Inspection on 03/09/07 for Mayfield House

This inspection was carried out on 3rd September 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Mayfield House 04/09/08

Mayfield House 23/05/06

Mayfield House 16/11/05

Mayfield House 16/05/05

Mayfield House 19/10/04

Mayfield House 11/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Mayfield House Mayfield House 29 Mayfield Road Walton-on-thames Surrey KT12 5PL Lead Inspector Lisa Johnson Unannounced Inspection 09:40 3 September 2007 rd X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Mayfield House DS0000013713.V342360.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Mayfield House DS0000013713.V342360.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mayfield House Address Mayfield House 29 Mayfield Road Walton-on-thames Surrey KT12 5PL 01932 229390 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) patprior@mayfieldhouse29.fsnet.co.uk Mr Colin Catton Ms Elizabeth Patricia Prior Care Home 34 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (34) of places Mayfield House DS0000013713.V342360.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. It is a condition of registration that of the 34 people accommodated, UP TO 3 MAY FALL WITHIN THE CATEGORY DE(E) The age/age range of the persons to be accommodated will be: OVER 65 YEARS OF AGE 23rd May 2006 Date of last inspection Brief Description of the Service: Mayfield House is a long established, privately owned care home situated in Walton-On-Thames. The home provides care and accommodation for up to 34 older people who need personal care and assistance. Accommodation is provided on two floors, there is access to the first floor via a lift and stairs. The home offers accommodation in single and double rooms. There are two large sitting rooms, a large dining room and a conservatory. There is a small well-maintained garden. There is limited parking on site, however parking is available in the adjacent pay and display car park. The home is close to the mainline railway station of Walton-On-Thames and the local bus route. The weekly fees range from £430- £880 Mayfield House DS0000013713.V342360.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was part of a key inspection. The visit was unannounced and took place over eight hours commencing at nine forty am and finishing at six pm. Mrs. L Johnson Regulation Inspector carried out the visit and Ms. P Prior registered manager represented the service. The inspector spoke to five people who use the service and three relatives to gain their views on the care provided. Five surveys were received from people living in the service and five were received from relatives. Two surveys were also received from health care professionals. Comments received are reflected in this report. A tour of the premises took place. Information was examined which was provided by the manager supplied in the Annual Quality Assurance Assessment (AQAA). Care plans, staff recruitment and training records, medication administration records and policies and procedures were sampled. The inspector spoke to four members of staff. The inspector would like to thank the people using the service and staff for their time, assistance and hospitality during this visit. What the service does well: The service provided a friendly, open and relaxed atmosphere, which was confirmed, by a number of people surveyed and from discussions held with people living in the service, which included: “The home provides an attractive, warm and comfortable environment”;” gives visitors a warm welcome”; “The staff are always friendly and smiling”; “The home gives great attention to detail, particularly to make people feel like this is their home” and “the home respects individuals privacy, provides choice and understands the diverse needs of people” and “I am very happy here all the staff are very happy and friendly”. During this visit the lunchtime meal was observed which was well presented, well balanced and nutritious. Choices are available which was recorded on the menu and people living in the service were observed to be offered a glass of sherry or drinks of their choice before their meal. People using the service and their relatives were satisfied with the meals provided. Comments included; “ If there is something I don’t like on the menu the cook will always provide me with something else”; “the food is excellent and enjoyable”; “the meals are well planned” and “the dining room is like a small restaurant with fresh flowers provided on the table”. Mayfield House DS0000013713.V342360.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: People using the service and or their representatives must be consulted about their care plans, which must be agreed with them. At the previous visit it was required that care plans are signed are signed and dated by the author this has not been fully completed, therefore a further requirement has been made ensuring that the most up to date information is being used. Care plans must provide in more detail as to the actions required by staff to meet the individual’s identified needs. This matter has not been completed therefore a further requirement has been made. Daily records sampled during this visit did not correlate to the care needs identified in the care plan. Risk assessments were completed for individuals who are identified at risk of falls but the actions to minimise the risks must also be reflected in the care plan and it was recommended that these be regularly reviewed. The home must