Inspection on 05/05/06 for Mayfields

This inspection was carried out on 5th May 2006.

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

Mayfields 14/08/07

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 Judith Morton Key Unannounced Inspection 5th May 2006 09:30 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.V294356.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V294356.R01.S.doc Version 5.1 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 45 Category(ies) of Dementia (7), Dementia - over 65 years of age registration, with number (45) of places Mayfields DS0000006684.V294356.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 45 service users to include: * Up to 45 service users in the category (DE(E) Dementia over 65 years of age * Up to 7 service users in the category DE (Dementia). The registered provider must at all times employ a suitably qualified and experienced manger who is registered with the Commission for Social Care Inspection. Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidance which can be issued through the Commission for Social Care Inspection. 26th September 2005 2. 3. Date of last inspection 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 service users. On the first day of the visit, (05/05/06), the manager said that the home charges £478.00 per week. This is a flat rate charge. Residents who are funded by Social Services receive £417.00 and have to pay the top up fee of £61.00 per week, bringing their charge in line with the privately funded residents. Mayfields DS0000006684.V294356.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit, part of the key inspection for this service, took place over 10 hours, over two days, on 5th and 10th May 2006. This included time giving feedback to the manager. Three residents care files were checked and seven residents were spoken with. In addition to talking with the manager, three assistant managers, five care assistants, five volunteer workers, and the new administration officer were spoken with. A tour of the building and gardens was also carried out. The report has also been written using information held by the Commission for Social Care Inspection (CSCI). What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by Mayfields DS0000006684.V294356.R01.S.doc Version 5.1 Page 6 contacting your local CSCI office. Mayfields DS0000006684.V294356.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mayfields DS0000006684.V294356.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 & 5. Standard 6 does not apply. Quality in this outcome area is adequate. This judgement has been made using available evidence, including documentation and a visit to the service. The detailed completion of the getting to know you documentation will make sure all of the staff have good insight into the personality, likes, dislikes, hobbies and interests of the residents. EVIDENCE: Residents had contracts that were held separately in a specific file in the manager’s office. The manager said that she has introduced a new process for obtaining the assessment information. A ‘Getting To Know You’ document is sent out to the prospective resident for them and their family to complete. Prospective residents then come into Mayfield for a full day, 10am – 3pm and stay for a meal so that observation of their mobility, mental health, behaviour and communication can also be part of the assessment. During that time a member of the staff team will undertake an assessment and complete other parts of the ‘getting to know you’ document that have not been completed. The manager said that she discourages the family from staying at this point so Mayfields DS0000006684.V294356.R01.S.doc Version 5.1 Page 9 that she can gain an accurate picture of the resident. This was seen to happen on the day of the inspection. Three residents’ files were checked, including one of a resident who had moved into Mayfields one week earlier. The two files of the longer-term residents contained assessments, completed by the manager and senior staff, before the residents moved in. These were detailed and identified specific needs from which a care plan could be drawn up. The assessments were made against a wide range of physical needs and specific mental health and dementia criteria. The new resident’s care file had the identifying information page completed and a contact number of one relative as next of kin. There were no additional contact numbers in case of emergency and the next of kin being unavailable. There was no further assessment information on the file. The telephone number of the GP was missing and must be recorded on the file. The next of kin was completed but did not say what relationship the person was, the getting to know me document had not been completed. The relationship of the next of kin and any other contact names should be recorded. The residents’ weight was not recorded as part of the initial assessment and a photograph of the resident was not on file. All residents must have a completed assessment prior to them moving into Mayfields. From this a care plan can be devised so that staff know immediately how they are to best meet a persons needs. (See requirement 1) Those files that had completed assessments gave good insight into the resident’s life, as a detailed history had been obtained. They also identified the person’s likes and dislikes, hobbies and interests so that appropriate activities could be designed around this knowledge. The manager said that prospective residents and their families can visit Mayfields at any time to have a look at the home, meet the staff and residents and decide if it is suitable to their needs. Mayfields DS0000006684.V294356.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11 Quality in this outcome area is adequate. This judgement has been made using available evidence, including documentation and a visit to the service. Guidance to staff, through supervision and training on accurate recording, would mean that care plans reflect more closely the needs of the residents and how these are to be met. EVIDENCE: Three of the residents care files were reviewed. Two contained care plans but the file of the new resident had very little information from which the staff would know what the residents’ needs were and how they should be met. The staff, through observation, had discovered that the resident did not eat a midday meal but preferred to eat a large meal later in the afternoon around 4.30 – 5.00pm. All residents should have a detailed care plan when they move into the home, devised from the information gathered at the assessment for staff to follow. (See requirement 2) Mayfields DS0000006684.V294356.R01.S.doc Version 5.1 Page 11 A well-designed front sheet, gives clear identifying information and a photograph of the resident was on the front of two of the files checked. In respect of the new resident it would be good practice if a photograph was taken at the assessment visit so that it is available for the file when the resident moves into