Inspection on 14/08/07 for Mayfields

This inspection was carried out on 14th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Mayfields 05/05/06

Mayfields 26/09/05

Mayfields 19/05/05

Mayfields 18/10/04

Mayfields 22/04/04

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

CARE HOMES FOR OLDER PEOPLE Mayfields Mayfields Naylor Crescent, Netherpool Road Overpool Ellesmere Port Cheshire CH66 1TP Lead Inspector Anthony Cliffe Unannounced Inspection 10:00 14 , 15 and 21 August 2007 th th st 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 Mayfields DS0000006684.V342626.R02.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. Mayfields DS0000006684.V342626.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mayfields Address Mayfields Naylor Crescent, Netherpool Road Overpool Ellesmere Port Cheshire CH66 1TP 0151 356 4913 0151 356 4915 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) home.fxg@mha.org.uk Methodist Homes for the Aged Josephine Bell Care Home 46 Category(ies) of Dementia (7), Dementia - over 65 years of age registration, with number (46) of places Mayfields DS0000006684.V342626.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 46 service users to include: * Up to 46 service users in the category (DE(E) Dementia over 65 years of age * Up to 7 service users in the category DE (Dementia). Date of last inspection 5th May 2006 Brief Description of the Service: Mayfields is a purpose-built single-storey home, which provides care for older people who have dementia. Opened in 1997, it is located in the Overpool area near to a range of local shops and within a mile-and-a-half of Ellesmere Port town centre. The home was extended in August 2002 to provide nine additional bedrooms and three additional lounge areas. Residents’ accommodation is of a high standard, with all individuals having single, en-suite bedrooms. The home consists of three wings off a main central lounge. Each unit has a separate large lounge/dining area (with domestic scale kitchen facilities) and a range of communal bathroom/toilet facilities. A separate ‘services wing’ contains a large kitchen, laundry, staff facilities (staff room and changing/shower-rooms), office accommodation and relatives/visitors accommodation. There are also very pleasant, wellmaintained and fully accessible garden areas. These are secure to protect the safety of residents. The home charges £502.00 per week. Mayfields DS0000006684.V342626.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place on the 14th, 15th and 21st August 2007 and lasted seventeen hours Two Regulatory Inspectors carried out the visit. This visit was just one part of the inspection. Other information received was also looked at. Before the visit the home manager was also asked to complete a questionnaire to provide up to date information about services provided. During the visit various records and the premises were looked at. A number of residents and staff, a hairdresser and district nurse were also spoken with and they gave their views about the service. What the service does well: The service provides a calm, welcoming atmosphere for both residents and visitors. Residents are seen to move freely around the home and activities have been devised in various parts of the building, such as the shop, café and central lounge, so that residents have a communal space to walk around to aid mobility and a change of environment. Residents receive a very good standard of care and the observational practice completed during the inspection, observation of staff practice and comments from staff support this. Care staff practices were good and staff were very patient, always took time to ask residents questions rather than deciding for them. Residents were encouraged to be active, but could also sit quietly if that was their wish. It was seen that staff respect people as unique individuals and maintained each persons dignity. Residents were confident in their environment and were experiencing a good quality of life. Residents’ were valued as people and their personhood recognised. The gathering of information about residents needs before they move in incorporates staff gathering information about potential residents’ lives and what they were like as individuals before they lived at Mayfields and required care and support. Mayfields DS0000006684.V342626.R02.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Provide residents with a detailed support plan when they move into the home so their needs can be identified and appropriate support provided for their health and social care needs. The person responsible for recruitment of staff must not employ a person to work at the care home unless he has obtained in all the necessary information and documents so resident are protected from harm. The person responsible for medicine management and administration must make arrangements to ensure that the medicine records are completed at the time of administration, stocks of prescribed medicines are maintained and records of controlled drugs are accurate so residents receive their medicines safely and accurate records are maintained so discrepancies are accounted for. The correct certificate of registration must be displayed so residents will be appropriately accommodated in a care home registered to meet their needs. More detail should be included in the care plans to ensure that the residents’ needs are fully met. The manager should consider devising a method of recording when