Inspection on 15/06/07 for Mayfield Hall

This inspection was carried out on 15th June 2007.

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

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

Other inspections for this house

Mayfield Hall 09/11/06

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Mayfield Hall 22 Bitton Park Road Teignmouth Devon TQ14 9BX Lead Inspector Sharon Goldsworthy Key Unannounced Inspection 15th June 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Mayfield Hall DS0000067329.V334853.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 Hall DS0000067329.V334853.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mayfield Hall Address 22 Bitton Park Road Teignmouth Devon TQ14 9BX 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) 01626 772796 Amethyst Care Ltd Mrs Elaine Tanya Sampson Care Home 20 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (20) of places Mayfield Hall DS0000067329.V334853.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th November 2006 Brief Description of the Service: The ownership of the home changed in June 2006 and is now owned by Amethyst Care Limited. Mayfield Hall is situated off a main road close to the town centre of Teignmouth, and some of the upstairs bedrooms enjoy good views of the Teign Estuary. The home is registered to offer accommodation to male and female residents from the age of sixty-five years with or without dementia. There are eighteen single bedrooms and one double bedroom. All of the bedrooms, except three, have an ensuite facility, which includes a toilet and a bath or a shower unit. There are also three communal toilets throughout the home, with a communal bathroom on the first floor, which has an assisted bathing aid provided. Easy accessibility between the ground and first floor is provided by a passenger lift and there is also the provision of two small chair lifts to further aid accessibility where there are a few additional steps to negotiate to some rooms within the home. There is a large communal lounge, dining area and a pleasant sun lounge. The home has adequate security in place in relation to the client group accommodated. A safe, secure patio area is also available for residents to enjoy and there is a small amount of parking facilities for visitors. The current weekly charge ranges between £312 and £372. The inspection report is available within the home’s communal hallway and upon request. Mayfield Hall DS0000067329.V334853.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place on a Friday over 6 hours. A tour the premises, examination of some records and policies, discussions with the owners, residents (who were able to converse) and staff on duty also formed part of this inspection, whilst staff on duty were observed, in the course of undertaking their daily duties with the residents. Other information about the home, including the receipt of a pre inspection questionnaire from the owners, three questionnaires from staff, one from a visiting professional and six from relatives/visitors to the home, has provided further feedback as to how the home performs, and this collated information has been used in the writing of this report. All required core standards were inspected during the course of this inspection. What the service does well: The owners have established an “open door” policy, which allow residents, staff and residents’ families/carers the opportunity to be able to speak openly and easily, which helps all concerned, deliver the appropriate care and a relaxed, family atmosphere operates within the home, for which the owners should be commended. The staff are providing very individual care for the residents, some of whom are unable to communicate their needs. The owners are very much involved in the running of the home, including providing personal care to residents. This has ensured they are both aware of the residents’ needs and therefore aware of how the staff can best meet these needs. Due to the category of the resident group that are cared for at Mayfield Hall (i.e. many residents suffer from advanced dementia), it means that carers need to take time and use good observational skills to determine what a resident may be trying to communicate. Care practice observed at this inspection visit was positive, sensitive, individualised and safe. It is evident that staff have taken on board recent training provided and are working well with the owners to continually improve this service. Comments received from some relatives include; “ the staff are very thoughtful and treat mum as a human being” “the staff are happy and provide a warm friendly atmosphere with lots of loving care and attention” “the conditions at Mayfield Hall have improved considerably in every respect” “the emphasis is just on CARE with unfailing kindness”. Mayfield Hall DS0000067329.V334853.R01.S.doc Version 5.2 Page 6 The owners are commended for their commitment and dedication to meeting any previous outstanding requirements, and for working with families, residents, professionals and staff to obtain feedback in order to improve the level of service offered in this home and to continually raise the standard of care as well as the building itself. What has improved since the last inspection? Feedback received from relatives, staff and health care professionals remains very positive, with many stating that everything about the home in the last year has been significantly improved (since the new owners have taken on the home). Particular examples given by relatives and staff include the maintenance of the building, the food, the care and attention given to people living in the home and the staff training. The building has been significantly improved in the last year. The owners are making their way through a lengthy and necessary refurbishment programme, which is including the redecoration and re-carpeting of most bedrooms and communal rooms, the electrical wiring and systems in the house are currently being replaced, the upgrading of the fire systems and equipment, there has been significant work carried out on the pipe work in the home, with the need to carry out damp proofing to some bedrooms, the fitting of hot water temperature valves to all hot water outlets in the home, the outdoor garden area has been significantly improved – now offering a pleasant place in which to sit out on warmer days and enjoy beautiful views over the river Teign. A new medication trolley has been purchased, and a new medication