Inspection on 19/07/07 for Mayfield House

This inspection was carried out on 19th July 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mayfield House 16/10/06

Mayfield House 10/10/05

Mayfield House 15/06/05

Mayfield House 30/11/04

Mayfield House 28/04/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Mayfield House 41 London Road Liphook Hampshire GU30 7AP Lead Inspector Wendy Thomas Unannounced Inspection 19th July 2007 11:00 Mayfield House DS0000011905.V341253.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 DS0000011905.V341253.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 DS0000011905.V341253.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mayfield House Address 41 London Road Liphook Hampshire GU30 7AP 01428 724982 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) Mrs Gayawotee Rayola Jingree Mrs Gayawotee Rayola Jingree Care Home 12 Category(ies) of Learning disability (12), Learning disability over registration, with number 65 years of age (2) of places Mayfield House DS0000011905.V341253.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th October 2006 Brief Description of the Service: Mayfield House is a care home providing personal care and accommodation for up to 12 service users in the category of learning disability and is owned by Mrs Jingree who is also the registered manager. The home is situated within close proximity of the town of Liphook that has a range of leisure and recreational facilities. Mayfield House has a communal lounge and communal dinning room and a garden to the rear with seating. The current average fee is £634 per week. Items not covered by fee include hairdressing, chiropody, toiletries, transport and holidays. Mayfield House DS0000011905.V341253.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report summarises information obtained about Mayfield House by the Commission for Social Care Inspection (the commission) from a variety of sources including; the Annual Quality Assurance Assessment (AQAA) supplied by the home, a visit to the home on 19 July 2007, and other information submitted to the commission such as details of any incidents. The visit to the home lasted six hours and the inspector spoke at length with the manager, two members of staff and two of the people living at the home. She spoke more briefly with several more of the people who use the service. Records and policies and procedures were examined that were relevant to the inspection process, including samples of care plans, financial recording, medication records and several policies and procedures. What the service does well: What has improved since the last inspection? As the manager proceeds with her training she is seeking to put into practice what she is learning and is encouraging the people living in the home to take Mayfield House DS0000011905.V341253.R01.S.doc Version 5.2 Page 6 more responsibility and be involved in more decisions about their individual lives and the running of the home. The people living in the home are being encouraged to help with food preparation and the manager is planning to increase the choices available at the main meal each day. The manager has updated the induction programme for new staff and confirmed that it conforms to the guidance produced by Skills for Care, the Sector Skills Council. Pre-employment checks for staff are now being carried out satisfactorily and staff are not starting work before all checks have been carried out. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Mayfield House DS0000011905.V341253.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mayfield House DS0000011905.V341253.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for assessing the individual needs of prospective residents enable them and the home to make a decision about whether the home can meet their needs. EVIDENCE: All the people who live at Mayfield House have done so for some time. There have been no new admissions and none are anticipated. Previous inspection reports for the home identified that arrangements for assessing the needs of prospective residents were good. The home conducts a formal assessment and obtains a care manager’s assessment where this is applicable. Prospective residents are able to visit the home prior to admission, for a meal and to spend time with the other residents. The manager confirmed that the arrangements had not changed since the last inspection. In the annual quality assurance assessment (AQAA) returned to the Commission for Social Care Inspection prior to the visit to the home, she said that if the situation were to arise where further admissions were to be considered, that the information materials produced by the home could be improved by adding pictures and photographs. Mayfield House DS0000011905.V341253.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living in the home benefit from having their needs assessed and plans developed to meet those needs. This process puts the person much more to the forefront than previously, however further development of a “person centred” approach will further enable the people living there to make choices and be in control of their own lives. EVIDENCE: Files for the people living in the home were sampled. They were found to contain a detailed review for the person describing them and their needs and achievements. Care plans included areas such as personal hygiene, oral hygiene, daily living skills, vision (e.g. support needed with spectacles), incontinence support, family contact and support needed with finances. Although some of these gave a good level of detail, particularly in the areas of Mayfield House DS0000011905.V341253.R01.S.doc Version 5.2 Page 10 physical needs, others were in need of further development and detail, in order for staff unfamiliar with the person to be able to support them effectively. The inspector spoke with a number of the people living in the home. All of whom expressed their satisfaction with the home and their lives there. They have established routines that they expressed satisfaction with. The manager, through training she has undertaken, is seeking to develop the service for the people living there and is working to develop ways in which they can have a greater role in determining what happens for them individually and within the home in general. She described a desire to empower those living there and was developing strategies to promote this. The staff, who the inspector spoke with, were also enthusiastic about these developments. Discussions with the staff and manager gave the impression of the service being one that was moving from being mainly about caring for people, to one that was working with people to support them to make decisions about their own lives. A member of staff explained that the people living there now had “wider choice” and cited as an example one person now going to a local hairdresser to have