acquire appropriate weighing scales and maintain records of regular weight checks. It was recommended that where two staff hand transcribe medication on to the medication administration record this should be checked and signed by two members of staff ensuring the well being and safety of people using the service. The registered manager must attend the Surrey multi agency safeguarding adults from abuse training and make arrangements for all care staff to receive up to date training ensuring the well being and safety of people using the service. A carpet in one bedroom must be replaced as it was torn and identified as a trip hazard to the individual residing in this bedroom. It was recommended that a ramp is installed the entrance to the garden ensuring that people living in the service can access this area and it was recommended that the manager consult with an occupational therapist to assess the equipment to be provided in the planned bathroom refurbishment. Mayfield House DS0000013713.V342360.R01.S.doc Version 5.2 Page 7 One member of staff had commenced employment in the home without receipt of a POVA first check or Enhanced Criminal Records Bureau Check (CRB). Although references had been applied for these had not yet be returned prior to the individual commencing employment. Further improvement is required to ensure that staff receive up to date mandatory training including moving and handling, safeguarding adults from abuse and infection control. The home must ensure that staff induction is based on the Skills for Care common induction standards ensuring people using the home are supported by staff that are appropriately trained. The responsible individual must conduct monthly quality visits and maintain a written report ensuring that the home is run in the best interests of people living in the service. During this visit the fire door was wedged open to the kitchen. It was immediately required that this matter was attended to which was promptly responded to by a member of staff During a tour of the home it was observed that a number of radiators in communal areas and in some bedrooms were not protected by covers, therefore it was required that risk assessments are conducted ensuring the health, safety and welfare of people. 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 DS0000013713.V342360.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mayfield House DS0000013713.V342360.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that pre admission assessments are completed prior to admission to the home. The home does not support people for intermediate care. EVIDENCE: Pre-admission assessments were sampled for three individuals. It was clear that these had been completed prior to any person moving in the service. Community care needs assessments had also been obtained from the local authority where these were required and evidence was seen of health care professional reports. Information supplied with the Annual Quality Assurance Assessment (AQQA) states that all prospective individuals are assessed by two members of staff and this may be undertaken in the individuals own home, hospital or at the care service. Family and friends are also encouraged to visit. The home is able to offer short term, respite care but it does not support people with Mayfield House DS0000013713.V342360.R01.S.doc Version 5.2 Page 10 intermediate care. One person said that they had received very good information about the home. Mayfield House DS0000013713.V342360.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each person is provided with an individual care plan but need further expansion. The health care needs of people living in the service are met and they are protected by the homes medication policy and procedures and they are treated with respect and their right to privacy is respected. EVIDENCE: During this visit three care plans were sampled. Care plans were based on full needs assessments including health, nutritional, mobility, personal, emotional, sensory social cultural and religious needs. It was observed that care plans had not been signed by people living in the service and or their representatives to agree them, therefore it was required that consultation takes place. Two people spoken with who use the service and two relatives spoken with were not aware of the care plan. Individual care needs were identified and recorded but it was required that the plans need further detail and expansion as to how these needs will be met and actioned to provide guidance to all staff. A comment received from a relative indicated that the home needs to have in plans to support individuals who need extra support with mobilisation and socialisation. Mayfield House DS0000013713.V342360.R01.S.doc Version 5.2 Page 12 There were occasional gaps where the author of the care plans had still not signed or dated them to ensure that this was the most up to date information. This requirement was made at a previous visit; therefore a further requirement has been made. Evidence of monthly care plans reviews was recorded in individual’s files, although it was recommended that the daily notes relate to the individuals identified care needs. Risk assessments were completed for those individual’s identified at risk of falls, although the manager is advised that more detail should be included in the care plan, as one risk plan did not correlate with the care plan and had not been updated for three months. People using the service are registered with a General Practioner and