and treatment room has been created. The staff team have been given a great deal of support from the new owners, with them being present on a daily basis to offer guidance and support, the implementation of a supervision and appraisal programme and significant training programme. Some people living in the home and staff and relatives responding to pre inspection surveys have stated that the food has greatly improved in the last year. The new owners have reported that they now routinely only use fresh vegetables, meat and offer fresh fruit daily. The level of activities offered on a daily basis has improved and the level of interaction between staff and people living in the home has significantly improved. Mayfield Hall DS0000067329.V334853.R01.S.doc Version 5.2 Page 7 What they could do better: A care plan and contract was not in place for one person who was admitted on an emergency basis, although the owners confirmed that this was awaited. Both the owners and staff need to complete some recognised and certificated training in the field of dementia care in order to further develop the care they give and be able to offer a truly specialist dementia care service. Along with this it would be considered good practice for the owners to obtain and work with the Alzheimer’s Disease Society Standards for residential care homes. These are good practice guidelines which homes who are offering a specialist service in dementia care should be measuring themselves against. The owners need to consider the information offered to people living in the home and design and present it in such a way that may be understood by persons who have communication needs. Examples of this are; menu and activity boards currently displayed in the lounge, the service user guide and care plans. Alongside this the owners need to work with people living in the home to further develop their existing skills of daily living and ways in which they can express an opinion on the way in which the home is run taking into account their communication needs. All newly recruited staff should attend all statutory training as planned, and staff should be registered onto NVQ training, to ensure they are competent and skilled to work within a residential setting. The owners need to extend their quality assurance system to visiting health and social care professionals in a more formal capacity to ensure that all stakeholders are consulted about their views and opinions on the way in which Mayfield Hall is run. This system will then be complete and will form the basis of the owner’s annual development plan, which can then be made available to all persons living in the home, their representatives and other stakeholders. The owners plan to implement a new set of policies and procedures in the near future and will gradually introduce these to all staff. Mayfield Hall DS0000067329.V334853.R01.S.doc Version 5.2 Page 8 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 Hall DS0000067329.V334853.R01.S.doc Version 5.2 Page 9 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 Hall DS0000067329.V334853.R01.S.doc Version 5.2 Page 10 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, 4, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process is managed appropriately and new residents and/or their advocates are given clear information regarding the service so that they, and/or their relatives/advocate, can make an informed decision. EVIDENCE: The new owners have improved the admission process since taking over ownership. They have admitted some new people to the home and it was noted that the admission process had been thorough, to ensure that residents are placed appropriately at the home. Relatives pre inspection questionnaires confirmed that the admission process had been such that the relatives knew the home would provide the required care and the subsequent care given did meet the individuals’ needs. The prospective residents and/or their families had been given access to necessary information including the home’s Statement of Purpose. In most cases with Mayfield Hall DS0000067329.V334853.R01.S.doc Version 5.2 Page 11 this home, it is the family members involved that made the decision to admit their relative. Appropriate contracts were seen to be in place for the two most recently admitted residents. One other newly admitted person, a contract was not in place, as they had been admitted to the home on an emergency basis and the owners were awaiting the appropriate documentation including the contract from the local authority responsible for this placement. Both the owners and staff need to complete some recognised and certificated training in the field of dementia care in order to further develop the care they give and be able to offer a truly specialist dementia care service. Along with this it would be considered good practice for the owners to obtain and work with the Alzheimer’s Disease Society Standards for residential care homes. These are good practice guidelines which homes who are offering a specialist service in dementia care should be measuring themselves against. The home does not provide an intermediate care service. Mayfield Hall DS0000067329.V334853.R01.S.doc Version 5.2 Page 12 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. All people living in this home are looked after well in respect of their health and personal care needs. Privacy and dignity is upheld and their life style choices respected. EVIDENCE: The care plans inspected related to the residents whose admission procedure was previously inspected. The owners are in the process of introducing a new care planning and assessment document. This is a clear, comprehensive and easy to follow document that will clearly define the full range of an individual’s needs as well as abilities and wishes. Staff spoken to about this document were pleased with it and felt that it was much clearer and easier to understand and follow. Following this inspection visit, the owners planned to complete these documents for all persons living in the home. Two of the new care plans seen were detailed and contain all relevant information appertaining to providing for the individual residents care. This Mayfield Hall DS0000067329.V334853.R01.S.doc Version 5.2 Page 13 includes any medical needs of the resident, as well as any visits made by District Nurses, G.P’s or any other health and social care professionals. A relatives’ meeting held on the 18th November informed the relatives present of care planning