Inspection on 10/01/06 for Mayfield Court

This inspection was carried out on 10th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mayfield Court 04/09/07

Mayfield Court 31/01/07

Mayfield Court 22/09/05

Mayfield Court 17/02/05

Mayfield Court 16/09/04

Mayfield Court 24/03/04

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

CARE HOME ADULTS 18-65 Mayfield Court Youens Way Knotty Ash Liverpool Merseyside L14 2EP Lead Inspector Inger Moynihan Unannounced Inspection 10th January 2006 3:30 Mayfield Court DS0000025358.V277810.R01.S.doc Version 5.1 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 Court DS0000025358.V277810.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 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 Court DS0000025358.V277810.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Mayfield Court Address Youens Way Knotty Ash Liverpool Merseyside L14 2EP 0151 283 9090 0151 283 9091 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) Mayfield Fellowship Mrs Carole Ackers Care Home 29 Category(ies) of Physical disability (29), Physical disability over registration, with number 65 years of age (29) of places Mayfield Court DS0000025358.V277810.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residents (PD) between the ages of 18 - 64 years within an overall number of 29 Residents (PD/E) over 65 years of age within an overall number of 29 Date of last inspection 22nd September 2005 Brief Description of the Service: Mayfield Court is a large purpose built single storey home providing residential care for 27 service users with a physical disability. The property is owned by Riverside Housing Association and the care is provided by the staff employed by the Mayfield Fellowship. The home is divided into a number of independent flats and two separate units. Most rooms are single occupancy although there are three double rooms; this arrangement is at the service users request. Most rooms have en suite-facilities comprising of a toilet and washbasin and sometimes shower. Each of the flats has a range of different facilities including a kitchen, laundry and a lounge and dining area. All of these arrangements have been set up to reflect the care needs of the service users. The communal facilities include two communal lounges and a dining area. The home is close to the local community amenities and public transport routes. Staff actively encourage service users to maintain contact with local community facilities. The home also provides regular social excursions as well as in-house social events. An activities co-ordinator is also employed on a full time basis. Mayfield Court DS0000025358.V277810.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 3.5 hours and was the second statutory unannounced inspection for 2005/2006. A tour of the premises took place and service users and staff were spoken to. A range of documentation relating to the management of the service and the care and support of the service users was examined. What the service does well: Service users care needs are assessed which ensures staff can provide the appropriate package of care. Service users care needs are met in a variety of ways which ensures their physical and mental well being. A care plan is in place for each service user, which ensures the staff are clear on how to provide the appropriate level of care. Service users are consulted on and participate in all aspects of life in the home. Service users have opportunity for personal development which enables them to maintain and develop their emotional communication and independent living skills. Service users are supported to participate in the local community through the use of healthcare and leisure facilities which ensures they are not segregated because of their disability. The practices in place at the home support the health needs of service users. The home has a comprehensive complaints procedure to ensure service users views are listened to and acted upon. Systems are in place to ensure service users are safeguarded from abuse and harm. The standard of decoration throughout the home remains very high and provides a comfortable and pleasant environment for the service users to live. Mayfield Court DS0000025358.V277810.R01.S.doc Version 5.1 Page 6 Staff have undertaken a range of appropriate training which ensures service users are cared for in accordance with good practice. There are clear lines of management and accountability within the home which is run for the best interest of service users. The quality assurance and the health and safety systems in operation at the home promote the service users well being. 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 Court DS0000025358.V277810.R01.S.doc Version 5.1 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 Court DS0000025358.V277810.R01.S.doc Version 5.1 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 and 3 Service users care needs have been assessed which ensures staff can provide the appropriate package of care. However, risk assessments have not been routinely incorporated into all parts of the assessment process. Service users care needs are met in a variety of ways which ensures their physical and mental well being. EVIDENCE: Records indicate that service users have been appropriately assessed prior to moving to the home. However, while some risk assessments had been carried out in relation to certain aspects of service users care needs, they had not routinely been incorporated into the assessment process. To ensure service users receive the care they need and are kept safe from harm, risk