information provided within the AQAA states that specialist nurses known to individuals prior to their move to the home are encouraged to continue their relationship. Five people surveyed said that they receive the medical support that they need. Information supplied with the AQAA states that the community eye care and domiciliary dental practice visit annually on request and chiropodists visit six weekly. Three surveys, which were received from health care professionals, say that the home works in partnership with them and that specialist advice unincorporated into the care plan. A community psychiatric nurse also supports individuals where this is required. Records were maintained of health consultations. During this visit the inspector had the opportunity to speak with one health care professional who was attending the home who stated that the home provides good care and they will always contact them for advice for such as nutritional and pressure area care. During this visit staff were observed to be knocking on peoples doors before entering and closing doors while carrying out personal care in the bathrooms. Staff were observed to speak to people with kindness and respect. Three health care professional surveys say that they are able to consult with individuals privately. One person surveyed commented, “I am very happy here, staff are friendly and helpful”. Another individual said “Staff always pop into my room if don’t always go downstairs”. One relative surveyed said, “The staff care and privacy is respected, the home gives choice and understands the diverse needs of clients”. The home has a medication policy in place. Photographs were available with the medication administration records. Records were maintained for the receipt and disposal of medication. All medication was administered was signed for and a homely remedies protocol was in place. There are currently no individuals who self medicate, although the manager has stated that this can be accommodated. The arrangements for medication administration were Mayfield House DS0000013713.V342360.R01.S.doc Version 5.2 Page 13 mainly satisfactory although improvement is recommended in ensuring medication that is transcribed by staff on to the medication administration record should be checked and signed by two members of staff ensuring the health, welfare and safety of people using the service. Mayfield House DS0000013713.V342360.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that people living in the service have access to a range of recreational and leisure activities and maintain links with their family/friends and the local community. People are supported to make choices and individual preferences are respected and they receive well-presented and balanced meals. EVIDENCE: The home provides an activities programme, which was seen on display throughout the home. The interests and hobbies of individuals were recorded in their care plan, although the home is advised that these could benefit from being expanded to include life histories which would provide staff with information and assist people with dementia. The home has their own piano and a pianist visits weekly. Various entertainers visit the service and during this visit an exercise session was held. Some people attend day services externally to the home and visit the local shops. A mobile library visits the service, which provides books in large print, and a hairdresser also attends. Three people spoken with during this visit said that were happy with the activities provided. Four out of five people surveyed said that there are enough activities. One person commented said that would like more to do. One comment received from a relative indicated that an extra member of staff Mayfield House DS0000013713.V342360.R01.S.doc Version 5.2 Page 15 would be beneficial to provide an extra member of staff to organise some other stimulating activities. Various ministers of religion visit the home on a weekly basis and all though this is not required at present information supplied with the AQAA states that other representatives from other religions would be contacted as requested. Information supplied in the AQAA states that functions are held at Easter, Christmas and a barbecue is held in the summer, which families and friends are invited to and the home also holds sherry mornings. During this visit a number or relatives were observed to be visiting the home and all relatives surveyed indicated that they are able to visit at any time and are made to feel welcome. During this visit one relative commented, “There is a welcoming atmosphere and the staff are always smiling”. Another relative said that she is always offered a cup of tea. One relative commented that she is able to have a meal with her relative and another person surveyed said that their relative has a telephone in their room with staff providing assistance to maintain contact. People moving in to the home are provided with the opportunity to bring their furniture and personal items into the home, which was seen, on display. Information supplied with the AQQA states that people moving in to the service may arrange for their room to be redecorated and carpeted to their own requirements. During this visit the lunchtime meal was observed which was well balanced, nutritious and well presented. The home is able to provide choices, which was indicated on the menu and this was confirmed by one person who said, “If I don’t like something on the menu the cook will always provide with