a referral has been made to a health care professional. Wherever possible staff should seek the views of the residents on how they feel their care has been and record this in the daily records. Residents’ method of communicating non-verbally should be identified and recorded in the support plan. The manager should explore alternative communication methods. A system of the dividing up support plans is recommended to give a standardised format and provide clarity. The manager should carry out regular full audits of the care files. Mayfields DS0000006684.V342626.R02.S.doc Version 5.2 Page 7 Full records should be kept are kept of health care visits and that annual visits and reviews are undertaken. Staff should receive appropriate training in the completion of Waterlow Charts and that terminology is fully explained to enable the staff to complete the forms accurately. If daily fluid and turning charts are to be used then they should be completed on a daily basis. Residents’ support plans should be drawn up with the involvement of the resident, recorded in a style accessible to the resident; agreed and signed by the resident whenever capable and/or their representative. The manager should seek and record the views of the residents and/or their relative as to whether they would like their bedroom doors locking during the day to prevent inadvertent access by other residents who walk about the home. The manager should ensure staff in the event of an emergency could easily open door-locking systems on bedrooms. 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. Mayfields DS0000006684.V342626.R02.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 Mayfields DS0000006684.V342626.R02.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): 1 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is gathered on residents’ needs prior to them moving in so their needs can be met. EVIDENCE: Mayfields accommodates mainly people from the Ellesmere Port area and is welcoming to anyone from outside the area or with a disability, different ethnic or cultural needs, religious beliefs, sexual orientation or political affiliation. The Statement of Purpose and Function was reviewed in August 2006. It was written in plain English. It contained all the relevant information including details about Methodist Housing Association Care Group and the homes facilities and services, objectives, accommodation, staff and complaints. The latest inspection report was available for inspection. Mayfields DS0000006684.V342626.R02.S.doc Version 5.2 Page 10 The Service Users Guide is known as the “Welcome to your new home” document. It is written in larger print, plain English with pictures throughout. Information within this document included a description of the services provided at Mayfields, relevant qualifications of the provider, manager and staff team, residents’ views of the home and the complaints procedure. These two documents enabled prospective residents make an informed choice about the home and whether their needs could be met there. Information gathered about residents was seen on all files examined. This covered personal information, care needs and support required, medication, carer and family support, interests and other relevant information. The support plans were written from the residents’ view of their care. An example of this was, I am quite and independent person who requires some help with day to day care’. The previous requirement made regarding completed assessments being available prior to admission has now been met. There was some confusion over the appropriateness of the accommodation of a resident. The information held at Mayfields indicated the resident did not have dementia and further clarification on this was requested. A deputy manager said that residents could be seen in hospital prior to moving in and not all information was gathered during an introductory visit. Mayfields DS0000006684.V342626.R02.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 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standards of recording information about and support of residents’ needs’ and medicine management and administration, needs to improve so residents’ health and welfare needs are protected. EVIDENCE: A total of six residents files and support plans were looked at. These included a “getting to know me” document which was completed by family or friends and assisted in the process of understanding new residents and their past life. Staff spoken with confirmed that this was a very useful document to show the past life residents had, and to give staff information to build upon. Mayfields DS0000006684.V342626.R02.S.doc Version 5.2 Page 12 The support plan was not an easy document to follow. Residents needs were documented however, staff had to complete an evaluation of one section of the plan each day as the daily record. These evaluation sheets were interspersed within the support plan and it made for disjointed reading. Health care needs were not fully met. Some residents had seen General Practitioners’, district nurses and physiotherapist, however this was not consistent within the records seen. Visits to chiropodist, optician, dentist and medication reviews were not seen. The district nurse regularly saw one resident but these visits were not recorded. The district nurse had a separate care plan to monitor the resident’s healthcare. A support plan was in place regarding tissue viability but it did not refer