Systems are in place for regular checks on receipts and balances to help safeguard people’s money. Mayfield DS0000067085.V310956.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A homely, clean and pleasant environment is provided, although there is scope for making Mayfield more comfortable and attractive. EVIDENCE: All communal areas were checked, along with some people’s rooms. Mayfield was seen to be comfortable, pleasant and homely, with people’s rooms being personalised. Some staff commented on the age of the building making it hard to keep clean and also resulting in areas of the home being quite dark. Some parts of the home would also benefit from redecoration. Good use was made of total communication principles in areas such as the kitchen, for example, through the use of photographs. The following points were noted as requiring particular attention: • Three bulbs were not working in the main light in the lounge. The manager said that bulbs kept blowing in this light, though the wiring had been checked. This may need investigating again. In the meantime bulbs need to be replaced when they blow. DS0000067085.V310956.R01.S.doc Version 5.2 Page 18 Mayfield • • • The first aid kit in the bathroom contained what appeared to be out of date and ripped sterile dressings. The box was also kept on a radiator. A dent/gash in the wall on the stairway requires repairing. As described in the previous report a self-closing mechanism linked to the fire alarms is required for the ground floor bathroom. This had been fitted but not yet connected. In addition the following points are made for consideration: • • The swivel chair in the main office should be replaced since it is very tatty. Some household chemicals were accessible in the ground floor bathroom since the lock had broken on a cupboard. These were removed and by the time of the second visit the lock had been repaired. Although prompt action was taken, this suggests that there may be scope for improvement in routine environment checks. One toilet has an internal bolt with no override mechanism. It was explained that whilst this presented some risks, one person in particular liked to use this room for that reason. It was suggested that a risk assessment be done taking into account householders’ views. The upstairs bathrooms were particularly in need of redecoration since the décor was tired and worn. A table and some chairs in the dining room were quite battered and worn and would benefit from repair/revarnishing or being replaced. The boiler in the kitchen is unsightly and should be replaced. The home was broken into last summer. Some security measures have been implemented but more work has been recommended. This includes fitting an intercom, raising the height of some fencing and improving lighting at the back of the home. • • • • • The manager reported that a representative from the new housing association would soon be visiting the home to assess work that needed undertaking. Since the last inspection work has been completed on the adapted bath such that, after a long delay, it is now fully functioning. The home has a pleasant and spacious garden with some outdoor furniture. Fixed and portable aids and adaptations are provided for people according to their individual needs. The manager said that usually the home employs a cleaner but has been without one for some time. Staff have done extra cleaning as a result. However, a new cleaner had been appointed and was expected to start in the home in the near future. The manager described infection control measures operating in the home as well as the training/input staff receive. Mayfield DS0000067085.V310956.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are skilled and receive appropriate training, promoting the quality and consistency of care. Recruitment and selection procedures are generally robust, helping to protect householders. EVIDENCE: Discussion with staff and general observation provided evidence that staff have a very good understanding of householders’ needs and of how each person communicates. A strong value base of respecting each person as an individual was also evident. Staff described good communication within the team. The communication book was seen to be well used. Good information was available in care planning or general files about areas such as total communication and particular conditions experienced by people living in the home. Staff were observed supporting householders in a warm and friendly manner. Householders in turn appeared relaxed and comfortable with staff and seemed able to express their thoughts and wishes. Mayfield DS0000067085.V310956.R01.S.doc Version 5.2 Page 20 The manager described which staff had undertaken LDAF training and NVQs in care. She reported that more staff would shortly be undertaking NVQ training, which would bring the home over the 50 qualified target cited in the National Minimum Standards. As noted, innovative and exciting work is taking place in the home around total communication in order to make information more accessible and to further involve householders in planning and making decisions in a meaningful way. Two staffing files were checked. These contained required information. However, the following points were noted: • • A reference had not been obtained from one person’s most recent social care employer (although it was not clear from the application form whether this job had been of three month’s duration or more). In one case a referee stated on the application form did not appear to tally with the sources of references on file. There was no corresponding explanation on file as to why a reference might have been obtained from a different source. A requirement had been made in the last report about completing checks on staff files to ensure all items required under the Care Homes Regulations are held. The manager reported that this audit was nearly complete but that some items remained outstanding. The manager described the recruitment and selection process. This includes a visit to the service giving householders a chance to meet the person and the candidate an opportunity to get a clearer idea of the role. The manager also described attempts to include householders more directly in the recruitment process. Training was discussed. The manager reported that she had booked a range of mandatory and specialist training for staff based on an audit of individual and group training needs. The whole team was booked on training about adult protection and fire safety in Autumn 2006. Some staff were booked onto food hygiene and first aid training as they were due for refresher updates. Some newer staff were being put forward for training about the safe handling of medication. The home has an in-house moving and handling keyworker. A team away-day was planned for October 2006, with staff being asked to submit agenda items. Minutes from a team meeting on 29/08/06 were viewed and provided evidence of a wide range of issues being openly and constructively discussed. Mayfield DS0000067085.V310956.