Inspection on 04/08/05 for Mayfield House

This inspection was carried out on 4th August 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Mayfield House 07/10/08

Mayfield House 30/10/07

Mayfield House 23/05/06

Mayfield House 22/02/06

Mayfield House 06/01/05

Mayfield House 15/06/04

Mayfield House 19/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Mayfield House Mayfield Mews Minshull New Road Crewe CW1 3FZ Lead Inspector Anthony Cliffe Announced 4 August 2005 9:30 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 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 F01 F51 S6654 Mayfield House V234099 040805 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Mayfield House Address Mayfield Mews Minshull New Road Crewe Cheshire CW1 3FZ 01270 500414 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Littleton Homes Limited Lynne Woodroffe Care Home 51 Category(ies) of Old age, not falling within any other category registration, with number (51) Both of places Mayfield House F01 F51 S6654 Mayfield House V234099 040805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 The service is registered for a maximum of 51 service users in the category of OP (Old age, not falling within any other category) 2 Within the overall number of service users to be accommodated a maximum of 23 service users may be accommodated in the category of DE(E) (Dementia over the age of 65 years) Within the overall numbers of service users to be accommodated 1 named service user may be accommodated in the category DE (Dementia under the age of 65 years) until 18/12/2007 The registered provider must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection 3 4 Date of last inspection 6 January 2005 Brief Description of the Service: Mayfield House is a two-storey purpose-built property that provides 51 places for older people. The home is located on a modern housing estate, and is within approximately a mile-and-a-half of Crewe town centre with access to bus links and the railway. The property has been extended and now has two separate units – one for residents with general care needs, and the other for residents who have dementia. Access to the home’s second floor is provided by a passenger shaft lift, and three stairways. There are accessible and wellmaintained gardens surrounding the home. Mayfield House F01 F51 S6654 Mayfield House V234099 040805 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by an inspector of the Commission as part of the inspection programme. The inspection took place over eight hours. It included inspection of records, observation of staff practice and discussion with residents and staff. Feedback was given to the registered manager and deputy manager immediately following the inspection. One requirement remains outstanding from the previous inspection visit. What the service does well: What has improved since the last inspection? Care plans are more detailed than at the last inspection, giving some clearer details on the needs of the residents, but require further work to ensure that they address all residents’ needs. Mayfield House F01 F51 S6654 Mayfield House V234099 040805 Stage 4.doc Version 1.30 Page 6 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 F01 F51 S6654 Mayfield House V234099 040805 Stage 4.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection Mayfield House F01 F51 S6654 Mayfield House V234099 040805 Stage 4.doc Version 1.30 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 Assessments of needs are completed, before residents move into the home, to ascertain if their needs can be met. EVIDENCE: The records of two residents who had recently moved into the home were examined. A pre-admission form is completed as part of the pre-admission assessment. The information includes the residents’ previous history, physical illnesses and current medication. Copies of the care management assessment and care plan were obtained and an assessment from the NHS had been obtained for one resident. Mayfield House does not provide intermediate care facilities and this standard is not applicable. Mayfield House F01 F51 S6654 Mayfield House V234099 040805 Stage 4.doc Version 1.30 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8 ,9 and 10. Residents’ care plans do not ensure that health and social care needs are identified and met. The procedures for managing medication must improve to ensure residents are not at risk from not having prescribed medication. Residents are treated with respect. EVIDENCE: The home continues to use a computerised system for translating assessments into pre formed care plans. Whilst there had been an improvement in care planning to provide a more detailed plan of need they do not provided an individualised care plan that takes into account all of the residents health and social care needs. The plans had been transferred into residents’ files and reviewed for some residents but a number still had a basic computerised print out which gave little details of the residents’ needs and the plan of care to meet the identified needs. Supporting assessment documents were not completed accurately and did not correlate with the care plans in place. There were examples of residents mental health needs not being identified or how staff were meeting these needs. A resident was assessed as having episodes of incontinence, which was being managed, but no care plans was in place for the management of the problem. Another resident had an