Inspection on 08/11/07 for Mayfield House

This inspection was carried out on 8th November 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 but made no statutory requirements on the home.

Other inspections for this house

Mayfield House 03/03/06

Mayfield House 16/11/05

Mayfield House 02/12/04

Mayfield House 17/05/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood Hall

Muston Road (70)

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

CARE HOME ADULTS 18-65 Mayfield House Woodhouse Lane East Ardsley Wakefield West Yorkshire WF3 2JS Lead Inspector Dawn Navesey Unannounced Inspection 8th November 2007 09:20 Mayfield House DS0000001480.V354624.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 DS0000001480.V354624.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 DS0000001480.V354624.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mayfield House Address Woodhouse Lane East Ardsley Wakefield West Yorkshire WF3 2JS 01924 828181 01924 872623 mayfield.house@craegmoor.co.uk www.craegmoor.co.uk J C Care Ltd 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) Vacant post Care Home 15 Category(ies) of Learning disability (15), Learning disability over registration, with number 65 years of age (15), Physical disability (15), of places Physical disability over 65 years of age (15) Mayfield House DS0000001480.V354624.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th January 2007 Brief Description of the Service: Mayfield House is owned by J C Care, which is a subsidiary of Craegmoor Health Care. Mayfield House is a semi-detached property, which is joined to another care home owned by the same company. The home is situated in its own grounds and ample parking is available. The care home is on Woodhouse Lane, which is within easy walking distance of the main road. The area is well served by public transport. There are a number of local facilities and people who live at the home can make use of amenities in the area. The care home is registered to provide accommodation and care services for up to fifteen people with a learning disability, who may also have a physical disability. There are nine people currently living at the service. The home is spread over two floors. There is no passenger lift, however some ground floor bedrooms are available. The home provides staff over twenty-four hours. The home also employs a maintenance officer and domestic staff. At present there are no catering staff employed, care staff cook all meals. Current information about services provided at Mayfield House in the form of a statement of purpose, service user guide and the most recent inspection report published by the Commission for Social Care Inspection are available by contacting the home. The current scale of charges at the home is £395.00- £1551.54 per week. Additional charges are made for outings, toiletries and various activities. Mayfield House DS0000001480.V354624.R01.S.doc Version 5.2 Page 5 Mayfield House DS0000001480.V354624.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) inspects homes at a frequency determined by how the home has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. More information about the inspection process can be found on our website www.csci.org.uk This visit was unannounced and was carried out by one inspector who was at the home from 9.20am to 5.50pm and another inspector who was at the home from 11.15am to 2pm on the 8 November 2007. Two hours were spent observing the care being given to a small group of people. The care of three people was looked at in depth when comparisons with the observations were made with the home’s records and the knowledge of the care staff. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people living there. And also to monitor progress on the requirements and recommendations made at the last inspection. Before the inspection evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. This information was used to plan the visit. An AQAA (Annual Quality Assurance Assessment) was completed by the home manager before the visit to provide additional information. Survey forms were sent out to people living at the home, their relatives and health and social care professionals. One of these has been returned and this information has also been used in the preparation of this report. During the visit a number of documents and records were looked at and some areas of the home used by the people living there were visited. Some time was spent with the people who live at the home, talking to them and interacting with them. Time was also spent talking to staff and the manager. Feedback at the end of the visit was given to the manager and acting Business Support Manager. I would like to thank everyone who contributed to the inspection process and to the home for their hospitality. What the service does well: Staff have good knowledge of the needs of the people who use the service. They have got to know them well and are aware of their likes and dislikes and how they communicate their needs. In a returned survey, a relative said, “My relative loves it too, staff is very good”. Mayfield House DS0000001480.V354624.R01.S.doc Version 5.2 Page 7 The home has a friendly and welcoming atmosphere. Staff interact well with people who use the service. They are kind and thoughtful. In a returned survey, a relative said, “The staff is helpful, when we come to see our relative we get a cup of tea