documents and informed relatives/advocates how they can be involved in this process if the resident and/or they wish to be. The owners have now purchased and are using new accident books in line with the Data Protection Act. The home’s accident recording was inspected and was found to be detailed and appropriate. There have been no serious accidents in the last three months. A new keyworking system has been introduced in the home. One person living in the home reported that this is working well and was able to identify her keyworker. However, this would not be the case with the majority of others living in this home. Staff confirmed that this system is now in place and feel it is working well. There is a record book that is completed by each key worker to allow the owners to conduct a weekly audit of what identified tasks the key workers are undertaking with the resident and to ensure the system continues to meet the residents’ needs. There were basic risk assessments in place including one on moving and handling. Appropriate handling and lifting devices were in evidence including a mobile hoist and handling equipment. The owners have provided an assisted bathing facility as well as five height adjustable beds to help lesser mobile residents be able to get in and out of bed more easily. Manual handling training has been provided for all but the newly recruited staff. All these measures ensure that residents are moved and handled in the most appropriate manner. The manual handling observed on the day of this inspection was entirely appropriate, according to the individual’s care plan and carried out with a degree of dignity and sensitivity. The owners liaise well with other professionals, as required, including care managers, the community mental health team etc. One very frail person was being nursed in bed and was noted as being very comfortable, well presented and had the use of pressure relieving equipment. A regular chiropodist visits the home. People living in the home who were able to verbally feedback their feelings, were very positive about the care received, saying that they felt well looked after and that the staff treated them well and were very kind to them. Mayfield Hall DS0000067329.V334853.R01.S.doc Version 5.2 Page 14 Others were noted as being treated by the staff with kindness and due regard for the maintenance of their dignity and rights to individuality. Such evidence that supported this was noting the gentle way that staff spoke to people, taking into account their individual levels of ability, all residents being nicely dressed, clean and well presented. Medications are well managed and securely stored. The home uses a recognised administration system. Medication records were inspected and seen to be in order. The administration of medication was witnessed during the inspection and was noted as in order. The owners have provided a drugs trolley to transport the medications to where the residents are i.e. bedrooms at night, communal areas during the day and therefore ensure that the medications are given straight from the package. There are pictures of each person living in the home, his or her name as well as their preferred term of address and their date of birth on their medication record. There is also a list of the staff signatories who are responsible for the administration of the medication. All these measures help protect vulnerable people and help ensure any risk in the allocation of medication is minimised. Medications requiring refrigeration is now stored in a recently purchased dedicated fridge. All staff responsible for the administration of medications has received training from the home owners. The home’s supplying pharmacist provided further training in November 2006. This ensures that people living in the home are further protected in respect of receiving their medications appropriately. Mayfield Hall DS0000067329.V334853.R01.S.doc Version 5.2 Page 15 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. People living in the home are able to enjoy a pleasant and reasonably varied life at the home, with visitors encouraged. Various informal activities are made available with new activities also tried out. Varied, balanced and nutritious meals are provided. EVIDENCE: The home operates an open visiting policy and the visitor’s book evidenced that people living in the home continue to have visitors at varying times throughout the day. Relatives responding to pre inspection questionnaires confirmed that they are able to visit and always made welcome. Staff undertake activities with people living in the home both individually and as a group on a daily informal basis. This can involve in house activities such as art, manicures, quizzes, flower arranging, floor games and music. A record is kept of activities made available. A photograph album is available that also evidences regular entertainment, parties and activities such as gardening. There is a two weekly musical afternoon and two weekly relaxation and entertainment afternoon facilitated by persons who are external to the home. On the day of this inspection visit, the musical afternoon was taking place. Mayfield Hall DS0000067329.V334853.R01.S.doc Version 5.2 Page 16 Most people living in the home came to the lounge to participate in this, as did a number of relatives. All appeared to thoroughly enjoy this event, either getting up to dance, singing or just listening to the music. All staff on duty were fully involved in this activity, as were a number of staff who were not on duty, who popped in for a few moments. A regular hairdresser visits for those people living in the home that wish to use this service. The atmosphere in the home is relaxed, friendly and compassionate and the people living in the home who have dementia certainly benefit from this, being noticeably relaxed and calm within the home’s environment and with the staff. Individuals continue to be encouraged to express their individuality and to this end choice is made available whenever possible i.e. at mealtimes, when there is a choice of main course and several sweet choices. These are brought round on a sweet trolley so that residents can see them, which then helps then make their choice. The new owners are currently undertaking the cooking and the meal on the day of inspection was appetising, well presented, nutritious and provided a choice. People spoken to following the meal, all said that they enjoyed it and one two stated that the food is very much improved