assessment to prevent pressure ulcers but this did not refer to the resident’s diabetes. The resident had displayed aggressive verbal behaviour and was at risk of wandering at night but these needs were not addressed in a care plan or risk assessment. Mayfield House F01 F51 S6654 Mayfield House V234099 040805 Stage 4.doc Version 1.30 Page 10 Staff gave good examples of how to manage the aggressive behaviour but this was not incorporated into a car plan. The resident had lost 11 Kilograms in weight over a period of time but this was not identified as a problem or if the resident had been referred to his general practitioner. Another resident was having a pressure ulcer monitored by the district nursing service, but records did not identify a care plan referring to the care from the district nurse. In discussion with staff it was clear that staff were aware of residents health needs. In managing aggressive behaviour a staff member said ‘we can distract him before he gets too aggressive if we see the signs and take him to a quiet area, which works’. A resident said that the standard of care was good and staff promotes her independence. ‘Staff know I can care for myself and I keep myself clean. I have gained a lot of confidence with staff support’. Another resident said She had lived at the home for ‘ one to two years, I moved in after a period of pneumonia. I am 96 and my health has improved, I really like it here. The staff are very good and I want for nothing. I enjoy the meals’. Another resident was making loud protests about walking with a Zimmer frame the resident said ‘I walk with out any help from the staff because I won’t let them help me, unless I need it, then I will ask. The staff always watch me to make sure I’m all right and ask me if I need help’. Signatures had not been recorded for the administration of medicines for several residents. A medicine prescribed as twice a day was being administered three times a day. Controlled drugs were being stored and administered by staff but there were no records of receipt or administration in a controlled drugs register or the administration of controlled drugs by two staff members. See requirements 1 and 2. Mayfield House F01 F51 S6654 Mayfield House V234099 040805 Stage 4.doc Version 1.30 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 14 and 15 Residents are supported to exercise choice in their lifestyle and to meet their social needs. Residents have a good choice of meals in pleasing surroundings. EVIDENCE: Residents were seen to be free to move around within the home. A variety of sitting areas were available. Staff were observed spending social time with residents. A resident said ‘I read a lot of books, my newspaper as it keeps me up to date. I have a review of my stay here in a week’s time. I stop myself getting bored. Today I’m going out for lunch. A friend visits me weekly and I am going out shopping with staff and for lunch at the weekend. I enjoy listening to music and watching television’. A staff member discussed the arrangements for the forthcoming outing arranged with the resident and confirmed the details to her. There were a number of visitors to the home throughout the day. They were made welcome and were clearly comfortable in approaching staff for information. The home provides three full meals a day. The deputy manager said that residents could choose to have a cooked breakfast. The main meal is at lunchtime and a choice of two main dishes is available. During lunchtime in both units there was staff available to assist residents. Assistance was offered in a polite and respectful manner. A carer was discussing her role but maintained her attention and eye contact with the resident she was assisting Mayfield House F01 F51 S6654 Mayfield House V234099 040805 Stage 4.doc Version 1.30 Page 12 at all times. The resident complimented on the good quality of the food she was eating. Mayfield House F01 F51 S6654 Mayfield House V234099 040805 Stage 4.doc Version 1.30 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Residents and relatives have access to a satisfactory complaints procedure. The management of physical intervention is unclear and staff are unsure what constitutes restraint and both residents and staff are at risk of being harmed. EVIDENCE: Each bedroom contained a residents’ guide, which contains a copy of the complaints procedure. Complaints records did not record any recent complaints with the last complaint recorded in November 2004. The policy in place in the home for managing aggressive behaviour guides staff to use a non physical approach, in allowing residents space, summoning assistance, talking calmly and not being confrontational in their approach to residents. The policy guides staff to give support and reassurance to residents, to listen attentively and not making sudden movements. A senior care assistant discussed the management of a resident who presented with aggressive and challenging behaviour on the dementia care unit. She said ‘he hits out at you and grabs hold of your hands, and you have to remove his hands and stop him by holding his hands. We are not supposed to use restraint, but I suppose that’s restraint, it’s not clear. Policies and procedures had bee developed for the home by a consultancy agency, which includes a policy on the use of restraint, adult abuse and adult protection. These policies have not yet been implemented. The home has the Cheshire County Council policy and