everytime”. There are good systems in place to make sure the money of people who use the service is protected. The new manager is showing good leadership to the staff team. What has improved since the last inspection? What they could do better: The organisation must provide each person using the service or their representative with an up to date contract. To show all charges and additional costs that are made to them. People who use the service must have a detailed and up to date care plan, which includes their specific health needs. This will make sure they receive person centred, safe support that meets their needs properly. All identified risks for people who use the service must have a detailed, up to date action plan in place in order to minimise or prevent the risk. People who use the service must have more opportunities for activity out of the home and in the community. This will make sure their needs for activity suitable to their cultural and leisure needs are met. Mayfield House DS0000001480.V354624.R01.S.doc Version 5.2 Page 8 The manager must make sure that referrals for up to date moving and handling assessments are made to the relevant health professional. This will make sure staff’s practice is safe. The furniture in the conservatory must be replaced as it is worn and dirty looking. The manager must make application to be registered with the CSCI. This will make sure the home has a person who is responsible for the day to day running and is also accountable to the CSCI. 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 DS0000001480.V354624.R01.S.doc Version 5.2 Page 9 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 DS0000001480.V354624.R01.S.doc Version 5.2 Page 10 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): 1,2 and 5 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that the home will meet their needs following assessment. Also written and verbal information that is available provides enough information for them to decide whether the home will meet their needs. EVIDENCE: The Statement Of Purpose, which provides information on the services provided by the home, has recently been updated to include information about the new manager. This is kept on display in the entrance hall of the home where families and visitors can have access to it. There is also a Service User Guide to the home. Each person using the service has a copy of this. It has been produced in an easy read format using pictures and symbols alongside the words. It gives good information about what the service can offer. Visitors to the home said they are always made to feel welcome. People using the service said they were very happy with the home. One said, “It’s great here”. Another person has shown some interest in moving on from the service and is being supported with this decision. Mayfield House DS0000001480.V354624.R01.S.doc Version 5.2 Page 11 The organisation is currently introducing new person centred care planning documents. This means that people who use the service are having their needs re-assessed to make sure all their needs are being met. This new document should make sure that care and support plans are developed from assessments of people’s current needs. The new manager has had some induction training on assessment. She is very clear on what the pre-admission assessment process will be for any new people thinking of using the service. People who use the service have a contract with the organisation. This shows the cost for their placement. However, people who use the service or anyone who could represent them have not signed these. They are not dated either, which means it is difficult to know if they are current. The manager said she would ask families and people who use the service to sign them and make sure they are dated in future. Mayfield House DS0000001480.V354624.R01.S.doc Version 5.2 Page 12 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 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Despite some gaps in care planning and risk assessment documentation, staff are, in the main, aware of the individual needs of people who use the service. The lack of detail in some care plans and risk management plans could however, lead to the needs of the people who use the service not being properly met. People who use the service are involved in decisions about their lives. EVIDENCE: Some progress has been made in improving the standard of care plans and risk assessments for the people who use the service. A new care planning format has been introduced and staff are currently working on them. The Mayfield House DS0000001480.V354624.R01.S.doc Version 5.2 Page 13 organisation has changed the format for care plans a number of times over the last two years. This seems to have resulted in care plans remaining incomplete. The standard of care plans and risk assessments have been required to improve for the last two years. Some of the plans seen gave some clear and detailed instruction on how the needs of people who use the service are to be met. Some of the information is person centred and gives good information on how people like to be supported. For example, a very detailed plan on how to bathe or shower someone. However, some of the care and support plans need more detailed information in them to make sure they give staff enough detail on how care tasks are to be carried out. Instructions such as “change regular” and “move