to the treatment provided by the district nurse. The last visit recorded in professional visits was June 2007. The district nurse that visited was very positive about how Mayfields supported residents’ healthcare and said they always contacted the surgery for advice. Waterlow charts were used within support plans to monitor the skin condition of residents. Some sections of these were not completed whilst others had been completed incorrectly. For example not recording medications such as anti inflammatory medicines or physical or mental health condition of the residents. In discussion with the staff team they indicated that they didn’t understand some of the terminology and therefore didn’t complete that part of the form. This had a severe affect on the outcomes recorded, showing people to be recorded as “better” that they should have been. Daily fluid and turning charts were seen in some files and these were not up to date. Some records had not been completed for several days. The entry on a daily fluid chart was dated 12th August 2007 and the turning chart 9th August. If they had ceased to be appropriate this needed to be recorded on the support plan and the records removed from the file. A resident had recently moved in and the ‘getting to know you’ document was complete. No support plans to meet the resident’s needs had been developed but daily records were in place to record care provided. Another resident’s care plans demonstrated it had been agreed and signed by the resident’s family. Support plans were written from the residents’ perspective of their care and recorded how residents wished to be cared for and reflected person centred thinking. The support plans conveyed a sense of respecting and supporting the residents’ lifestyle choices and promoting their dignity, choice and independence. The regional manager was present at the site visit and explained that the final date of introduction of the new support plan format had been delayed, as there were problems in using it across the organisation. Mayfields DS0000006684.V342626.R02.S.doc Version 5.2 Page 13 The routines around the administration of medicines seemed disjointed. Information provided by the managers on duty was that the morning medication round took two hours due to regular interruptions. One said there was not enough sufficiently trained staff to support them and those that were trained made mistakes. Medicine receipt, storage, administration and disposal were examined on the three units. There were several missing signatures dating back to the 30th July 2007. Two items of medicines were recorded as out of stock. Another had an additional hand written entry of ‘prn’ on it when the dose was a four times a day dose. It was unclear if this entry had been agreed with the resident’s General Practitioner. There was a stock of a controlled drug stored in the controlled drugs cupboard. The stock consisted of two bottles one of which was open and in use. The label on it was obliterated and the remnants of this were green. The bottom of the controlled drugs cupboard was green and sticky. The controlled drugs book recorded a stock of 370ml of the medicine. When the opened bottle was measured and witnessed by a staff member there was a discrepancy of 25ml. There was no record of what was later described as spillage by the manager. Otherwise medicines were managed with records of receipts on medicine administration records and disposal of medicines recorded. Medicines were audited by both the manager and deputy manager and identified where errors occurred. An action plan was written to rectify the errors but did not clearly identify if individual staff were accountable for errors and what action was being taken. For example if this was addressed through individual training or supervision. The deputy managers did a daily audit of medicine records each day to identify if records were unsigned and recorded this in a book. A deputy manager said it could be several days before a staff member could sign a record of administration they had missed. The regional manager said she had advised this book should not be used. Mayfields DS0000006684.V342626.R02.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): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported in making choices about their lifestyle so they have more control over their lives. EVIDENCE: The activities coordinator was on holiday and her hours were not covered. Staff spoken with said they didn’t work on the same unit all the time and felt they got to know all the residents but it added to residents’ confusion of staff, as they didn’t see their faces regularly. They said the activities coordinator planned the weekly activities and they were involved as well as the volunteers that came into Mayfields. On the 14th August residents were going out with staff to a tait a tait afternoon at Tarvin Hall in Ellesmere Port which held regular activities for people over 65 years of age. A carer took six residents to this. There was a programme of activities displayed in each of the three units. These generally took place between 14.30 and 18.30. Some were optional but highlighted activities had to take place. Mayfields DS0000006684.V342626.R02.S.doc Version 5.2 Page 15 Residents had access to the kitchen areas, which contained kettles, toasters and bread makers as some examples. A general risk assessment was in place for residents using electrical equipment. An observation of the care and