CARE HOME ADULTS 18-65
Mayfield House King Cross Road King Cross Halifax West Yorkshire HX1 3LN Lead Inspector
Liz Cuddington Unannounced Inspection 27th February 2006 15:15 Mayfield House DS0000000990.V255498.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 DS0000000990.V255498.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 DS0000000990.V255498.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Mayfield House Address King Cross Road King Cross Halifax West Yorkshire HX1 3LN 01422 362121 01422 362121 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 Mrs Sharon Linda Porteus 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.V255498.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 25th October 2005 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. There is one manager with overall responsibility for the two parts of the premises. The manager and staff support the ladies and gentlemen who live at Mayfield to live active, independent lives pursuing their own work and recreational interests and maintaining connections with family and friends. Mayfield House DS0000000990.V255498.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Over an inspection year from April until March, care homes have a minimum of two inspections; these may be announced or unannounced. This was the second unannounced visit to the home. There have been no further visits to the home until this unannounced inspection. One inspector carried out the inspection and spent approximately three hours in the home. The purpose of this inspection was to assess the home against a predetermined selection of the National Minimum Standards for Adults aged 18-65 years. The methods used in this inspection included conversations with six residents and five staff, examination of records, a tour of the ground floor area of the main house and a look at the garden. This was a short inspection to assess the remaining six key standards, which must be inspected during the year. The other key standards were assessed at the last inspection in October 2005. Three good practice recommendations have been made following this inspection. Once again this was a good inspection, reflecting the commitment to offering a high quality support and care service to the ladies and gentlemen who live at Mayfield House and Cottages. I would like to thank everyone who lives and works at Mayfield for taking the time to talk to me and for their welcome and hospitality during the inspection. What the service does well: What has improved since the last inspection?
The home has taken advice from their supplying pharmacist about the safest way to give service users their medicines to take if they are away from home. The system is not ideal, but it does make sure staff are not handling medicines other than to administer them directly to the service user.
Mayfield House DS0000000990.V255498.R01.S.doc Version 5.1 Page 6 The home has a quality assurance system in place which, although it should be extended to include other interested people, is providing feedback and information to further improve the quality of the services offered at Mayfield. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Mayfield House DS0000000990.V255498.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mayfield House DS0000000990.V255498.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2 & 4 were assessed in October 2005. None of the other standards were assessed at this inspection. EVIDENCE: Mayfield House DS0000000990.V255498.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, 8 & 9 were assessed in October 2005. None of the other standards were assessed at this inspection. EVIDENCE: Mayfield House DS0000000990.V255498.R01.S.doc Version 5.1 Page 10 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): Standards 12, 13, 15, 16 & 17 were assessed in October 2005. None of the other standards were assessed at this inspection. EVIDENCE: Mayfield House DS0000000990.V255498.R01.S.doc Version 5.1 Page 11 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): 20 Standards 18, 19, 20 & 21 were assessed in October 2005. A safe system of administering medicines when service users are away from home has been agreed with the pharmacy. EVIDENCE: The home has taken advice from Boots, their supplying pharmacist, about the safest way to give service users their medicines to take when they are away from home. The pharmacy will not support the home’s staff transferring medicines into other containers, since there is the potential risk of mistakes occurring. While the new system is not ideal, it is the safest option. Mayfield House DS0000000990.V255498.R01.S.doc Version 5.1 Page 12 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 Standard 22 was assessed in October 2005. Policies and procedures referring to adult protection and handling difficult situations are robust but need to be reviewed annually. EVIDENCE: The home has policies and procedures in place detailing how any adult protection concerns, or potentially difficult situations are to be handled. The systems are robust and follow the best practice guidance. The policies and procedures referring to adult protection need to be reviewed and, if necessary, updated regularly to make sure they are still current. The one held at Mayfield House was dated May 2003. Mayfield House DS0000000990.V255498.R01.S.doc Version 5.1 Page 13 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): Standards 24, 27, 28, 29 & 30 were assessed in October 2005. None of the other standards were assessed at this inspection. EVIDENCE: Mayfield House DS0000000990.V255498.R01.S.doc Version 5.1 Page 14 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): 32 & 34 Standard 35 was assessed at the last inspection. Staff interact well with service users and show respect and consideration. Suitable training courses are available, which staff attend. Not enough staff have achieved an NVQ qualification in care. The recruitment and selection process is thorough and safe. EVIDENCE: New staff take an induction training course, followed by the Learning Disabilities Framework Award (LDAF) foundation training. Some of the support staff at Mayfield House already have an NVQ in care, and another five are taking the qualification. Until these staff have completed the course the home is unable to meet the standard of having half of its staff with a suitable qualification. More staff should be encouraged to take a qualification. Other training is provided to help staff learn and develop the skills and experience they need to understand the needs of the service users and to do their jobs effectively. Staff show respect towards the people who live at Mayfield House and spend time listening to and talking with them. The atmosphere is relaxed and friendly and service users and staff have a good relationship with each other. Mayfield House DS0000000990.V255498.R01.S.doc Version 5.1 Page 15 Following restructuring within the organisation the recruitment and selection procedure for Mayfield House and Cottages is now being managed at the home. New staff are not appointed until two suitable references, a satisfactory Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) check have been received. In addition, the candidate also attends a service users advocacy meeting, so that the service users can decide if they are happy with the choice of new staff. There is a six month ‘probationary’ period. A new member of staff confirmed that they are given copies of the General Social Care Council’s codes of conduct of practice. Mayfield House DS0000000990.V255498.R01.S.doc Version 5.1 Page 16 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): 39 & 42 Standards 37 & 39 were assessed at the last inspection. A good quality assurance system has been started, but needs to be extended to include other stakeholders. Health and safety and food hygiene are maintained throughout the home. EVIDENCE: Surveys to obtain the views of the people who live at Mayfield have been carried out. I saw evidence showing that the home had acted upon the comments people made. The quality assurance system could be developed further to include obtaining the views of other people who have an interest in the home, such as staff, service users families and visiting health and social care professionals. I looked at some of the health and safety standards. The house and grounds are maintained and there is ongoing work to make improvements. The premises are secure and any accidents or illnesses are recorded and reported. Refrigerator and deep freezer temperatures are recorded regularly. I discussed
Mayfield House DS0000000990.V255498.R01.S.doc Version 5.1 Page 17 with the cook discussed how the kitchen is used by staff and service users. Safety is considered very important. For example, one service user who likes to cook is able to do so within a safe area of the kitchen. Mayfield House DS0000000990.V255498.R01.S.doc Version 5.1 Page 18 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 2 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 X X X 2 X X 3 X Mayfield House DS0000000990.V255498.R01.S.doc Version 5.1 Page 19 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. Standard Regulation Requirement Timescale for action 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. 3. Refer to Standard YA23 YA32 YA39 Good Practice Recommendations Policies and procedures referring to adult protection should be updated annually. In order to meet the standard more staff should complete a suitable NVQ qualification. The quality assurance system should be extended to include other stakeholders. Mayfield House DS0000000990.V255498.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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