Inspection on 18/04/07 for Mayfield House

This inspection was carried out on 18th April 2007.

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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mayfield House 27/02/06

Mayfield House 25/10/05

Mayfield House 17/02/05

Mayfield House 01/07/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Mayfield House King Cross Road King Cross Halifax West Yorkshire HX1 3LN Lead Inspector Liz Cuddington Unannounced Inspection 18th April 2007 15:00 Mayfield House DS0000000990.V329086.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Mayfield House DS0000000990.V329086.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Mayfield House DS0000000990.V329086.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mayfield House Address King Cross Road King Cross Halifax West Yorkshire HX1 3LN 01422 250254 01422 381835 r.heywood@mayfield-trust.org.uk 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 Trust *** Post Vacant *** Care Home 20 Category(ies) of Learning disability (20), Learning disability over registration, with number 65 years of age (20) of places Mayfield House DS0000000990.V329086.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th February 2006 Brief Description of the Service: Mayfield House consists of a large house and a separate building, set behind the house and known as The Cottages, where the people who wish to live more independently have their homes. The two buildings are separated by a courtyard and car park. Behind The Cottages is a garden, patio and barbeque area. The main house has a stair lift to the upper floor. There is one manager with overall responsibility for both parts of the premises. The manager and staff support the people who live at Mayfield to live active, independent lives pursuing their own work and recreational interests and maintaining connections with family and friends. The weekly fees are £344.27. Calderdale Social Services provides additional funding for outreach and other services. The amount depends upon the individual level of need. Personal items and expenses are not included in the fees. Mayfield House DS0000000990.V329086.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the inspection was to assess the quality of the care and support received by the people who live at Mayfield House and Cottages. The methods I used to gather information included conversations with the people who live at the home and the staff, case tracking, examining records and touring the home. I sent questionnaires to the people who live at Mayfield House and Cottages and to two of the GP surgeries that visit the home. I received seven completed questionnaires back and spoke to three people’s relatives to gain their views on the quality of care and support offered at Mayfield House and Cottages. I also received the home’s pre-inspection questionnaire. These questionnaires provide a lot of valuable information to help me form a judgement about the quality of service offered at Mayfield House and Cottages. Although there are still a few areas for development, the home continues to make significant improvements. I would like to thank the people who live at Mayfield House and Cottages, and the staff, for their welcome and hospitality and for taking the time to talk to me during my visit. What the service does well: The whole ethos of the home is based on supporting the people who live at Mayfield House and Cottages to lead lives which are full and rewarding and meet their expectations and wishes. The manager and staff work hard to support people to live their lives in the way they choose. One person who lives at the home said ‘I like it here very much and I love to play music, watch tv and drawing’. Another commented that he or she ‘…came for short stays and liked it’. One person’s relative said that her relative at Mayfield ‘…does the things she wants to’. Another relative said they have ‘no complaints at all’ and that the home and staff have ‘been amazing’. The home is well managed and the plans for improvement have either been achieved or are well under way. The people who live at Mayfield House and Cottages and the staff are all involved in how the home is run. One person commented that ‘Everyone listens’. One relative told me that if they have any concerns the manager deals with them. During my visit I observed that everyone receives the level of support and care they need, in accordance with their wishes. Changing needs are acted upon and professional advice is sought, where necessary. Staff receive Mayfield House DS0000000990.V329086.R01.S.doc Version 5.2 Page 6 training to help them meet people’s needs and provide good quality care and support at all stages of people’s lives. Where needed, advice on medication storage and administration is sought and acted upon to make sure all medicines are handled correctly and stored safely. A visiting healthcare professional returned one of my questionnaires and all the questions had positive responses, confirming satisfaction with the care & support provided for their patients. The interaction between staff and the people who live at the home is relaxed, friendly. Staff maintain people’s dignity and privacy. They spend time with people, but respect their right to be left alone if they wish. One person commented that ‘The staff are lovely’. People are protected by the organisation’s recruitment procedures, which are safe and thorough. There is suitable training for staff, to give them the skills and knowledge to provide good quality care and support for the people who live at Mayfield House and Cottages. What has improved since the last inspection? What they could do better: The care plans need to be kept up to date in order to reflect the current health and personal care needs of each individual. Wherever possible each plan must show that the person, or their representative, has been involved in developing and reviewing the plan. Mayfield House DS0000000990.V329086.R01.S.doc Version 5.2 Page 7 The new, easier to read person centred format for care plans should be introduced as soon as possible to make the plans more accessible and give people a greater opportunity to be involved in their development. To reach the minimum of 50 of care staff with an NVQ qualification, one more staff member needs to complete the course. The new wet rooms, to replace the downstairs bathrooms, should be installed with minimal delay to improve bathing facilities for the people who live at Mayfield House and Cottages. 