Inspection on 16/11/05 for Mayfield House

This inspection was carried out on 16th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mayfield House 08/11/07

Mayfield House 03/03/06

Mayfield House 02/12/04

Mayfield House 17/05/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood Hall

Muston Road (70)

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

CARE HOME ADULTS 18-65 Mayfield House Woodhouse Lane East Ardsley Wakefield West Yorkshire WF3 2JS Lead Inspector Karen Westhead Unannounced Inspection 16th November 2005 10:00 Mayfield House DS0000001480.V264734.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 House DS0000001480.V264734.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 House DS0000001480.V264734.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Mayfield House Address Woodhouse Lane East Ardsley Wakefield West Yorkshire WF3 2JS 01924 828 181 01924 872 623 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) J C Care Ltd Care Home 15 Category(ies) of Learning disability over 65 years of age (15), registration, with number Physical disability over 65 years of age (15) of places Mayfield House DS0000001480.V264734.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd December 2004 Brief Description of the Service: Mayfield House is owned by J C Care, which is a subsidiary of Craegmoor Health Care. It is managed by Joy Andrews, who has not yet been through the registration process with the CSCI. Mayfield House is a semi-detached property, which is joined to another care home owned by the same company. The home is situated in its own grounds and ample parking is available to the front of the property. The care home is on Woodhouse Lane, which is within easy walking distance of the main road. The area is well served by public transport. There are a number of local facilities and service users make good use of amenities in the area. The care home is registered to provide accommodation and care services for up to fifteen service users with a learning disability, who may also have a physical disability. Fourteen rooms are used for permanent service users and one room is retained for respite care. The home is spread over two floors. There is no passenger lift, however some ground floor bedrooms are available. The home provides staff over twenty-four hours. There are at least five staff on each shift during the day and evening. A senior member of staff oversees each shift. Two waking staff are in the home during the night. The home employs a handyman and domestic staff. At present there are no catering staff employed, care assistants cook all meals. Mayfield House DS0000001480.V264734.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection year runs from April to March and within that twelve-month period, the Commission for Social Care Inspection (CSCI) is required to undertake a minimum of two inspections of all regulated care homes. This was the first inspection of this home for the 2005/2006 inspection year. Reports of previous inspections are available at the home and can also be accessed at www.csci.org.uk on the Internet. One inspector undertook the inspection, which was unannounced. The visit started at 10.00am and finished late afternoon. The purpose of the inspection was to ensure the home was being run properly and managed for the benefit of residents. The last inspection of this service was on 2nd December 2004. At that time four requirements were highlighted with no recommendations. The registered person had to clarify the banking arrangements for residents; make sure all residents had an up to date contract; make sure care plans were reviewed and that staff had regular supervision. These have now been addressed. The inspector spent a large proportion of time speaking with residents, staff members and the manager. A number of documents were inspected and a tour of the premises carried out. All staff on duty were spoken to and observed carrying out their work. The inspector spoke to residents in private as well as in groups. A number of CSCI comment cards and post-paid envelopes were left, to be distributed to residents and their relatives. After completion these are returned to the CSCI. Feedback about the findings from the inspection were given to the manager at the close of the visit. What the service does well: Mayfield House continues to provide a good standard of care and is clearly a resident led home. Staff put residents first as much as possible. It was clear from the evidence gathered on the day that residents are able to make informed choices about their lives. Those residents with difficulties with communication or understanding are supported. Staff have been able to adapt their working practices to make sure everyone has a voice. Staff work hard to make sure residents develop at their own rate and create opportunities for them to achieve personal goals. Mayfield House DS0000001480.V264734.R01.S.doc Version 5.1 Page 6 Activities and training for residents is seen as an important part of their lives and staff support residents in this area. There has been a significant improvement in this area. The standard of the décor and maintenance of the building is good. The presence of a maintenance worker is seen as a key factor in this area. The home has good adult protection procedures and staff understand what to do if they observe or receive a report of inappropriate behaviour. The home gives training and support for staff, which enhances and develops their skills and abilities. What has improved since the last inspection? What they could do better: The work already started on up dating the care plans needs to be completed to make sure the information held is relevant. Where specialist equipment has been provided, there must be a record of the maintenance schedule and any checks carried out to make sure the equipment is working properly. A record must be kept of which staff have been trained to give out medication. There must also be a copy of staff sample signatures. Any steps taken to minimise risk must be fully risk assessed and a record kept for all eventualities. The names of those people taking part in a fire drill must be kept in the fire register. Mayfield House DS0000001480.V264734.R01.S.doc Version 5.1 Page 7 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 House DS0000001480.V264734.R01.S.doc Version 5.1 Page 8 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 House DS0000001480.V264734.R01.S.doc Version 5.1 Page 9 