assessments must be incorporated into the whole assessment process. The senior member of staff conducting the inspection agreed with the comments made and confirmed she would address this issue straight away. Service users care needs are met by way of staff being provided with appropriate training, the provision of a range of social activities and specialist adaptations and equipment to support the service users with their disability. Mayfield Court DS0000025358.V277810.R01.S.doc Version 5.1 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 and 8 A care plan is in place for each service user which ensures the staff are clear on how to provide the appropriate level of care. Service users are consulted on and participate in all aspects of life in the home. EVIDENCE: A sample of service user care plans was examined. The information they contained was useful and relevant to service users care needs. The care plans had been reviewed regularly with a daily record being made of service users general welfare. Any accidents that had occurred were recorded in the accident book with supporting documentation in the care plan. In one instance insufficient detail had been recorded in relation to a service user who had fallen and suffered a knock to their head. In the event of such an accident, the registered person is required to ensure detailed records are kept of the observations made following the accident. If this does not happen then important aspects of the service users care needs may be missed and they may be left vulnerable to the risk of harm. Mayfield Court DS0000025358.V277810.R01.S.doc Version 5.1 Page 10 The registered manager has established an ethos in the home whereby service users are encouraged to air their views and ideas on the running of the home and any future developments. Mayfield Court DS0000025358.V277810.R01.S.doc Version 5.1 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): 11 and 14 Service users have opportunity for personal development which enables them to maintain and develop their emotional, communication and independent living skills. Service users are supported to participate in the local community through the use of healthcare and leisure facilities which ensures they are not segregated because of their disability. EVIDENCE: Service users are supported in their personal development through the assessment and care planning process. This enables the service uses to live as fulfilled a life as possible. A number of service users have established personal relationships which the staff support in a discreet and appropriate manner. Links with the community are maintained through the use of healthcare and social facilities. This ensures service users participate in normal community life and they are not segregated because of their disability. Service users are encouraged and supported to pursue their own interests and hobbies outside of the home and a range of activities are also provided within the home. Service Mayfield Court DS0000025358.V277810.R01.S.doc Version 5.1 Page 12 users social care needs have been assessed and the registered manager has carried out a great deal of work to develop this side of the service. Mayfield Court DS0000025358.V277810.R01.S.doc Version 5.1 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): 19 The practices in place at the home support the health needs of service users. EVIDENCE: Service users are supported to attend healthcare appointments and have access to health care services when they are needed. Regular contact is made with a range of health care professionals who give advice and support as and when required. A record of service users general welfare is in place along with the outcome of any health care appointments. All of this is in line with good practice and ensures service users physical and mental health is monitored and maintained. Mayfield Court DS0000025358.V277810.R01.S.doc Version 5.1 Page 14 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 and 23 The home has a comprehensive complaints procedure to ensure service users views are listened to and acted upon. Systems are in place to ensure service users are safeguarded from abuse and harm. EVIDENCE: The CSCI has not received any complaints about the standard of care provided at Mayfield Court. Nor have any complaints been made directly to the staff at the home. A documented complaints procedure is in place which staff and service users have access to Documentation is in place on the protection of vulnerable adults from abuse and the staff spoken to demonstrated they were aware of the action they should take in the event of them knowing or suspecting an incident of abuse had taken place. Most staff have completed the training on this aspect of care provision although one member of staff did say they required an update in this training. Mayfield Court DS0000025358.V277810.R01.S.doc Version 5.1 Page 15 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 and 30 The standard of decoration throughout the home remains very high and provides a comfortable and pleasant environment for the service users to live. EVIDENCE: The standard of the décor throughout the home remains very high and a planned programme of maintenance is in place. The home is decorated in a way that gives a comfortable and bright environment for the service users to live. All parts of the home are clean and tidy and free from offensive odours. Adaptations have been made to ensure all parts of the home are accessible to people who use wheelchairs. The home is built in a square so has an inner courtyard which has an attractive