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 House DS0000000990.V329086.R01.S.doc Version 5.2 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 DS0000000990.V329086.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A comprehensive pre-admission assessment and introduction is carried out before offering someone a place at the home, to make sure that the home can meet their needs. EVIDENCE: Even though the last new admissions to the home were in 2000, the care plans showed that all the necessary pre-admission procedures had been followed. This includes a planned introduction period, which is tailored to meet individual requirements. On the completed questionnaires, three of the six people who answered said that they had sufficient information to allow them to make a decision before moving to Mayfield House and Cottages. Mayfield House DS0000000990.V329086.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 & 10 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. To maintain their autonomy and independence, staff support people in making choices and decisions about all aspects of their daily lives. People are involved in planning their care and are supported to take risks, but care plans need reviewing and updating to make sure that they reflect people’s current needs. EVIDENCE: All the care plans that I looked at include a comprehensive summary of the individual’s needs. The plans contain fully developed risk assessments for all areas where a potential or actual risk has been identified. These assessments should be dated so that staff know when reviews need to be carried out. Mayfield House DS0000000990.V329086.R01.S.doc Version 5.2 Page 11 The care plans for people whose needs have changed significantly must be reviewed and amended without delay; to provide staff with written confirmation of the way people’s needs are to be met. From talking to the people who live at the home, and the staff, it is clear that each individual is involved in developing and reviewing their own plan of care and support. This involvement should be recorded on the plan. The home has started to look at using an improved, more person-centred planning format which is much easier to read and will make the plans accessible to the individual. They will also show clearly that the person concerned has been involved in the plan’s development. The acting manager has arranged training for the staff, to give them the knowledge and confidence to complete the new plans. Five people who completed the questionnaires said that they do what they want during the day, evening and weekend, one person said they can sometimes do what they want at the weekend. One person commented that doing what they want sometimes depends on staff being available. One family member I spoke to said that her relative ‘…does the things she wants to’. Another family member said that their relative is happy at the home. One person’s relative expressed a high degree of satisfaction at the care and support their relative receives at Mayfield House and Cottages. They are kept up to date with progress and any changes and told me that the staff have ‘Been amazing’. The people who live at the home are involved in all the decision-making processes. There also residents’ meetings at the home and the organisation’s Board of Trustees has resident representation. My observations confirmed that people are very confident about telling the staff what they want, and the staff always respect people’s preferences. During my visit people showed me what changes there had been in their home, and in other aspects of their lives. It was clear that these changes follow the wishes of the individual. All confidential information is securely stored and is only shared with people who need to know. Mayfield House DS0000000990.V329086.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to access a range of work, educational and leisure activities and to maintain contact with family and friends. This makes sure each person’s needs and aspirations are met. The meals are of a high standard and mealtimes are relaxed, providing both the nutrition essential for health and a pleasant social occasion. EVIDENCE: The people who live at Mayfield House and Cottages choose how they prefer to spend their time. Everyone’s plan of care and support includes details of their goals and how they wish to achieve them. Because of the increased costs, and the consequent reduction of services available to people outside the home, Social Services has agreed to fund a certain number of hours of outreach service. Outreach staff are employed to support people to go out to their education, leisure and recreational activities. Outreach staff also work with Mayfield House DS0000000990.V329086.R01.S.doc Version 5.2 Page 13 people in the home. During the evening of my visit, one new outreach worker was doing craft work with some of the people who live at Mayfield House and Cottages. This member of staff told me she was enjoying the work. The staff support people to take up employment opportunities if they wish. One person has worked for a local firm for some time now. Although one family member I spoke to was concerned that there seems to be fewer opportunities for their relative to go out to work places. Other people choose to attend adult education classes and take part in activities, such as going dancing at Square Chapel. One person chose the education classes she wished to attend. This has been arranged and the lady said she is pleased about this. In the questionnaires people commented on the activities they enjoy. These included; ‘most of the time I go to see my (family)’ and ‘I also go to see shows if there’s enough staff available’. Some people told me they enjoy working on projects around the home, such as assisting with gardening and maintenance work. The relatives I spoke to all confirmed that good contact is maintained. The people who live at the home regularly go to visit their families, or their families visit them. The people who live at Mayfield House and Cottages are involved in menu planning. Everyone who commented said they enjoy their meals. On the day I visited a birthday was being celebrated. The staff had worked hard to prepare a special buffet meal at teatime, which everyone enjoyed. The daily menus are well balanced and provide both good nutrition and an appetising choice of meals. Individual preferences are catered for and any assistance needed during mealtimes is offered discreetly. Drinks and snacks are available at all times of the day and night. Mayfield House DS0000000990.V329086.