regularly” do not give clear and specific guidance and could lead to important care needs being overlooked. Some plans have conflicting information in them, which could lead to confusion. A good support plan should give clear and detailed information on how and when care is given, taking particular notice of the peoples’ preferences and choices. The new manager has been looking at the care plans and is aware of where they need to improve and which staff need further support and training. She is working with her new senior support worker on a plan of action to bring the care plans up to a good standard. She has also written to families and friends of people who use the service to try and get them involved in the process. Despite the gaps in care planning staff have good knowledge on some of the care and support needs of the people who use the service. Most were able to accurately describe the care they give and talk about the detail of how people like to be supported in their daily routines. In a returned survey, a relative said, “My relative loves it too, staff is very good”. However, some staff gave different responses to others on care or support needs. This could lead to important needs being missed. Staff interactions with people were, in the main, very good. Staff showed warmth and a positive approach to people who use the service. People were offered choices throughout the day on what to do, where to go and what to eat. Staff showed a good understanding of how to offer choices to people who do not use verbal communication. However, on occasions, staff pushed a person who uses the service in their wheelchair but did not speak to them or explain where they were taking them. This did not respect the person’s dignity. People who use the service have meetings about two or three times per year. Issues discussed are holidays, activities, menus and any dissatisfaction people may be feeling. The manager has also introduced a suggestions box in the home for people or their representatives to suggest any changes to the service. This has not been used as yet. The manager said she is going to make sure it is more noticeable at the front entrance of the home to try and encourage more people to use it. Mayfield House DS0000001480.V354624.R01.S.doc Version 5.2 Page 14 Mayfield House DS0000001480.V354624.R01.S.doc Version 5.2 Page 15 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13, 15 16 and 17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home offers opportunities to people who use the service, for personal development in addition to an increasing range of leisure activities. People who use the service are able to make choices about their lifestyle. They also benefit from a good, healthy and varied diet. EVIDENCE: Activity on offer at the home is slowly improving. The home has now recruited more staff who can drive the home’s mini-bus which means people who use the service have more access to activity within the community. However, on looking through activity records for people who use the service, it is clear that some people do not get out very often. One person had been on one community outing in a period of a month, others had been out more frequently, but mainly for walks to the local shop or to the doctor’s surgery. The manager is aware of the need to offer more activity and is planning to put Mayfield House DS0000001480.V354624.R01.S.doc Version 5.2 Page 16 a more structured plan in place to make sure people get out more. One person has recently gained extra funding to provide more one to one activity suitable to their needs. In the AQAA, the manager said, ‘more day trips and in house activity would improve the service’. The home’s senior support worker is also looking to increase activity within the home. Recently, there have been themed parties, introduction of tabletop games and some people have been supported to use the local church. On the day of the visit, some people went out to the local shops and some went out to a big shopping centre. Others played tabletop games, had a manicure, listened to music, watched television, played musical instruments and used sensory equipment. Most people who use the service seemed to be in a positive and happy mood when interacting with staff. It is clearly something they enjoy. Staff interaction was good and people enjoyed the use of fun and humour. One person who uses the service has one to one staff support throughout the day. This person showed lots of signs of positive well being and clearly loves the interaction with staff. Staff have good knowledge of the communication needs of people who use the service. They are aware of people’s individual signing systems and ways of communicating their needs. In the main, staff said they felt there were enough staff to make sure people who use the service get a good level of activity. Some staff said it could be more difficult to get people out on occasions when there is staff sickness or vacancies. Staff said that the organisation had provided agency or bank staff to cover any gaps in staffing when they had had a number of vacancies a few months ago. People who use the service have an annual holiday. Some people who use the service talked enthusiastically about recent holidays and enjoyed showing their photographs. One person said, “I had a great time, plenty to do and lots of fun”. Others, who do not use verbal communication, smiled and gave ‘thumbs up’ signs