garden with a fishpond, patio and garden furniture. All of this area is level with a hard surface. All communal parts of the home and a selection of bedrooms and bathrooms were inspected and noted to be clean and tidy. Clearly the domestic staff are working very hard to maintain this high standard. Mayfield Court DS0000025358.V277810.R01.S.doc Version 5.1 Page 16 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): 35 Staff have undertaken a range of appropriate training which ensures service users are cared for in accordance with good practice. However, further training does need to be provided in relation to service users specialist health care needs. EVIDENCE: Staff have undertaken a range appropriate training to support the service users with their care needs and to ensure the smooth running of the home. Many staff have completed training in line with the National Vocational Qualification standards and other staff are in the process of completing this qualification. Staff have completed specialist training to reflect service users individual care needs although the senior member of staff conducting the inspection did agree that this aspect of care provision needed to be developed. In the light of this the registered person is required to incorporate further specialist training into the training programme for the forthcoming year. The senior member of staff conducting the inspection confirmed that training on the issue of diversity was provided during induction training but that this issue was not included in the annual training programme. In the light of this, the registered person is required to ensure all staff are updated in this aspect of care to ensure service users specific care requirements are met in relation to their religion, sexuality, disability or cultural background. Mayfield Court DS0000025358.V277810.R01.S.doc Version 5.1 Page 17 Only two new staff have been employed at the home since the last inspection. This is a positive aspect of the home and ensures consistency in the care provided to service users. A member of staff confirmed that staff vacancies, such as holidays and sickness are always filled and there were sufficient staff available to care for the service users in accordance with good practice. Mayfield Court DS0000025358.V277810.R01.S.doc Version 5.1 Page 18 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 and 42 There are clear lines of management and accountability within the home which is run for the best interest of service users. The quality assurance and the health and safety systems in operation at the home promote the service users well being. EVIDENCE: The senior member of staff conducting the inspection demonstrated she was aware of her responsibilities with regard to the supervision of staff and the care of service users. The staff spoken to during the inspection confirmed the registered manager is always available for support and advice when necessary and the home is well managed. This is a positive aspect of the home and ensures staff receive good leadership in their role. Safe working practices are promoted within the home and staff are provided with appropriate training for this purpose. Regular fire safety checks and checks on all equipment are carried out. All of these issues demonstrate a Mayfield Court DS0000025358.V277810.R01.S.doc Version 5.1 Page 19 high quality of care is being provided at this service and the issue of service user and staff safety and welfare is made a priority. A quality assurance system is in place to ensure high standards of care are set and maintained. This issue was discussed with the person conducting the inspection and it was agreed that this aspect of care could be developed to include seeking out the views of other stakeholders, ie GPs, social workers etc, on the standard of care provided. Mayfield Court DS0000025358.V277810.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 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 3 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 2 ENVIRONMENT Standard No Score 24 4 25 x 26 x 27 x 28 x 29 x 30 4 STAFFING Standard No Score 31 x 32 x 33 x 34 x 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 x 3 x x LIFESTYLES Standard No Score 11 3 12 x 13 x 14 4 15 x 16 x 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 3 x x 3 x x x x 4 x Mayfield Court DS0000025358.V277810.R01.S.doc Version 5.1 Page 21 no 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 Standard YA3 Regulation 14 Requirement The registered person is required to ensure risk assessments are routinely incorporated into all parts of the assessment process The registered person is required to ensure all aspects of service users care plans accurately reflect the observations made in relation to any accidents that have happened. The registered person is required to ensure staff are provided with training on issues of diversity. The registered person is required to ensure specialist training in relation to service users specific care requirements is incorporated into the forthcoming years training programme. Timescale for action 10/03/06 2 YA6 13 10/03/06 3 4 YA35 YA35 18 18 10/09/06 10/03/06 Mayfield Court DS0000025358.V277810.R01.S.doc Version 5.1 Page 22 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 There are no recommendations resulting from this inspection Mayfield Court DS0000025358.V277810.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Liverpool Local Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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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