their hair done. Another member of staff said that they thought that the home was improving by becoming more “client centred” and was offering people more choice. Supporting people with communication needs is an area for further development. The manager explained that one of the people living at the home who used sign language (Makaton) before coming to the home no longer does so. The home has now obtained information about Makaton and the manager plans that staff will start to use this with the person. There is little pictorial signage around the home, however the manager explained that pictures and photos are being collected to help in meal planning and menu selection. The manager explained that the home is developing key working and staff records showed that they had recently had training about this. Those staff spoken with were positive about the recent series of training sessions and said they had found them helpful. Some risk assessments were in place, however risk assessment and risk management is an area that needs further development and should tie in with care planning. Of the staff asked about risk management, one said that they had had training and one had not. They had both been involved in carrying out risk assessments. The risk assessments seen related to supporting one of the people with issues connected to their behaviour. Other risk assessments covered bathing and diabetes. The manager, staff and one of the people living in the home all mentioned the residents’ meetings held in the home. Notes are kept outlining what is discussed and it was noted that there had been seven such meetings in the past ten months. Staff and the manager spoke about how the people living in Mayfield House DS0000011905.V341253.R01.S.doc Version 5.2 Page 11 the home are being encouraged to be more involved in decision-making about their lives in the home. One of the people living in the home described the meetings and said that they talked about, “What we want to eat, what we want to do and where to go on holiday.” Mayfield House DS0000011905.V341253.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): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living at Mayfield House benefit from being able to take part in a variety of activities organised by the home or the day service facilities they attend. The staff team are being proactive in developing these opportunities further to promote choice and a more individualised service. EVIDENCE: The people living in the home expressed their satisfaction with their lifestyle. They gave the appearance of being an established family style group comfortable in each other’s company, supporting each other and experiencing the frustrations at aspects of each other’s personalities or behaviour, that living with others usually brings. Mayfield House DS0000011905.V341253.R01.S.doc Version 5.2 Page 13 The people living at Mayfield House take part in a variety of activities within and outside of the home. Most of the daytime activities that people participate in out of the home are supported by the local day services for people with a learning difficulty, and include attending local clubs for older people, and aqua fit at the swimming pool. People living at the home described enjoying art and craft and gardening activities through the day services. Those who didn’t go out much confirmed that this was because they did not want to, with one saying, “I’m quite happy with what I do.” The manager said that one person regularly attended church and that Anglican Communion was held in the home once a fortnight and about five of the people living there attended. The manager has arranged for someone to come and lead a Tai-Chi session once a week, and she said that she hopes to introduce reflexology. The manager explained that she was trying to introduce more activities arranged by the staff at the home. Staff confirmed this, and they, the manager and those living there spoke with enthusiasm about a barbecue they had recently in the garden. There were a number of board games and activities such as jigsaws available in the lounge and dining room. One of the staff said that sometimes people would play hoopla. One of the people living at the home said that they liked knitting, and another was seen doing some knitting. The manager said that some people also like to do embroidery. The home organises group activities, and in the past transport has been hired to take the group for a short break at Butlins and on day trips to the Isle of Wight, Longleat and the seaside. The manager reported that a further trip to Butlins or to Euro Disney was being considered. A member of staff and one of the people living at the home described a trip to London before Christmas to see the lights. From 8pm there is one member of staff on duty so it is not possible for people to go out later in the evening if they need support. However the manager said that most people do not wish to go out in the evening, and several confirmed that they liked to stay at home and watch the soap operas on television. One member of staff described supporting one of the people who use the service to the local pub, and the manager said that one person attends a local club. The files of the people living in the home include activity sheets listing the activities they have undertaken. However, discussion with the staff indicated that people were taking part in a wider range of activities than were recorded on their sheets. At the previous inspection a recommendation was made suggesting the documentation of how the home meets people’s occupational, leisure and social needs should be improved. There are still gaps in this documentation, especially in the use of local facilities and community activities outside of day service hours. Mayfield House DS0000011905.V341253.R01.S.doc Version 5.2 Page 14 One of the people living in the home explained that they visited and received visits from one of their relatives. They talked about their family and had photographs of relatives in their room. The people living at the home said that the food was good, one person described it as, “Very nice.” One explained that they would be helping to cook the evening meal and that this was something they enjoyed doing. People were observed having support to make their own sandwiches at lunchtime. It was explained by staff and the manager that this was a new development and that the people living in the home were being encouraged to take more responsibility for themselves. The manager explained that vegetables were now being served in dishes at the table and people were able to help themselves to what they wanted. She reported on plans she had to increase the involvement of the people who live at the home in deciding what meals are offered and in improving choice. The menus planned for the week were seen and offered a variety of nutritious meals. Mayfield House