when asked if they had enjoyed their holidays. One person who uses the service said they wanted to go on holiday again. Staff responded promptly and began gaining information on making a booking. The new document for person centred care planning has sections within it that should make sure people who use the service are given help to keep in touch with family and friends and to remember special occasions such as birthdays and anniversaries. The cultural need of people who use the service and their likes and dislikes have not been properly identified. Again, the manager is aware of the need to develop this side of care planning to make it more individual and person centred. Menus are developed based on the likes and dislikes of people who use the service. They are well balanced and nutritious. A good variety of food is Mayfield House DS0000001480.V354624.R01.S.doc Version 5.2 Page 17 available and staff make sure there is plenty of fresh produce such as fruit and vegetables. People who use the service said they enjoyed the food. One said, “The food is lovely, we get plenty of choice, they are all good cooks”. In a satisfaction questionnaire received by the home a relative said, “Good food, plenty of choice”. Both the lunchtime and teatime meal looked appetising and attractive. The food is still brought from the kitchen on a trolley to be served in the dining room. There is a risk that food could get cold in this time. This was brought up at the last inspection at the home. Staff said they now make sure food is kept as hot as possible by keeping it in warm serving dishes. The manager said she would look into getting a hot food trolley. In a returned survey, a relative said, “Food is nice too”. In the main, people who use the service were supported with their meals with courtesy and thought for their dignity. One person, who needed to be fed, at times, experienced this with very little interaction from staff. They were given their meal in silence. However some good practice was seen in people being assisted to be more independent. There was also some confusion at the lunchtime meal as there were not enough staff to support all people who needed assistance. This led to an incident of behaviour that challenged others. The manager explained this had occurred as a staff member was sick and they were working one short for some of the day. Mayfield House DS0000001480.V354624.R01.S.doc Version 5.2 Page 18 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The lack of some written documentation could lead to some personal and health care support needs being overlooked, however staff’s practice is, in the main, safe. People who use the service are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Staff were seen to support people who use the service with their personal care needs in private and with dignity. The level of detail in some support plans on how personal care and health related tasks are to be carried out is not always detailed enough and could lead to some needs being overlooked though. A person who has epilepsy has a plan in place on how they are supported in the event of having a fit. Some of the information is vague and could lead to Mayfield House DS0000001480.V354624.R01.S.doc Version 5.2 Page 19 different ways of the instructions being interpreted. Staff were however, clear on what they would do in the event of a medical emergency. Another person who uses the service has a support plan for needs related to asthma. Again, this was also vague but staff said they knew what to do to keep this person safe in the event of an asthma attack. They also knew what preventative measures were in place for this person’s asthma. As already mentioned in the Individual Needs and Choices section of this report, there were some good plans in place on how to support people with some of their personal care needs. People’s individual likes and dislikes, preference of toiletries and how they are kept safe during personal care was well written. In a satisfaction questionnaire received by the home a relative said, “My relative’s care is beyond good”. Improvements are needed to the moving and handling plans of some people, to make sure practice is safe. One person who uses the service was seen being moved using an out dated technique and in a way that was different to what was written in the care plan. The manager said that this person’s needs had recently changed and that she needed to make a referral for an assessment of this person’s moving and handling needs. Referrals to health practitioners have been made for others who use the service. A detailed physiotherapy programme is in place for one person. The manager has ordered new equipment to make sure staff can safely carry out the programme of exercises with the person. All staff have received training in PEG feeding (tube feeding direct into the stomach). Good systems have been put in place to make sure the feeding is safe and well monitored. Staff said they felt confident and well supported by health practitioners. Most staff have received training in other health needs of people who use the service. For example, epilepsy. The manager should make sure that staff who are not familiar with epilepsy are given some training as part of their induction in case this comes up before they have done the training course. The support plans have details of any health professionals that people who use the service see. These