and is always nice. Those individuals that needed assistance with feeding were given this in the communal dining room in a sensitive and discreet manner. There is a menu board displaying the menu for the week. The home caters for specific dietary needs. Staff and relatives responding to pre inspection surveys have stated that the food has greatly improved in the last year. The new owners have reported that they now routinely only use fresh vegetables, meat and offer fresh fruit daily. The routines within the home are very flexible to ensure that people living in the home can choose how they spend their time. During the inspection individuals freely went to their rooms, enjoyed the company of others or their visitors. The board in the in the lounge displaying the activities was for the whole week. The board for the menus displayed the days menus. A discussion took place with the owners to revise this, given that a number of people living in this home may not be aware of the day, or time of day, and as such, the boards used properly can assist with orientation and be more informative to those with memory difficulties. Mayfield Hall DS0000067329.V334853.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. Arrangements for protecting residents and responding to their concerns are satisfactory. EVIDENCE: The home’s complaint policy was centrally displayed and is also contained within the home’s statement of purpose. Returned questionnaires received back from staff members and relatives indicated that they were aware of the complaints procedure. The owners keep a log of complaints received, and this was seen to have recorded in detail the receipt of two formal complaints, both of which were dealt with appropriately and effectively. Staff members confirmed that they are aware of and have received training in relation to adult protection procedures operating within the home. Staff training records indicate that some staff have attended training in relation to adult protection. Mayfield Hall DS0000067329.V334853.R01.S.doc Version 5.2 Page 18 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. The home presents as safe, comfortable, clean and well maintained. EVIDENCE: The tour of the home confirmed that the owners are continuing with major upgrading of the home’s environment. The building has been significantly improved in the last year. The owners are making their way through a lengthy and necessary refurbishment programme, which is including the redecoration and re-carpeting of most bedrooms and communal rooms, the electrical wiring and systems in the house are currently being replaced, the upgrading of the fire systems and equipment, there has been significant work carried out on the pipe work in the home, with the need to carry out damp proofing to some bedrooms, the fitting of hot water temperature valves to all hot water outlets in the home, the outdoor garden area has been significantly improved – now offering a pleasant place in which to sit out on warmer days and enjoy beautiful views over the river Teign. Mayfield Hall DS0000067329.V334853.R01.S.doc Version 5.2 Page 19 Bedrooms throughout the home were personalised as desired and residents can bring in personal items with them if they wish to. The lounge, dining area and sun lounge provide adequate communal space and all are well appointed. The owners are maintaining the day-to-day home’s fire precautions in line with the requirements of the local fire department. Fire awareness training has been provided for staff from an outside trainer and additional fire notices have been provided throughout the home as well as two additional fire extinguishers having also now been provided. The home presented, as very clean with no odours present at all, for which all the staff, but especially the domestic member of staff, should be commended for. Two relatives responding to pre inspection questionnaires commented on the home being very much cleaner since the new owners have taken over and free from odour on all occasions when they visit. The home maintains suitable infection control measures, including the provision of suitable protective clothing as required i.e. aprons and gloves and clean overalls when working in the kitchen as well as anti bacterial gel and adequate hand wash facilities for staff within bedrooms. The security of the home and individuals’ safety is maintained by the use of a keypad lock on the main doors and an enclosed patio to ensure the safety of persons living in the home. Mayfield Hall DS0000067329.V334853.R01.S.doc Version 5.2 Page 20 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 adequate. This judgement has been made using available evidence including a visit to this service. Staff at the home are employed in sufficient numbers to meet the individual needs of people living in this home. Staff are not fully trained in relation to the needs of the people who live in this home. The home’s recruitment programme protects people living in this home. EVIDENCE: Staff rotas supplied by the owner’s evidence that there are a good number of staff on duty at all times. Observation on the day of the inspection indicated that there were sufficient staff on duty to adequately meet the needs of the people currently living in this home. There are a small number of individuals that currently require a good level of supervision or additional support – one being cared for in bed. Staff were seen to be able to offer this additional care and support in a relaxed and unrushed manner and were still observed spending time sitting with others and as mentioned earlier enjoying spending time dancing and singing with individuals during the musical entertainment. One member of staff in a pre- inspection questionnaire stated that there should be two members of staff on duty at nights. There is currently one waking and one sleeping in staff on duty at nights. The sleeping in cover is usually one of several staff who live on the premises. Staff spoken to on the day of this inspection visit confirmed that staffing levels were good and sufficient. Mayfield Hall DS0000067329.V334853.R01.S.doc Version 5.2 Page 21 The owners work each day within the home and are currently undertaking the cooking of meals. This time ensures that one or other is always available and has direct contact on a daily basis with both people living in the home and staff members. Training has been provided for all staff members (with the exception of recently recruited staff), including moving and