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 & 21 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Each individual’s personal and healthcare needs and preferences are being met in the way they prefer and people are supported to maintain good health. People are protected by the medication systems, which ensure that medications are stored and administered safely and accurately. To maintain their dignity, the staff treat people with respect and consideration at all times. EVIDENCE: The people who live at Mayfield House and Cottages are offered the level of support and care they need, in accordance with their wishes. Professional healthcare advice is sought whenever it is needed, and any changes are recorded and acted upon. People who need medical treatment are fully Mayfield House DS0000000990.V329086.R01.S.doc Version 5.2 Page 15 supported by the staff, both when they are at home and in hospital, in order to make the time as comfortable and stress-free as possible. The manager described how she and the staff act as advocates for people, to make sure they receive the medical care they need. Relatives confirmed that they are kept informed of changes in people’s healthcare needs. On the questionnaires I sent to the people who live at Mayfield House and Cottages, everyone said that the staff listen & act on what they say and all agreed that the staff treat them well. There is a lively, relaxed atmosphere at the home and my observation confirmed that the staff respect and promote people’s individuality and dignity at all times. The daily records and records of appointments are all kept up to date. From my own observation and talking to people, it was clear that the staff are fully aware of each individual’s personal and healthcare needs and how their needs are to be met. The medical record file clearly shows where healthcare changes have occurred. For the safety of the people who live at Mayfield House and Cottages all medicines are securely stored. There is a safe system for storing and administering any controlled drugs, based on advice given by the home’s pharmacist. The staff have received training on the safe administration of medicines. My observation during the visit confirmed that staff administer medicines correctly. This is essential to help make sure people maintain optimum health. One relative commented that the family are concerned about the levels of medication taken by their relative. The home has made some of the planned changes to its layout and facilities, and the staff have had training, to meet people’s altered circumstances and health needs. From my own observation, and comments made by the people who live at the home, the staff do everything they can to care for and support people when their health and well-being has declined. Professional healthcare advice is sought when needed. The family of one person whose health has altered, were very positive in their appreciation of the quality of care and support their relative receives. Mayfield House DS0000000990.V329086.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home, and their relatives, are aware of how to raise a concern or make a complaint if they are dissatisfied with the service. Staff have received suitable training and understand the adult protection policies and procedures, which makes sure that people living at the home are safe. EVIDENCE: The complaints information written for the people who live at Mayfield House and Cottages, has been developed in an easy to read format, which is attractive, clear and usable. Everyone who sent in the questionnaires said they know what to do if they are unhappy. One person said ‘….if I do (have any complaints) … I can speak to the staff or my brother’. The home’s policies and procedures are up to date. There are adult protection and ‘whistle-blowing’ policies and procedures in place that cover the way any concerns or allegations of abuse or poor practice would be handled. All staff have taken Protection of Vulnerable Adults training and are waiting to be updated with new procedures. The people who live at Mayfield House and Cottages are involved in the way the home is run. Their influence is central to the decision-making processes. Everyone is able to contact someone who will advocate for him or her, or support them to self-advocate, if they wish. Mayfield House DS0000000990.V329086.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26 & 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Although further improvement work is needed, the house and grounds are generally well maintained, attractive and accessible. The bedrooms and flats are well furnished and doors can be locked for privacy. The whole house is clean and hygienically maintained. These factors combine to provide a safe, comfortable and homely environment. EVIDENCE: A new ground floor bedroom with en suite toilet, washbasin and level shower area has been completed and is now in use. The person who is using the room told me it is very nice and seemed highly satisfied with it. Other bedrooms have been altered to improve the layout for the person whose room it is. All the rooms that I saw reflect the person’s individual preferences and taste. The bedroom doors all have locks. Mayfield House DS0000000990.V329086.R01.S.doc Version 5.2 Page 18 Re-decoration work and other improvements are underway in one of the flats at Mayfield Cottages. The person who lives there showed me the alterations and explained the other changes he wants. Further improvements to other bedrooms are planned for this year. There are plans to make the two downstairs bathrooms into two ‘wet rooms’. These will provide more accessible, level showers for people where seating can also be used if the person wishes. The ‘wet rooms’ will also have a toilet and washbasin fitted. There will still be a bathroom upstairs for those people who prefer a bath. The grounds are looking tidier than at the last inspection. The area between the house and the cottages has had tarmac laid, and other parts of the grounds have been tidied. The home is working in partnership with two other organisations on their plans for the large garden area at the rear of the cottages. Some of the people who live at Mayfield House and Cottages enjoy working in the garden and assisting with practical jobs around the house. One gentleman showed me what he had achieved and explained his plans for the future. The home is fresh, clean, comfortable and well looked after. Everyone who commented agreed that the home is well kept. Mayfield House DS0000000990.V329086.