level of interaction between resident, their environment, with staff and one another was done within a communal lounge for two hours. The purpose was to get first hand experience of sitting alongside people for a couple of hours during a regular part of the day within a communal area. The care of three people was looked at. When comparisons with the observations were made with the homes records and the knowledge of the care staff. During this two hour observation two of the people remained within the communal area and the other person moved between this area, the corridors, other communal areas and her own bedroom. Care staff practices were good and staff were very patient, always took time to ask residents questions rather than deciding for them and people were encouraged to be active, but could also sit quietly if that was their wish. It was seen that staff respect people as unique individuals and maintained each persons dignity. From the findings of the observation it was noted that 86 of the time residents well being was positive and that people were confident in their environment and were experiencing a good quality of life. All the interactions between staff and residents were noted to be good. There was a high level of engagement with residents during this period on average 85 of the time seen. Staff were actively engaged with residents throughout the whole of the observation period, not just at mealtimes. A staff team of three were on duty in each group of fifteen residents. General observations at this time were that the room was warm and music was playing in the background. Several residents were singing/humming or tapping their feet to the music. Most of the residents showed pleasure at this. When the music finished the staff member gave residents a choice of music to play next. The lighting was good in the room and it was warm. A staff member quickly asked one person who was rubbing her arms as if cold if she wanted a cardigan, she answered “yes” and the staff member brought one to her. During the observation many residents got up and moved about, most did not go back to the same chair. There were one or two exceptions where specialist chairs were used for certain residents. Residents could freely move from one area of the home to the other and when they appeared in an area they were welcomed into it. Mayfields DS0000006684.V342626.R02.S.doc Version 5.2 Page 16 A resident talked about living at Mayfields and said, “I like my flat I have my own furniture, settee and photographs of my daughter. She telephones me regularly. I know I’m living in Birkenhead or near it. I like my own company. I like to watch my TV if there’s nothing else to do. I have my key to my front door and lock it when I’m or out. I don’t have a handle on my door as people keep trying to open it and it annoys me. I have terrible problems with my memory but can find my way around and see other people regularly. I eat here and don’t cook for myself. I like the meals but can’t remember what I eat. I know I feel safe and enjoy living here. I don’t need a lot of help with care as I can wash and dress myself”. Meals were seen being served in the different lounges. The two different meals were plated up and staff took these meals to each table and asked each resident which meal they would like. This seemed to work well for the residents as they could identify the meal and decide which they would prefer. On discussion with staff they stated that they had found this was the best way to offer choice and that they had tried other ways of asking in advance, but due to the residents memory problems arose in that some people “forgot” what they had ordered and preferred a different meal. Tables were set with cutlery and a daily menu displayed. Vases of flowers were also placed on tables. Residents had glasses of juice with their meal. The Chaplin was seen visiting and sharing a meal with residents. Staff explained she visited regularly and this included escorting residents to appointments or hospital if necessary and providing spiritual comfort to residents and their families. Mayfields DS0000006684.V342626.R02.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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints and concerns are acted on to demonstrate they are taken seriously. An informed staff group protect residents from abuse. EVIDENCE: The complaints procedure was seen and this contained details of the CSCI. The Commission had not received any complaints since the previous visit. The home had received one complaint regarding personal care and this had been responded to in an appropriate manner and to the complainant’s satisfaction. On examination of four staff files it was evident that Adult Abuse training had taken place. It was stated by the assistant manager that the manager of the home cascades training to the staff team. The POVA policy and “No Secrets” guidance were in place and the home also had policies on restraint and whistle blowing. The manager and assistant managers also provide challenging behaviour and yesterday, today and tomorrow training to the staff team. Mayfields DS0000006684.V342626.R02.S.doc Version 5.2 Page 18 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, comfortable and well-maintained environment, which is equipped to meet their needs. EVIDENCE: The environment is well presented with good décor which is colour coordinated within each wing of the home. Good practice in dementia care in