handling, vulnerable adult training, fire awareness training, medication administration and awareness, dementia care, continence care, health and safety and infection control. The owners are also planning to provide training opportunities to allow staff to obtain the recognised qualification in care (NVQ level 2) and training in food hygiene and first aid. They also confirmed that they would now be looking at more formal dementia care training for themselves initially, but would like to extend this to the whole staff team. The owners should be commended for introducing the staff training already given and for planning to ensure that future training will ensure that at least fifty percent of the staff have a recognised qualification in care. There was evidence that staff are responding well to training received, in particular good observations of care practice in relation to manual handling. Staff members spoken to and who responded to pre inspection questionnaires confirmed that the training offered is good and they are pleased with what has been offered. The recruitment records for the two most recently recruited staff members were inspected and were noted to be in order with two written references having been received and a Protection of Vulnerable Adult checks and Criminal Record Bureau checks applied for and awaiting their clearance. The owners confirmed that these particular staff members are currently working under the supervision of either themselves or the senior staff and do not have access to people living in the home on an individual basis. The home has maintained a fairly stable staff group with regular staff remaining in post during the change of ownership. This has ensured a continuity of care for the residents. Mayfield Hall DS0000067329.V334853.R01.S.doc Version 5.2 Page 22 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, 36, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being managed efficiently and well, with both the new owners being easily available and approachable. Their leadership is ensuring that the home runs in the best interests of the residents. People living in this home are protected from the owner’s maintenance, health and safety procedures and good level of monitoring. EVIDENCE: Two of the owners have many years experience in caring for elderly clients and are both qualified, level 1 Registered General nurses. One of the owners has just completed a nationally recognised qualification in management (NVQ level 4) and the second owner, who is the home’s registered manager, is to also commence the same training to allow her to achieve the award in the near future. Mayfield Hall DS0000067329.V334853.R01.S.doc Version 5.2 Page 23 They are improving the overall management of the home by ensuring all practices are carried out in the residents’ best interests. They provide regular supervision to staff which helps enhance the lines of communication within the home, which ensures that staff are now fully supported. The owners are well respected by staff, people living in the home and their relatives whilst visiting professionals also spoke well of the improvements they have undertaken within the home. The owners are in the process of undertaking a full and continuous quality auditing programme on all aspects of the running of the home and it is clear that they were acting on their findings and improving the quality of care within the home. Regular staff and relative meetings have taken place and the owners have sent out and are receiving back surveys from relatives and representatives. They plan to extend these surveys and as such the quality assurance programme to health and social care professionals and other persons regularly visiting the home. The families/advocates mostly deal with any financial matter appertaining to the people living in the home. The owners manage monies for a small number of people living in the home, although this is for very small amounts and appropriate records are kept in relation to this. The owners are planning to introduce a new set of policies and procedures in the home. The owners have implemented a thorough maintenance and monitoring programme in relation to health and safety in this home. Appropriate fire safety checks are in place, COSHH assessments are in place, accident records are kept appropriately, water outlets are now fitted with appropriate water regulation controls, windows to the first floor are fitted with window opening restrictors and there are appropriate risk assessments in place. One of the owners takes specific responsibility for the health and safety of the building. Mayfield Hall DS0000067329.V334853.R01.S.doc Version 5.2 Page 24 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 2 X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 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 3 X 3 Mayfield Hall DS0000067329.V334853.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP30 Regulation 18(1) Requirement All staff should be competent and trained in relation to the people’s needs for whom they care. This relates specifically to dementia care and NVQ. All staff should receive the relevant statutory training including first aid, food hygiene and POVA. Timescale for action 31/12/07 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 OP3 Good Practice Recommendations Ensure that a care plan/referral contract is obtained at the time of a person’s admission to the home for an emergency placement and no later than 48 hours following their admission. Obtain and work with the Alzheimer’s Disease Society Standards for residential care homes. Consider ways in which the level of choice and information offered to people living in the home can be enhanced. 2. 3. OP4 OP4 Mayfield Hall DS0000067329.V334853.R01.S.doc Version 5.2 Page 26 4. 5. 6. 7. OP19 OP30 OP33 OP37 The owners should continue with their identified plan to upgrade the home. The owners should ensure that 50 of the staff employed have commenced the required training to obtain NVQ level 2 in care within the next twelve months. Further extend the quality assurance system to other stakeholders such as health and social care professionals. The owners should ensure that all the home’s policies and procedures are reviewed and amended as required. Mayfield Hall DS0000067329.V334853.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mayfield Hall DS0000067329.V334853.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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