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Sufficient staff are employed to meet the needs of people living at the home. The people who live at the home are protected by thorough recruitment procedures. Suitable staff training is provided; to make sure staff have the skills and knowledge they require to meet people’s needs. EVIDENCE: There are enough staff on duty at all times to meet the needs of the people who live at Mayfield House and Cottages. The home does not use agency staff and any additional shift cover needed is provided from within the organisation. I looked at a selection of staff files. They all included completed application forms and two written references. The files showed that satisfactory Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) register checks have been obtained. I was assured that no new staff start work until a POVA register check had been completed. Then, if the CRB check had not been received, they would work only under the supervision of an experienced staff Mayfield House DS0000000990.V329086.R01.S.doc Version 5.2 Page 20 member. The organisation is reviewing the frequency with which they update staff member’s CRB and POVA checks. The manager makes sure that staff have all the necessary training to help them do their work as well as possible. There is a wide range of courses available and the records confirmed that the staff are allowed the time to attend. Staff qualification certificates were included in the staff files. The staff have taken specialist training courses in subjects such as dementia care and managing challenging behaviour. Seven of the sixteen support staff have a relevant National Vocational Qualification (NVQ). Three staff are currently working towards their NVQ level 2 qualification and three more will register in September. One member of staff intends to take NVQ level 4 in the near future. Mayfield House DS0000000990.V329086.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed and everyone who lives and works at the home is involved in the decision-making processes. The quality assurance systems have been further developed, to provide additional information to help improve the service. The policies and procedures are up to date and are available to guide staff in all aspects of their work. EVIDENCE: The acting manager has the qualifications and the skills to manage the home effectively. The manager promotes an open and inclusive management style and everyone is involved in the decision-making processes. My own Mayfield House DS0000000990.V329086.R01.S.doc Version 5.2 Page 22 observation and comments from other people confirm that everyone’s views are valued and taken into account. The whole ethos of the home is centred on supporting the people who live at Mayfield House and Cottages to lead lives which are full and rewarding and meet their expectations and wishes. The quality assurance systems are being revised. The new questionnaires for the people who live at the home are being produced with photos of the home to illustrate the questions. There is a questionnaire for staff, providing valuable feedback which the manager has acted upon. Questionnaires for other stakeholders have not produced enough responses. The manager has plans to improve this and at the same time provide stakeholders with more information about the home. The Registered Provider carries out monthly quality assurance visits. All this gives valuable information to help further improve services for the people who live at Mayfield House and Cottages. The annual budget for the home includes provision to complete the planned improvements to the facilities. The policies and procedures have been updated within the last year, to make sure they provide up to date information to guide staff on how to act in every situation. All the regular health and safety checks for the home are carried out in a timely manner. Staff have basic health and safety training. All these measures make sure that the health, safety and welfare of the people who live at the home is promoted and safeguarded. All new support staff follow an approved induction course, followed by the Learning Disabilities Award Framework (LDAF) foundation training. This makes sure new staff have a good understanding of their role and responsibilities, and provides a sound basis for NVQ study. Mayfield House DS0000000990.V329086.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 4 3 3 3 LIFESTYLES Standard No Score 11 4 12 3 13 3 14 4 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 3 4 4 3 X X 3 X Mayfield House DS0000000990.V329086.R01.S.doc Version 5.2 Page 24 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(2)(b) Requirement Each individual’s care plan must be reviewed regularly in order to show how the person’s current, assessed needs are to be met. The care plans must show that the people who use the services, or their representatives, have been involved in developing and reviewing their plans, to confirm that the plans reflect each individual’s wishes. Timescale for action 30/06/07 2. YA6 15(2)(c) 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Mayfield House DS0000000990.V329086.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 House DS0000000990.V329086.R01.S.doc Version 5.2 Page 26 - 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. 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