include, GP, chiropodist, dentist, specialist nurse, and optician. Good records are kept of any health appointments and their outcome. Staff give good support in helping people to attend appointments and remaining with people if they become in-patients in hospital. The home uses a monitored dosage pre-packed system for medicines. All staff take responsibility for the administration of medication and have been trained to do so. There are good ordering and checking systems in place, with a clear audit trail for any unused medication returned to the pharmacy. The medication administration record (MAR) sheets were checked and showed no errors in administration. Mayfield House DS0000001480.V354624.R01.S.doc Version 5.2 Page 20 Mayfield House DS0000001480.V354624.R01.S.doc Version 5.2 Page 21 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service and their relatives have their views listened to, taken seriously and acted upon. There are good systems in place to protect people who use the service from abuse. EVIDENCE: The home has a comprehensive complaints procedure and an easy read procedure with pictures and symbols. A copy of this is kept in the service user guide, which each person who uses the service has a copy of. There have not been any complaints made at the home in the last year. Most staff have received training in the protection of vulnerable adults. They were able to say what action they would take if they suspected abuse or had an allegation of abuse made to them. They were also able to describe the different types of abuse. Some staff are still on their induction training and have not yet done this training. However, they were aware of their responsibilities to report any concerns. The organisation has a comprehensive adult protection policy and a whistle blowing policy, which encourages staff and people who use the service to report concerns. The whistle blowing policy is displayed in the home. Staff and people who use the service are given a copy of this too. Mayfield House DS0000001480.V354624.R01.S.doc Version 5.2 Page 22 Information on a local advocacy service is available in the home. Some people who use the service have now got an independent advocate to speak on their behalf. People who use the service have their own bank account or a company account with monies held on their behalf. There are systems in place to protect their finances and the manager checks transactions on a regular basis. Good practice was seen during the visit when the manager responded well to requests for money from people who use the service. Some people who use the service also have care plans in place to show how their finances are protected. One person has a plan that clearly states money should not be spent on their behalf and they like to be present for any money that is spent. This is good safe practice. Mayfield House DS0000001480.V354624.R01.S.doc Version 5.2 Page 23 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): 24,27 and 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The environment in the home is homely, clean, safe and hygienic. Staff’s practices, in the main, control the spread of infection. EVIDENCE: The home is spacious and homely, providing sufficient room for people. In a satisfaction questionnaire received by the home a relative said, “The environment is homely and comfortable”. Bedrooms have been decorated and furnished to suit individuals and their interests and personality. A number of bedrooms have been decorated and one person’s room has been fitted out with sensory equipment. Another person is currently in the process of changing rooms, to a room that is bigger and suits their needs better. People who use the service said they had been able to choose the colour schemes for their rooms. Mayfield House DS0000001480.V354624.R01.S.doc Version 5.2 Page 24 The home is nicely decorated and has furniture and furnishings of a good standard. However, the furniture in the conservatory is looking worn and stained and is in need of replacement. A maintenance officer is employed by the home. He makes sure any maintenance work is attended to promptly and has a programme of regular re-decoration for the home. On the day of the visit, the stairs and landing were being re-decorated. There is also a new carpet on the stairs. Communal areas were clean and there were no odours noted. The home employs a part time domestic assistant. Some people who use the service like to help out with small cleaning jobs around the home. One person said, “I like to help and do a small job”. All areas of the home are now freely accessible to people who use the service. In the past toilet and bathroom doors had been locked due to the needs of one person who uses the service. Other measures have now been put in place so that they need not be locked and people can use them freely. Some of the bathrooms and toilets have also been re-decorated and look clean and fresh. The kitchen is domestic in style and food hygiene practice is good. Foods are being stored according to manufacturers instructions. Clinical waste is properly managed and staff wear protective clothing when attending to the personal care needs of people who use the service. Staff have received training in infection control as part of their induction and are able to say what infection control measures are in place. However, one incident of poor infection control practice was seen. A staff member