DS0000011905.V341253.R01.S.doc Version 5.2 Page 15 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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living at Mayfield House benefit from a staff team that know them well and are familiar with how to meet their needs. Their health care needs are monitored, and medication is satisfactorily managed thus promoting their health and well-being. EVIDENCE: A key worker system operates in the home. One of the people living there described how this worked for them and was clearly happy with the system. They described the support given by their key worker/s. They said that they liked their key worker/s. Care plans were seen describing the support needed for personal care issues. Records of any medical treatment and contact with health care professionals are kept and staff are directed to these via the home’s communication book. Mayfield House DS0000011905.V341253.R01.S.doc Version 5.2 Page 16 The manager explained that, where appropriate, support was sought from the specialist health care team. Several of the staff have a background in general nursing and described satisfactory systems for monitoring health issues and referring to health care professionals as the need arose. Staff spoken with were able to explain the medication procedure and knew where the policy was kept. The medication cabinets were kept tidily and the inspector was assured that the newly delivered medication would be stored away securely. On examination, records of the administration of medication were found to have some gaps, or incorrectly coded entries. The manager was able to explain most of these, however any codes for omissions etc. must be explained on the recording sheets, and any missed medication explained in the records. Mayfield House DS0000011905.V341253.R01.S.doc Version 5.2 Page 17 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 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff training and the home’s procedures promote the well-being of those living there, protecting them from abuse and acting on their concerns. EVIDENCE: The home’s policies and procedures file included some useful information about safeguarding adults from abuse. The home was not able to produce a copy of the Hampshire procedure for the protection of vulnerable adults from abuse, although the manager confirmed that the home did have a copy and that their own procedure ties in what the bodies charged with following up any such concerns would do. A member of staff confirmed that they had received training in safeguarding adults from abuse. An external trainer had provided this. When an issue concerning safeguarding adults from abuse was raised at the home, appropriate action was taken Most of those living at the home require support to manage their personal finances and choose for the home to hold their money. The home has a very thorough policy for the management of people’s finances, which was seen. Records of money held on people’s behalf were seen and tallied with the amounts held. People can only access the money looked after for them when Mayfield House DS0000011905.V341253.R01.S.doc Version 5.2 Page 18 the manager or administrator are working. However this did not appear to be a problem for anybody. The manager confirmed that all the people living in the contributed £35 per month towards the running of the home’s vehicle and that this was a contractual arrangement agreed with the people’s care managers. Additional charges are made for group trips out when a vehicle needs to be hired. The complaints record was seen but there had been no complaints since the last inspection. At the previous inspection the written complaints policy and procedure was found to be comprehensive. A member of staff explained that they would try to resolve any concerns rose to them as soon as they arose, but if they were unable to would refer it to the manager. Through observation of the interactions between staff and people living in the home, it would seem that there is a relationship of trust between all parties, indicating that people’s concerns would be listened to and appropriate action taken. Those spoken with did not have any complaints about the home, or any suggestions to make improvements. Mayfield House DS0000011905.V341253.R01.S.doc Version 5.2 Page 19 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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living at Mayfield House benefit from a clean, safe and comfortable environment. EVIDENCE: People living in the home showed the inspector around the communal areas of the home and their own bedrooms. Some of the décor is dated and the manager described an ongoing programme of redecoration and purchase of new furniture. This programme is underway with some bedrooms having been redecorated, along with the hallway and stairs. The plans also include the replacement of the call bell system and possibly new lounge furniture within the year. Two of the people living at the home spoken with shared their bedrooms. They said that they were happy with this arrangement. Bedrooms were seen to be Mayfield House DS0000011905.V341253.R01.S.doc Version 5.2 Page 20 personalised with the personal belongings of those living there. There was sufficient furniture and storage space appropriate to people’s needs. Those living in the home, the staff and manager confirmed that there was always enough hot water, and those who wanted could have a bath every day. The home was very clean at the time of the visit and a member of staff was carrying out cleaning duties and vacuuming one of the bedrooms. A person living in the home, who returned a questionnaire to the commission, stated that the home was “always” clean and fresh. Staff described the measures taken to prevent cross infection. Robust systems promoted high standards of hygiene. Some idiosyncrasies in people’s bedrooms were discussed, such as lack of curtains, or curtains being hung the wrong way round. The manager confirmed that this was the wish of the people living in these rooms, who did not want support to change how their rooms were set out. Mayfield House DS0000011905.V341253.R01.S.doc Version 5.2 Page 21 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, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living at Mayfield House benefit from a committed and well-trained staff team, who are working with the manager to develop the service and promote the autonomy of those living there. Recruitment procedures further the employment of staff suitable for the work and contribute to safeguarding the people who use the service from abuse. More regular staff supervision would build on staff competence and address deficits. EVIDENCE: The people living at the home said that they liked the staff including comments such as, “Nice staff, really lovely staff.” Staff said that they worked together well as a team and were supportive