something I do like”. The inspector spoke with the cook who said that advice is sought from a dietician where this is required for example one individual has gluten free diet. The meals are home cooked and fruit was available for people to have. The chef is completing a National Vocational Qualification in health and hygiene and hopes to be starting an advanced cookery course. During this visit people who live in the service told the inspector they were happy with the meals provided and one person said that they are offered with a pre- meal sherry which was seen during this visit. The dining room is well presented and people who wish to take meals in their rooms had their meals presented attractively on trays. Staff were observed to provide assistance to people who required help with their meals. Five out of Five surveys received from people living in the service said that they were happy with the meals provided and comments included, “ excellent food, very enjoyable”. Comments received from relatives stated, “the meals are well planned”; “the dining room looks like a small restaurant with fresh flowers on the table” and “the staff help people who have difficulty cutting up their food and they are supported to eat. Another visitor told the inspector that their relative has a Mayfield House DS0000013713.V342360.R01.S.doc Version 5.2 Page 16 preference for a particular type of breakfast that meets their cultural background and the home has responded to this request Mayfield House DS0000013713.V342360.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People using the service and their representatives have access to an effective complaints procedure and their views are listened to and acted upon. Policies and procedures are in place; although improvement is needed to ensure that staff receive appropriate training ensuring people living in the service are protected from abuse. EVIDENCE: The home provides a complaints procedure, which is available with the service user guide, although the manager was advised to up date the details for contacting the Commission for Social Care Inspection. Since the previous visit the Commission has received no complaints. The manager maintains a record of any complaints received. Two complaints have been received by the manager who provided written evidence that these matters had been appropriately responded to. Five people surveyed said that they knew whom they could talk to if they were not happy and that staff listen to their views and act upon what they say. Four surveys received from relatives state that they know how to make a complaint and that the service has responded appropriately to any raised concerns. One person commented, “We have never had to raise any concerns and the very occasional suggestion i.e. need for a doctors visit, always seems to be in hand”. The manager stated that she has a copy of the Surrey multi- agency safeguarding adult policies and procedures, although this could not be located during this visit. Information supplied in the AQQA states that staff have been Mayfield House DS0000013713.V342360.R01.S.doc Version 5.2 Page 18 issued with the homes recognition and prevention booklet. During this visit the procedure was viewed which was detailed, and comprehensive. One member of staff spoken with confirmed that this document has been bought to their attention and two members of staff spoken with were clear in their responses as to the actions that would take should they ever witness any abuse. The manager must attend the Surrey multi- agency safeguarding adults from abuse training and three staff training records sampled indicated that all care staff must receive formal up to date training ensuring that they have acquired the most up to date training to ensure the welfare and safety of people using the service. Mayfield House DS0000013713.V342360.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 23 & 26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People living in the service in a well-maintained, clean, comfortable, homely environment. One Matter was identified that needs attention ensuring that the environment is safe. EVIDENCE: During a tour of the service the home was observed to be well maintained and furnished. Due to the age of the property continuous redecoration and maintenance is required. There are two communal sitting rooms, which were comfortable and well furnished and one room was provided with a piano and a small library area. There is a garden to the rear of the home and it was observed that there was a step making it difficult for people to walk across, therefore the service is advised to install a ramp to ensure that the garden is accessible for all people using the service. Some bedrooms have ensuite facilities and there are a number of separate toilets. The manager stated that some of the rooms that have bathing facilities Mayfield House DS0000013713.V342360.R01.S.doc Version 5.2 Page 20 are not used, as residents cannot assess these. There are two assisted bathrooms, which were identified as needing modernising and upgrading. The manager stated that this has been identified as the next project and the home wishes to install showers as this has been requested by some people using the service although it is recommended that an occupational therapist is contacted to advise on the facilities and equipment. During a tour of the premises it was observed that a bedroom carpet was torn and was identified as a hazard, therefore it is required that this carpet is replaced