continued to wear gloves that had been used when attending to personal care needs while they were then pushing the person’s wheelchair. This was pointed out to the manager who said she would address it. Mayfield House DS0000001480.V354624.R01.S.doc Version 5.2 Page 25 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 and 36 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff are competent to meet the needs of people who use the service. People who use the service are also protected by the home’s recruitment procedures. EVIDENCE: There are staff on duty throughout the day and night. There should be four staff on the daytime shifts and two staff at night. On the day of the visit, there was some staff sickness, which reduced the numbers to three. However, the manager made efforts to cover this and another staff member was brought in for some of the time. In addition to this staffing, the manager is supernumerary, giving her time to attend to her management role. An on-call manager also supports staff out of hours. Recruitment is properly managed; interviews are held, references and CRB (Criminal Record Bureau) checks are obtained before staff start work and checks are made to make sure staff are eligible for work. Mayfield House DS0000001480.V354624.R01.S.doc Version 5.2 Page 26 There has been a fairly high turnover of staff since the last inspection. There have been seven new staff started in this time period. The manager is working hard to try and get staff through their induction and all the associated training courses. She said that training availability was limited in this area but the organisation had recognised this and were now putting courses on nearer to the home. This will make it easier for staff to get to them. One staff member said they were enjoying the induction and showed the induction manual they were working on. The induction has been developed based on the Skills for Care Common Induction Standards. In the AQAA, the manager said that 22 of staff have got an NVQ (National Vocational Qualification) in level two or above. One more staff member is currently working towards this and others will start once they have completed their induction training. Staff said their training is mostly up to date and refresher courses have been given or are booked. Records are kept of staff’s training and the manager had kept these up to date. In the AQAA, the manager said, that training is provided specific to the service user group. Staff spoke highly of their training and said they felt they did a better job because of it. One said, “All my training has made me a better carer”. People who use the service gave positive comments about the staff. One said, “They are all lovely”. Others who did not use verbal communication, nodded, smiled and gave ‘thumbs up’ signs when asked if staff treated them well. In a satisfaction questionnaire received by the home a relative said, “Staff are always kind and courteous”. A visiting professional to the home said that staff were caring and considerate. In a returned survey, a relative said, “The staff is helpful, when we come to see our relative we get a cup of tea everytime”. Staff said they felt they had a good team and the new manager was very approachable and supportive. Staff said they felt communication and teamwork within the home is good. One said, “It is an absolute pleasure to come to work”. Regular team meetings take place. The manager has put a schedule in place for staff supervisions where she will have one to one meetings with staff. She is aware that some staff have not had this type of supervision for some time and wants to use these opportunities to develop the staff team. She must make sure that this supervision is kept up to make sure staff feel supported in their role. She said she wanted to make sure staff had some leadership after an unsettled time in the home with a lot of staff changes. Mayfield House DS0000001480.V354624.R01.S.doc Version 5.2 Page 27 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38,39,41 and 42 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well managed and the interests of people who use the service are seen as important to the manager and staff and are safeguarded and respected at all times. EVIDENCE: The home has a new manager who has now completed her induction with the organisation. She has a number of years experience of working with people who have a learning disability. She also holds the NVQ level 4 in care and the Registered Managers Award qualification. She has not yet applied to the CSCI Mayfield House DS0000001480.V354624.R01.S.doc Version 5.2 Page 28 to be the registered manager of the home. She is aware of the need to do this and said she had been waiting to finish her induction before applying. The manager said she had received a thorough induction to her role. She said she had been given the support of another manager in the organisation and that her area manager was in regular contact with her. She said she felt well supported and prepared for her job. Staff spoke highly of the manager, saying she was a good leader. Staff said they were hoping for a settled period of time as they had had a number of managers in the last year or so. Staff also said that the new senior support worker had enhanced the management support they received. Staff said they felt “Motivated and enthusiastic”. The area manager visits the home on a monthly basis to