providing residents with aids to recognise their bedrooms was in use. The home was found to be clean and mainly odour free but there some areas of the corridor areas around bedrooms, which had a stale odour. The communal areas and a selection of bedrooms were seen. In the bedrooms new curtains and bed throws had been purchased. Mayfields DS0000006684.V342626.R02.S.doc Version 5.2 Page 19 Personal items and mementoes were evident within bedrooms and the communal areas. Residents were seen walking freely around all the building with no restrictions imposed upon them. Generally no bedroom doors were locked giving residents free access to their private accommodation, but a resident had been given a key to his bedroom which he kept locked when inside. There was no evidence that suggested previous recommendations made regarding consulting residents about doors remaining unlocked or door systems, which would allow staff entry on emergency, had been done. All bedrooms were en-suite. The overall impression was of a calm and friendly atmosphere for residents to live in. There were additional facilities such as the entrance lounge, residents’ shop and café. Mayfields DS0000006684.V342626.R02.S.doc Version 5.2 Page 20 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): Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff are adequate to meet residents’ needs. Staff recruitment does not ensure that residents are protected. The induction and training programme provides a skilled workforce that protects residents’ welfare. EVIDENCE: On arrival at the home the assistant manager was supported by a large staff team. The number of staff appeared to meet appeared to meet the needs of residents. Three care staff was on duty in each of the three units. However there appeared to be difficulty in arranging cover to administer medicines, staff sickness and holidays Four staff files were examined and they all contained job descriptions, person specifications, application forms, terms and conditions of employment and CRB checks. Some files also contained only one reference of employment, and not all contained identification. Files contained photographs and POVA first checks. Mayfields DS0000006684.V342626.R02.S.doc Version 5.2 Page 21 A range of mandatory training had been undertaken by most of the staff team. This included health and safety, moving and handling, first aid, fire awareness, COSHH, food hygiene, medication and three day dementia course. Specialist training included adult abuse, challenging behaviour, yesterday, today and tomorrow and care planning. Progress is being made in relation to NVQ level II training. Staff were spoken with throughout the site visit and said the staff team were very supportive and the care of residents a priority and was very good. A carer said, “ I’ve been working here for over a year. I’ve not done any medication training as yet as you have to be 21. I’m key worker to two residents though we move around the units regularly. As a key worker your responsible for talking to their family about them, talking to them about then health, making sure their appointments are booked, have clean clothes, money and that support plans are up to date. I’m responsible for writing their support plans and recording their personal care. We’ve had new support plans and were still getting use to them. I get a lot of help and support from the staff team.” A recently appointed carer said, “ I started in June. Before I could work with residents I had induction training in the training room. I had training on moving and handling, food hygiene, health and safety, fire and infection control. The staff team are very good, very caring. The residents are well cared for. We help them to remain independent and some can make drinks with help. They help wash up and dry dishes. Some residents will keep their bedrooms tidy. People are treated really well and they have lots of activities going on they can join in. The activities organiser is on holiday this week but she left a programme of activities for us to do. We will do them as she leaves the materials. Some of the residents are going out this afternoon and they can choose what they do. I think that the staff are really good at promoting choice, but we are always reminded to encourage them to do activities. You can sit and talk to residents but you must do activities”. Several staff said they had a dilemma about waking residents up to do activities as though they were not respecting their choice. The manager said residents were gently woken to participate in activities, which were important as residents spent a lot of time sleeping and being inactive. She was asked to discuss the staff concern as staff said they felt they were coercing residents. Mayfields DS0000006684.V342626.R02.S.doc Version 5.2 Page 22 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, 37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The quality assurance systems, financial procedures and maintenance of the building and equipment safeguards residents and ensure they are safe. EVIDENCE: The manager has been registered with The CSCI since 2005. She has worked in care services for many years and has achieved NVQ level 4. She was not present during the site visit when the two deputy managers managed Mayfields. The deputy managers were undertaking the registered manager’s award. The regional manager was present at the second day of the site visit and feedback was given to her about the findings