ensuring the wellbeing and safety of the individual residing in this bedroom. Bedrooms were personalised with individual’s belongings and the manager stated that as a bedroom becomes vacant the room is redecorated and carpeted and if needed a new sink or toilet facilities are upgraded. The home has a lift and call bells are installed. During this visit the home was seen to be clean and hygienic. The home employs four ancillary staff. Separate laundry facilities are available and a cleaning schedule for this area is in place. Appropriate handwashing facilities and equipment was observed. The home has an infection control procedure in place that was based on the Department of Health guidance. Two relatives surveyed stated, “”there is a high standard of cleanliness and laundry is always put back neatly” and “the home is always clean and tidy”. The home has received a visit from environmental health, which was satisfactory. Mayfield House DS0000013713.V342360.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The numbers of staff on duty were adequate to meet the needs of people living in the service. Improvement is needed to ensure that people living in the home are protected by the homes recruitment policies and procedures and further improvement is needed with staff training ensuring that people living in the service are in the safe hands of the staff who are competent and trained to do their jobs. EVIDENCE: During this visit adequate numbers of staff were on duty. During the morning one senior carer and four carers are provided. During the afternoon there is one senior carer and three carers and two waking night staff are provided at nighttime. The manager works supenummary and the home is also assisted by ancillary staff, a chef and kitchen assistant. The home also employs an administration assistant. The home benefits from a stable staff team who have worked at the home for a number of years. The home has equal opportunities in place and the staff team are of mixed ethnicity. Five people surveyed said that they receive the care and support they need although one person said that they would like more support. One person spoken with during this visit told the inspector that the would like more help with washing which was bought to the attention of the manager. Five surveys received from relatives indicate that the home meets the needs of their Mayfield House DS0000013713.V342360.R01.S.doc Version 5.2 Page 22 relatives. Two people spoken with during this visit staff respond when they require help or use their call bells. Information supplied with the AQQA states that eight care staff hold National Vocational Qualifications (level2) or above and three members of staff are working towards these qualifications. Information supplied with the AQAA indicates that the manager has recognised that they need to improve in ensuring that mandatory training for staff is updated in health and safety and infection control. During this visit the training records were sampled for three members of staff. It was observed that some of the mandatory training was out of date. One member of staff had completed training in safeguarding adults and a range of training in her previous employment. One person had attended training in moving and handling three years ago and there was no evidence that this person had attended training in infection control. The manager stated that arrangements are in place for staff to commence first aid updates in September 2007. Therefore it is required that all staff training files are audited to identify any short falls and that all staff receive updated training where this is required including safeguarding adults from abuse, moving and handling, health and safety, infection control. One persons training recorded indicated that they received training in dementia awareness and pressure area care. One member of staff spoken with during this visit said that they had also received training in dementia awareness. The home provides induction and a staff handbook but the induction process was not based on the Skills for Care core induction standards, therefore it was required that these matters must be attended to ensuring that the health, wellbeing and safety of people using the service is protected. The personnel files were sampled for three members of staff. One of these files was for a new member of staff, although Criminal Records Bureau Check had been applied for the results of the POVA First check or the CRB had not been obtained prior to this individual commencing employment in the home. Two written references had also not be been acquired for this person therefore an immediate requirement was made that this matter was attended to ensuring the welfare and safety of people using the service. Mayfield House DS0000013713.V342360.