carry out regulation 26 visits. This involves talking to people who use the service and staff about the home. A report of these visits is made showing details of any action to be taken to improve the service. The manager said that the area manager often spends a day at the home to make sure these visits are thorough. The organisation sends out annual questionnaires to people who use the service and relatives asking for their views of the home. These are then analysed and any changes are made to the service as necessary. One of these was available at the home. Comments included, “My relative is very happy here”. The manager said she was currently in the process of sending this years questionnaires out. The manager is aware that some of the records, such as care plans, need to be brought up to a good standard. As mentioned in previous sections of this report, she is currently going through them to see what needs to be done. She is fully aware of her responsibilities, as the manager of the home, to make sure records are well kept Maintenance staff carry out weekly or monthly health and safety checks around the home such as fire alarms, emergency lighting, water temperatures and checks on the house vehicle. Maintenance records are well kept. Environmental risk assessments are completed and mainly up to date. The manager was aware that some were in need of review to make sure they are current. Accident or incident reports are completed and kept on file for the people who use the service. The manager has not got a system in place where she can analyse accidents to see if there are patterns, trends or ways of avoiding future accidents. She said she would make sure she put something in place. In the AQAA, the manager said that all equipment at the home is up to date with servicing. Also that gas and electrical safety certificates are in place and Mayfield House DS0000001480.V354624.R01.S.doc Version 5.2 Page 29 up to date. The home has a comprehensive range of health and safety policies and procedures in place. The manager, in the AQAA, said that these were all reviewed and current. Mayfield House DS0000001480.V354624.R01.S.doc Version 5.2 Page 30 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 3 2 3 3 X 4 X 5 2 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 2 25 X 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 3 3 X 2 3 X Mayfield House DS0000001480.V354624.R01.S.doc Version 5.2 Page 31 YES Are there any outstanding requirements from the last inspection? No. Standard 1 YA5 Regulation 14 Requirement The manager must make sure that all people who use the service have an up to date contract so that people know what the current costs for the service are. The previous timescale of 30/03/07 has not been met. Timescale for action 31/12/07 2 YA6 15.1 People who use the service must have an up to date detailed care plan, which includes their specific health needs. This will ensure that they receive person centred support that meets their needs. The previous timescales of 30/04/07, 31/10/06, 3/3/06 and 16/11/05 have not been met in full. 31/01/08 3 YA9 13.4 All identified risks for people who use the service must have a detailed up to date action plan in place in order to minimise or prevent the risk. The previous timescales of 30/04/07, 31/10/06, 3/3/06 and 16/11/05 have not been met in full. 31/01/08 4 YA14 16.2 The manager must make sure that all people who use DS0000001480.V354624.R01.S.doc 30/11/07 Mayfield House Version 5.2 Page 32 the service have opportunity to access leisure services within the community. This will make sure their needs are properly met. The manager must make sure that a referral is made for advice on up to date moving and handling for anyone using the service whose needs have changed. This will make sure staff’s practice is safe. The manager must make sure that the conservatory furniture is replaced, as it is worn and dirty. The manager must make sure that all staff receives regular supervision so that they are clear on their responsibilities and are properly supported. The previous timescale of 30/04/07 has not been met. 8 YA37 CSA The manager must make Section 11 application to be registered with the CSCI. This will make sure the home has a person who is responsible for the day to day running and is also accountable to the CSCI. 31/12/07 5 YA19 15.1 15/11/07 6 YA24 23.2 31/12/07 7 YA36 18 30/11/07 Mayfield House DS0000001480.V354624.R01.S.doc Version 5.2 Page 33 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 YA17 Good Practice Recommendations The manager must consider the use of a hot food trolley for bringing food from the kitchen to the dining room. This will make sure that food is served hot for people who use the service. This was recommended at the last inspection of the home. The manager should make sure that the health needs of people who use the service are brought to the attention of staff during their induction training. This will raise staff’s awareness and make sure all staff’s practices are safe. The manager should make sure that accident reports are analysed to identify any patterns and trends and ways of preventing accidents in the future. 2. YA19 3. YA41 Mayfield House DS0000001480.V354624.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 DS0000001480.V354624.R01.S.doc Version 5.2 Page 35 - 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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