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run, promoting positive outcomes for householders. Reasonable systems are in place for monitoring and improving the quality of the service, although further work is planned which should help to formalise and develop the processes. Good systems are in place for ensuring that the home is a safe place to live and work. EVIDENCE: Since the last inspection the registered manager has left the post. A new manager has been appointed and at the time of the inspection was in the process of applying for registration. She already has experience of managing the home and is qualified with a Diploma in Social Work. In addition the manager had just completed the Registered Manager’s Award. Mayfield DS0000067085.V310956.R01.S.doc Version 5.2 Page 22 Staff spoken with expressed confidence in the manager and described her as approachable and skilled. Throughout the inspection there was evidence that home continues to be well run. The manager said that there had been recent budget cuts. She described where savings had been made and was confident that there had not been an impact of the quality of the service for householders. This will be monitored during future inspections. Some staff expressed fears about possible future impacts of these cuts. Quality assurance was discussed. The manager said that, whilst she was confident that practice in the home was good, the systems for formally monitoring this were less developed. She reported that letters had gone to householders’ families asking for feedback, resulting in some positive comments. The Trust has a series of quality standards and home managers have been asked to audit their service against these. Their line manager will in turn check this. The manager understood that these standards are due to be reviewed and relaunched along with the overall quality assurance strategy. As noted, good systems are in place for reviewing care plans and other key documentation. Considerable work has gone into making care plans and other material more accessible and meaningful to householders. Reports of Regulation 26 are being forwarded to CSCI. The manager said that these visits are more thorough than before. Records showed that routine health and safety checks were being undertaken at appropriate intervals, including gas and electrical safety and fire precautions. It was agreed that the temperature of a first floor shower should be included in the periodic water temperature tests. The manager had recently noted that checks on fridge and freezer temperatures were not happening consistently and had raised this through the communication book. Some work was due to be done on a door between two householders’ bedrooms to install a locking mechanism which would release when the fire alarms sounded (since the route also formed an emergency exit). The Trust’s health and safety policy was available in the home. Mayfield DS0000067085.V310956.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 x 2 2 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 3 x 3 x x 3 x Mayfield DS0000067085.V310956.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? 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 2 3 Standard YA10 YA24 YA34 Regulation 17 (1) 23 (2) 17 (2) Sch. 4 19 (1) Requirement Timescale for action 30/11/06 Ensure that confidential information is kept securely in the home. Attend to the four points made in 31/12/06 the text about the environment. Complete the checks on staff 31/12/06 files to ensure that all items required under the Care Homes Regulations are held. 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 Refer to Standard YA2 Good Practice Recommendations The Trust should fully review and update the admissions policy dating from 2000. An assessment tool should be devised for use when assessing the needs of people referred to the service. Aim to retype care plans and risk assessments where handwritten entries are beginning to impact on clarity. Daily records could include more information about activities, such as the duration and destination of a walk/drive and whether the person appeared to enjoy the experience. Through health action planning, explore different options DS0000067085.V310956.R01.S.doc Version 5.2 Page 25 2 3 YA6 YA12 4 Mayfield YA19 5 YA20 for promoting aspects of routine healthcare for people who found it difficult to attend regular appointments/check-ups. Where there is a handwritten entry on the medication administration record a second person should sign this having verified that what is written is correct. Review, update and distribute the Trust’s medication policy as soon as possible. Ensure that all staff are familiar with the whistle blowing policy. Consider the seven recommendations made in the text about the environment. Consider the points made about recruitment and selection in the text and verify whether practice fully conforms to the Care Homes Regulations. The temperature of a first floor shower should be included in the periodic water temperature tests, as discussed. 6 7 8 9 YA23 YA24 YA34 YA42 Mayfield DS0000067085.V310956.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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. 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