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager is able to demonstrate that she has the appropriate qualifications and experience to manage the home. One matter was identified needing attention to ensure that it is run in the best interest of people living in the service. The financial interests of people are protected and the health, welfare and safety of people is mainly protected with two identified matters needing attention. EVIDENCE: The registered manager has thirteen years experience in working with care of older people. The manager also holds the Registered Managers Award. During this visit the manager was observed to have an open approach and was accessible to people living in the home, their relatives and staff. Five relatives surveyed said that the home always keeps them informed of up to date issues affecting their relatives The home has also recently recruited a new deputy Mayfield House DS0000013713.V342360.R01.S.doc Version 5.2 Page 24 manager who is a Registered General nurse. Staff spoken with stated that were all happy working in the home, and supported by the manager and felt that there was good teamwork. The home carries out annual quality assurance surveys for residents and their relatives and these were last updated in April 2007. Some of these surveys were sampled and a number of positive comments had been received. It was clear where any matters had arisen through the surveys that require action these had been followed through by the manager. The responsible individual visits regularly and carries out weekly health and safety checks, which were viewed during this visit, and maintains daily contact with the home, although a written report must be made available on other matters when visiting the home which must be recorded monthly to include feedback from people living in the service, their representatives and monitoring of any complaints that may have been received. The home has a range of policies and procedures in place, which have been updated. The home has a policy in place for the management of resident’s monies and valuables. Some monies are maintained in the home on behalf of service users for sundries such as newspapers and hairdressing. All reasons for expenditure were recorded and balances documented. The home then uses an invoicing system to relatives. Information provided with the AQAA states that staff are provided with a health and safety handbook. The fire book was examined which indicated that fire drills and fire alarm checks are conducted. The manager stated that records of water temperature checks are maintained in the bathrooms. Information provided stated that all routine maintenance and servicing are up to date. During this visit an immediate requirement was made as it was observed that the fire door to the kitchen was closed as this had been propped open. A member of staff immediately responded to this matter when it was bought to their attention. During a tour of the premises it was observed that a number of radiators in the communal areas and bedrooms did not have protective covers and it was required that a risk assessment is conducted ensuring the welfare and safety of people using the service. Mayfield House DS0000013713.V342360.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 X X 2 2 X X 3 STAFFING Standard No Score 27 2 28 X 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 2 Mayfield House DS0000013713.V342360.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation 15 (1)(2) Schedule 3.1(b) Requirement a) The manger must ensure that the care plans are expanded to ensure that they give a clear picture of the needs of the service user without depending upon prior knowledge (Previous requirement 30/6/06 not met) b) It is essential that once the of review process has been completed all care plans must be signed and dated to ensure that the most up to date information is being used. (Previous requirement 30/6/06 not met) c) People using the service and or their representatives must be consulted about and agree their care plan. 2 OP8 12(1)(b) The home must obtain appropriate weighing scales and maintain written weight records. a) The manager must attend the Surrey multi- agency safeguarding adults from abuse training. DS0000013713.V342360.R01.S.doc Timescale for action 03/11/07 03/10/07 3 OP18 13(6) 03/12/07 Mayfield House Version 5.2 Page 27 b) All staff working in the care home must receive up to date training in safeguarding adults from abuse. 4 5 OP26 OP30 23(2)(b) 18(1) (c) 1 The torn carpet in one bedroom must be replaced. a) All staff training files must be audited to identify any shortfalls in mandatory training which must be provided b) The staff induction programme must be based on the skills for care common induction standards. 6 OP29 19(1-5) Schedule2 a) Staff must not be employed in the home until a POVA first check has been obtained b) Two written references must be obtained prior to any member of staff commencing employment in the home. 7 OP33 26 A monthly quality-monitoring visit must be conducted with the written report from these visits to be maintained in the home and available for inspection. 03/10/07 03/09/07 03/10/07 03/02/08 8 OP38 13(4)) (a,c) Risk assessments must be conducted in respect of the radiators that are uncovered in the home. 03/10/07 Mayfield House DS0000013713.V342360.R01.S.doc Version 5.2 Page 28 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 4 5 Refer to Standard OP7 OP8 OP9 OP22 OP22 Good Practice Recommendations It is recommended that the daily notes be recorded to reflect the outcomes of individuals identified care needs. It is recommended that risk assessments are regularly reviewed. It is recommended that where medication is transcribed on the medication record this should be checked by two members of staff. It is recommended that the manager consults with an occupational therapist to assess the equipment required in the planned bathroom refurbishment. It is recommended that the home installs a ramp to the door to enable people who use the service to access the garden. Mayfield House DS0000013713.V342360.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 DS0000013713.V342360.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!