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): None of the standards were assessed during this visit. EVIDENCE: Mayfield House DS0000001480.V264734.R01.S.doc Version 5.1 Page 10 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, 8 and 9 The care files seen were well ordered and provided a chronological record of the care being delivered. Some updating was required. Residents are helped to make choices about their lives. Residents who could communicate verbally gave an account of their experiences in the home and talked about their wishes for the future. Thus providing the inspector with an insight into their lives and demonstrating they retained some control over what happened to them. EVIDENCE: Staff have received instructions on how to complete care plans. The files examined were in different stages of completion. However work was well underway and the manager thought they would all be completed within the next two months. The format has changed and old documentation was being archived to make room for more up to date information. The care plans are checked by a senior person from the organisation on a monthly basis. Mayfield House DS0000001480.V264734.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, 12 and 15 Educational, social and recreational activities provide a good balance between structured programmes and opportunities for personal development. EVIDENCE: Information recorded showed there is a diverse range of structured activities for residents to take part in. Activities include attendance at some further education centres and individual recreational events. There has been a significant improvement in this area. On the day of the visit, some residents were out attending colleges, planning trips out later in the day or relaxing at home. Residents, who were able to speak, said they could welcome visitors and friends and that this was encouraged by the staff. It was clear from the information seen that the home endeavours to maintain links with family and friends and promote opportunities where residents can meet people who do not have a similar disability or illness. Mayfield House DS0000001480.V264734.R01.S.doc Version 5.1 Page 12 The inspector was able to talk to one resident in his bedroom using a communication board. He was forthright and frank about his life at Mayfield House. He informed the inspector about his future intentions and this was being dealt with by his social worker. He confirmed he had had a meeting with his social worker and a review had taken place. Mayfield House DS0000001480.V264734.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): 18, 19 and 20 In general the care files seen give a good indication of the level of care each resident receives. Support around health needs is good. Comments from the district nurse endorsed this view. The record of medication was accurate. However, a sample of staff signatures is required and confirmation of which staff have received training. Specialist equipment is provided however, a record of maintenance checks must be kept to show it is working properly. EVIDENCE: The care plans include details of how individual goals are to be met. The information identifies how much support is required to maintain people’s wellbeing and health. Staff access information from a variety of agencies and use the help of other professionals to make sure residents receive the best advice and treatment. During the visit the district nurse was in the home looking after two residents. She commented on the way staff had responded to the care of residents with pressure sores and said they had acted appropriately and carried out her care instructions properly. The pressure sores have now healed. She said she had a good relationship with staff. Specially designed beds had been sourced and put in place to safeguard the health of two residents. Appropriate risk assessments had been carried out. Mayfield House DS0000001480.V264734.R01.S.doc Version 5.1 Page 14 However, a record of all maintenance checks carried out must be kept, to make sure equipment is working properly. One resident’s health had deteriorated over recent months. Appropriate steps had been taken to ensure the resident was pain free and comfortable. The manager and staff on duty said they could meet the resident’s needs at the current time. This must be monitored to ensure the placement remains suitable. The home has good links with the local doctors surgeries. All medication is delivered in pre-dispensed packages. The record of medication was found to be up to date, apart from the list showing samples of staff signatures and who had been trained to a competent level. The medication file includes useful supplementary information of drugs in use. None of the current resident group takes responsibility for taking and storing their own medication. This decision is determined by a risk assessment and if appropriate, a discussion with the resident. Mayfield House DS0000001480.V264734.R01.S.doc Version 5.1 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): 23 The home has a robust adult protection procedure and all staff have been trained to understand the subtle aspects of abusive behaviour and the action to be taken if suspected abuse is reported to them. EVIDENCE: Staff have received training on the protection of vulnerable adults. Training varies from base line in house training to a one-day session provided by an external trainer. In the last six months there has been one adult protection issue in the home. The manager and senior staff from the organisation were in the process of dealing with the matter. At the time of the visit a plan was in place to minimise any risk to the resident concerned. A member of staff spoken with was able to describe the action to be taken in the event of concerns being raised or if they observed bad practice. Those residents who were able to communicate said they were confident in the abilities of the manager and that if they complained about anything, she would ‘see to it’. The manager and staff team try to resolve ‘grumbles’ within the home before they develop into a complaint. Mayfield House DS0000001480.V264734.R01.S.doc Version 5.1 Page 16 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, 25, 28 and 30 The home is comfortable, with a domestic feel to the furniture and fittings. Appropriate risk assessments must be written to take into account the use of external bolts to bathroom and toilet doors. Improvements, furnishings and redecoration