procedure on adult protection. The manager confirmed that staff had not received training on the local authority policies and procedures. The manager said newly appointed staff receive the policies and procedures on commencement of employment See requirement 3. Mayfield House F01 F51 S6654 Mayfield House V234099 040805 Stage 4.doc Version 1.30 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26 Residents live in a safe and well-maintained home, which is clean and hygienic. There is a commitment to improving the standard of accommodation for the benefit of residents. EVIDENCE: All communal areas and some bedrooms were seen. The interior and exterior of the building was well maintained. One bedroom had been decorated following it becoming vacant. The manager was able to demonstrate that a refurbishment programme of the corridors and dining room carpets has been planned. The manager was able to provide evidence that these areas had been measured for quotes for replacement. The manager said the replacement of these carpets would commence in the near future. The home was free from odours. A resident confirmed that she had been offered the opportunity to personalise her bedroom and said ‘its full of my books and personal effects’. Mayfield House F01 F51 S6654 Mayfield House V234099 040805 Stage 4.doc Version 1.30 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 The numbers and skill mix of staff are adequate to meet service residents’ The home’s recruitment procedures were not completed and do not ensure residents are protected. EVIDENCE: On the day of the inspection there was the manager, deputy, senior care and care assistants on duty in sufficient numbers to meet the needs of residents. The manager said that she had recruited staff to cover the rota. Examination of staff rotas provided evidenced that these levels were maintained at all times. A resident commented that the staff ‘faces change all the times, just as you get to know someone they leave’. There is a core of staff that has been employed at the home for a number of years that provide consistent care to residents. Discussion with the manager, deputy manager and a staff member and examination of records of employment found recruitment procedures were not followed. A staff member had been recruited and commenced employment in July 2005 without a POVA First check being obtained. The home had accepted a Criminal Records Bureau check from a previous employer. When the manager and deputy were asked about the employment of staff the manager said the registered person was the counter signatory for the home and responsible for this. The deputy manager said she did not know what POVA referred to. See requirement 4. Mayfield House F01 F51 S6654 Mayfield House V234099 040805 Stage 4.doc Version 1.30 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 The system for seeking the views of residents about the standards in the home has improved. EVIDENCE: Discussion with the manager and examination of records identified that the home had responded positively to a recommendation to improve the quality assurance system. The registered person had employed the services of a recognised consultancy agency to devise satisfaction surveys for residents, relatives and other interested stakeholders. The manager confirmed that the surveys would be introduced within the near future. Mayfield House F01 F51 S6654 Mayfield House V234099 040805 Stage 4.doc Version 1.30 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x 3 x x x x x Mayfield House F01 F51 S6654 Mayfield House V234099 040805 Stage 4.doc Version 1.30 Page 18 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. 1. Standard OP7 Regulation 14 and 15 Requirement The registered person must ensure records that identify residents needs, and staff responsibilities in meeting their health and welfare, are kept under review and include appropriate risk assessments and risk management strategies. (timescale 1.3.05 not met) The registered person must ensure that staff administer medicnes as prescribed and record on medication administration record sheets all administrations of medicines, and any reason for nonadministration of medication. The receipt of controlled drugs must be recorded and the administration of controlled drugs witnessed by two persons. The registered person must ensure that the policy on the use of physical intervention is clear to all staff, and staff provided with suitable training on adult abuse and understanding and dealing with residents who present with challenging behaviour. The registered person must not Timescale for action 1.12.05 2. OP9 13(2) 1.11.05 3. OP18 18(1)(i) 1.12.05 4. OP29 19 1.11.05 Page 19 Mayfield House F01 F51 S6654 Mayfield House V234099 040805 Stage 4.doc Version 1.30 employ a person to work at the care home unless he has obtained in respect of that person the information and documents specified in paragraphs 1 to 9 of Schedule 2. 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. Refer to Standard Good Practice Recommendations Mayfield House F01 F51 S6654 Mayfield House V234099 040805 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection Unit D, Off Rudheath Way Gadbrook Park Northwich CW9 7LT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mayfield House F01 F51 S6654 Mayfield House V234099 040805 Stage 4.doc Version 1.30 Page 21 - 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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