of each other. Those spoken with demonstrated an enthusiasm for the work and a commitment to the people they worked with. They said that they liked working at Mayfield House. Mayfield House DS0000011905.V341253.R01.S.doc Version 5.2 Page 22 Staff training records were seen and since the last inspection; safeguarding adults from abuse, food hygiene, infection control and first aid training had been carried out. An external trainer had also been commissioned to provide a series of two to three hour weekly seminars, which covered such subjects as; challenging behaviour, the biological basis for learning disability, epilepsy triggers, monitoring behaviour, causes of learning disability, devising care plans, key working, care review and empowerment. Those staff spoken with were pleased with the training they had received and with the support and encouragement they were given to undertake NVQ qualifications. The manager explained that she had recently commissioned the local association of care homes, of which she is a member, to conduct a training analysis of the staff team. This has now been completed and she said she was now in negotiation with them to provide for the training needs identified. Since the recommendation in the previous inspection report that the staff induction programme should be in line with the Skills For Care common induction standards, the manager confirmed that she had rewritten the home’s induction standards to incorporate these. The staff files of the two most recently appointed staff were seen. They contained sufficient information to ascertain the person’s suitability for the work, such as; an application form, two references, and Criminal Records Bureau checks. However, one did not include a full employment history. Best practice guidelines recommend this to verify their suitability. The manager confirmed that she had interviewed the staff, however there were no notes of this in their files. She said that she follows a set format and marks scores for each candidate. She said that she would keep these on file in future. The rota shows that staff work from 8am to 2pm or 4pm and 2pm or 4pm to 8pm. One member of staff sleeps in the home and is working until 10pm. A member of staff said that staff meetings were approximately every 4 weeks. The manager explained that the aim was to have monthly staff meetings, but that these had tailed off a bit since April because staff training sessions had been scheduled for the times usually kept aside for staff meetings. Records showed that there had been six staff meetings in the last year. Although staff said that they were receiving formal supervision from the manager, records showed that this was not happening at the recommended frequency of every two months. The manager explained that this was an area that had now been covered in her own training, and that she was gaining in confidence to carry out this aspect of her role. The requirement regarding this from the last inspection report has been repeated here, as it has not yet been fully met. Mayfield House DS0000011905.V341253.R01.S.doc Version 5.2 Page 23 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, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed by a manager who is keen to develop the service. The people living at the home benefit from being consulted and their views sought. However, developing the quality assurance process further will lead to better defined aims for the service and more measurable results for those living there. EVIDENCE: The manager is studying for her NVQ level 4 in care and management. She described the benefits to the service through the learning she is undertaking and said that she is finding the course very useful. She is putting into practice what she is learning and is keen to empower both the people living in the Mayfield House DS0000011905.V341253.R01.S.doc Version 5.2 Page 24 home and the staff team. She seeks to share her learning with the staff team and to support theirs by passing on information and reading material. A member of staff described the manager as being “always helpful” and “approachable”. She was felt to be knowledgeable, but honest about her knowledge gaps, seeking to find out information if she didn’t know it. One of the people living in the home who returned a questionnaire to the commission said that the manager, “ is nice, isn’t she? A good laugh.” The manager explained that through studying for her NVQ 4 she learnt more about quality assurance and said she was working at developing some forms at the moment. She reported that she had sent out questionnaires to the relatives and other professionals involved with the people living at the home. Currently the formal forward planning for the home consists primarily of maintenance issues and staff training. However the manager described lots of areas she was planning to develop and the need to bring these into the home’s business plan was discussed, along with the need to develop an annual quality assurance cycle. The home’s AQAA confirmed that all health and safety checks were being carried out and plant and machinery serviced satisfactorily. This was confirmed by sampling the maintenance records for fire detection and alarm equipment, gas appliances and the chair lift. The AQAA confirmed that all the necessary policies and procedures were in place and being regularly reviewed. Again sampling verified that well developed policies were in place. The care plans for the people living in the home included an individualised fire plan, describing the actions the person should take, and the support they would need to do this, in different scenarios. The manager explained that fire procedures were discussed at all residents’ meetings, and one of the people living at the home explained very clearly what they would do in the event of fire. Mayfield House DS0000011905.V341253.R01.S.doc Version 5.2 Page 25 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Mayfield House DS0000011905.V341253.R01.S.doc Version 5.2 Page 26 yes 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. 2. Standard YA36 Regulation 18(2) Requirement The registered person must ensure that all staff members are formally supervised at least six times a year. This requirement is repeated from 16/10/06. Timescale for action 11/10/07 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. 2. Refer to Standard YA9 YA39 Good Practice Recommendations Risk management should be developed further and risk assessments developed that relate to care plans. The quality assurance process should be more formalised and include goal setting. In this way the improvement in outcomes for the people living there can be measured. Mayfield House DS0000011905.V341253.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 DS0000011905.V341253.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. 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