are funded from the annual budget. EVIDENCE: The communal areas and most of the bedrooms were seen. Some residents were at home and using these areas for relaxation. Since the last inspection new settees and dining room and bedroom furniture has been purchased. Residents said they liked the new furniture. A new carpet has been fitted to the main corridor. Residents now have full use of a conservatory, which had not been completed at the last inspection. Mayfield House is now a non-smoking environment. Some alterations have been made to make the main office more accessible, provide a quiet area for staff to complete records and the old office is to be fitted with sensory equipment. Preliminary work had been completed at the time of the visit. Mayfield House DS0000001480.V264734.R01.S.doc Version 5.1 Page 17 The home was fresh and clean. Staff and residents clearly take a pride in the home. Residents assist with household tasks. Their involvement is determined by their individual skills and abilities. Due to the complex needs of one resident, the manager has taken the decision to fit external bolts to the toilet and bathroom doors. This prevents access to the more vulnerable residents. Whilst it is acknowledged that this has been done to prevent, what could be a fatal incident. Documentation was not available to show that appropriate risk assessments had been carried out to cover all eventualities. The home has a rolling programme of refurbishment and redecoration. A maintenance worker is employed by the organisation. He spends a set amount of time in the home. He is involved in health and safety meetings and records any maintenance carried out on fire safety equipment and other services. All staff and residents have received fire safety training. However, the record needs to show which staff and residents had been involved in fire drills. Mayfield House DS0000001480.V264734.R01.S.doc Version 5.1 Page 18 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): 31, 33 and 36 The number of staff available on each shift is adequate. Formal supervision is provided for all staff and records kept of the key points talked about. Routine training is given to allow staff to update their skills and knowledge. EVIDENCE: Since the last inspection there have been changes in the staff team. A new manager started work at Mayfield House in May 2005. The previous manager has taken a different role and now works as the Deputy. This change had raised some operational issues. However, the manager was working through this with support from senior managers from the organisation. A small number of overseas workers have been appointed and two will go on to complete an adaptation course, which will give them the qualifications to work as a nurse in this country. The home was carrying two vacancies for support workers. The staff roster allows for five staff during the day and evening and two waking staff during the night. The manager is supernumerary. There is always a senior member of staff on duty and on call arrangements are well organised. Two staff spoken to during the visit confirmed they had received regular in put from senior members of staff and felt the training provided had given them the Mayfield House DS0000001480.V264734.R01.S.doc Version 5.1 Page 19 skills to carry out their job well. The staff on duty were seen to reply to residents requests in a clear, competent and patient manner. Staff on duty said they had regular supervision sessions, which included looking at individual care files, training needs and working practices. Mayfield House DS0000001480.V264734.R01.S.doc Version 5.1 Page 20 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, 38, 40, 41 and 42 The manager and senior team offer staff the opportunity to develop skills and keep their relationships with residents supportive. The health and safety of residents is safeguarded without unnecessary restrictions. EVIDENCE: The current manager has been in post since May this year. Staff described the new manager as ‘proactive’ and ‘a doer’. They said she was committed to the residents and had brought fresh ideas to enhance the quality of their lives. They said the ‘buzz’ in the home was driven by the manager and themselves, who would always put residents first. The management of risk is done in such a way that does not impose undue restrictions on people’s lifestyles. However, as detailed above in the section regarding the environment, additional risk assessments are required. Mayfield House DS0000001480.V264734.R01.S.doc Version 5.1 Page 21 Since the last inspection alternative bank arrangements have been put in place. For residents who require help with their finances, all transactions are recorded and receipts kept for all purchases. There is restricted access to the safe. The requirements noted in the body of this report impact on the health and safety of residents, these are itemised in the appropriate sections. Mayfield House DS0000001480.V264734.R01.S.doc Version 5.1 Page 22 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 X 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 X 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 X 33 3 34 X 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 X 14 X 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 3 3 X 3 3 2 X Mayfield House DS0000001480.V264734.R01.S.doc Version 5.1 Page 23 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 YA6 Regulation 15 Requirement The registered person must make sure the care plans are kept up to date and reflect an accurate picture of current events. The registered person must make sure there is a record of maintenance schedules and checks carried out on specialist equipment. The registered person must make sure there is a record showing those staff who have received training around the administration of medication and a sample of staff signatures. The registered person must make sure there are adequate risk assessments in place. The names of those people taking part in fire drills must be included in the record kept. Timescale for action 27/02/06 2 YA18YA42Y 13 20/01/06 3 YA20YA42 17(1)(a) Schedule 3 20/01/06 4 YA24YA42 13 and 23 20/01/06 Mayfield House DS0000001480.V264734.R01.S.doc Version 5.1 Page 24 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 Mayfield House DS0000001480.V264734.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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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