of the two days. Mayfields DS0000006684.V342626.R02.S.doc Version 5.2 Page 23 The hairdresser was working at Mayfields during the site visit. She stated that she liked working there and that the staff were great with the residents. She felt that the residents were happy. She said that the manager was good and had lots of new ideas, which she had been implementing and these had proved popular, such as the resident’s café. Quality assurance processes include: residents meetings, relative meetings and a newsletter. The last residents’ meeting was held on 29 April 2007 when fourteen residents attended. Areas covered included meals, activities, DVD’s and videos, church activities and any other business. The previous meeting was held on 24 December 2006. The last relatives meeting was held on 20 June 2007 and seven people attended. Issues discussed include residents’ monies, information held regarding residents, activities, hairdressing, clothes show, staffing issues and the new no smoking legislation. A newsletter is produced at the home and the current edition dated summer 2007 was seen. It is produced by volunteers at the home and included information on the home, staff, residents, chaplain corner and volunteer news. Minutes of a managers’ meeting for 26th July 2007 were made available The personal monies held at the home for three residents were examined. The administrator held monies securely. Records for deposits of monies and monies spent by or on behalf of the resident were kept. Balances tallied with the records on file and receipts for monies spent at the shop or the hairdresser kept. All staff had undertaken supervision training. One staff member file seen was not up to date. All staff had received an appraisal this year. No supervision or appraisal had been recorded for the new staff member yet. The Annual Quality Assurance Assessment recorded that all the necessary maintenance checks had been completed. The handyman provides fire training and had been trained as a fire marshal ten years ago. Fire records for training were completed for January, May and August 2007. A fire drill had taken place on 30th July 2007 and the fire alarm activated during the site visit 14th August due to burnt toast. Records recorded regular testing of the fire alarms, emergency lighting and fire doors. Routes of escape were checked weekly. The handyman also checks dead end water buts and drains these weekly to reduce risk of legionella. Mayfields DS0000006684.V342626.R02.S.doc Version 5.2 Page 24 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 3 Mayfields DS0000006684.V342626.R02.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 Timescale for action All residents must have a 14/08/07 detailed support plan when they move into the home so their needs can be identified and appropriate support provided for their health and social care needs. The registered person must not 14/08/07 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 so resident are protected from harm. The registered person must 14/08/07 make arrangements to ensure that the medicine records are completed at the time of administration, stocks of prescribed medicines are maintained and records of controlled drugs are accurate so residents receive their medicines safely and accurate records are maintained so discrepancies are accounted for. Requirement 2. OP29 19(1)(a) (b)(c) 3. OP9 13(2) Mayfields DS0000006684.V342626.R02.S.doc Version 5.2 Page 26 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. Refer to Standard OP7 OP7 OP7 OP7 Good Practice Recommendations More detail should be included in the care plans to ensure that the resident’s needs are fully met. The manager should consider devising a method of recording when a referral has been made to a health care professional. Wherever possible staff should seek the views of the residents on how they feel their care has been and record this in the daily records. The resident’s method of communicating non-verbally should be identified and recorded in the care plan. The manager should explore alternative communication methods. A system of the dividing up support plans is recommended to give a standardised format and provide clarity. The manager should carry out regular full audits of the care files. Full records should be kept are kept of health care visits and that annual visits and reviews are undertaken. Staff should receive appropriate training completion of Waterlow Charts and that terminology is fully explained to enable the staff to complete the forms accurately. If daily fluid and turning charts are to be used then they should be completed on a daily basis. Residents’ support plans should be drawn up with the involvement of the resident, recorded in a style accessible to the resident; agreed and signed by the resident whenever capable and/or their representative The manager should seek and record the views of the residents and/or their relative as to whether they would like their bedroom doors locking during the day to prevent inadvertent access by other residents who walk about the home. The manager should ensure staff in the event of an emergency could easily open door-locking systems on bedrooms. 5. 6. 7. 8. 9. 10. OP7 OP7 OP7 OP7 OP7 OP7 11. OP19 12. OP19 Mayfields DS0000006684.V342626.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 Mayfields DS0000006684.V342626.R02.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. 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