the home. There was a good social history report on two of the files. This also gives an insight into the residents’ personality, which may change because of the dementia. Although the daily routine had been completed, within two of the three files, some areas were incomplete. Ie. Foot care, oral care, skin care, medication and diagnosis. The oral care read, has own teeth or wears dentures. This needs to be more detailed to show how the teeth are to be cleaned, by whom and with what. Also, whether dentures, should be removed at night. (See recommendation 1) The daily recordings on one file stated that a referral to the chiropodist was needed. However, it was not recorded anywhere in the file that this had been done. A form should be devised to show clearly when a referral has been made to any outside health professionals to ensure that a referral was made and so that it can be chased up if a response is delayed. (See recommendation 2) Where possible staff should sit with the individual resident to seek and record their view on how their day has been in the daily recordings. (See recommendation 3) Further detail of the communication methods with each resident need to be included on the care plans. It was recorded that one resident was becoming increasingly agitated and staff felt that it was due to frustration at no longer being able to communicate her needs. Her care plan should reflect the alternative methods of assisting the resident with her communication. If non-verbal communication is used a description of what facial expressions, behaviours or gestures may mean, should be recorded. The manager should consider developing alternative methods of communication to assist the residents who have limited verbal skills or poor comprehension skills. (See recommendation 4) Although the staff members had signed the care plans neither the resident nor their representative had signed them. (See requirement 3) Mayfields DS0000006684.V294356.R01.S.doc Version 5.1 Page 12 The care plans were reviewed regularly by the key workers and were updated as necessary. Although risk assessments were available for each resident they were kept together in a separate risk assessment file. It would be easier for new or agency staff to read these together with the care plans to know how to safely meet the resident’s needs. (See recommendation 5) A record of visits from health professionals, including GP, chiropodist and optician, showed that the resident’s health needs were being met. The manager said that she does audit the care plans but does not check through the whole of the care file. The manager should consider the benefits to the residents and to the staff development if she was to randomly check the care files. (See recommendation 6) In one file was a form called ‘challenging behaviour analysis’. Staff had completed this form correctly but had also ticked the box, which said, ‘care plan has been updated’. There had not been any additional entries made in the care plan to reflect this. Staff should state the section where the care plan had been altered on the behaviour analysis form so that it can be clearly identified. (See recommendation 7) The manager should source training for the staff on recording with care. (See recommendation 8) The three newly appointed assistant managers and the senior support staff are able to administer medication. They have each received updated training on the safe storage, administration and recording of medication. The medication administration record (MAR) sheets were checked at random and were found to be accurate. However, the pharmacy had printed that a cream should be taken orally. Staff should check the MAR sheets when they come in and ask the pharmacy to correct any mistakes. This would be important for overseas staff that may have difficulty with understanding written English. (See recommendation 9) A member of staff was observed checking in new medication with another member of staff. This was checked in accurately and both signed the record sheet. Medication was stored and labelled appropriately and the trolley was locked away. Mayfields DS0000006684.V294356.R01.S.doc Version 5.1 Page 13 All of the MAR sheets and some of the dividers with the resident’s photograph on were loose in the file and in danger of falling out. A more secure system of filing these should be explored. (See recommendation 10) The staff were seen interacting with the residents in a number of care situations and were respectful and polite. At other times staff were seen knocking on residents doors and waiting for an answer before entering. Mayfields DS0000006684.V294356.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence, including documentation and a visit to the service. The invaluable service provided by the volunteers at Mayfield will keep the residents stimulated and occupied. It ensures that activities for the residents can continue without relying solely on staff time. EVIDENCE: Mayfields activities co-ordinator had left since the last inspection. There are a large number of volunteers who regularly visit Mayfields. Some assist in the resident’s shop, others do a variety of activities with the residents and a timetable is devised by one of the volunteers who co-ordinates the activities. The timetable is displayed on the notice board in the large central lounge. They were varied and plentiful and, in the main, would occupy and stimulate the residents. Each of the residents was to have an individual timetable of activities, devised around their hobbies and interests, held on their file. The manager said that staff were in the process of devising these. One was seen on one of the files checked. Each of the three wings has an allocated day for attending the shop and residents were seen visiting the shop, some on their own and some with the support of staff. Mayfields DS0000006684.V294356.R01.S.doc Version 5.1 Page 15 In the afternoon residents were seen making a collage of old photographs from newspapers and discussing the content of the pictures, which were of famous film stars and the royal family etc. The manager said she is intending changing one of the small lounges into a coffee shop environment and serve drinks and cakes in the afternoons. There won’t be a charge for this but the environment will be the same. Some of the staff were seen conducting activities with residents in the wings. The visitor’s book showed that there were no restrictions on visiting. The manger and staff confirmed that visitors were welcome at any time. Residents could make choices about some aspects of their lives at Mayfield. These included, what time they wanted to get up, go to bed and what they wanted to eat at meal times. Residents were seen to get up at varying times and, in some instances, were able to help themselves to breakfast, as there is a small kitchen in each of the lounges. The manager and staff explained that if a resident didn’t a like choice at mealtime the staff would make them an alternative. The menu appeared wholesome and varied and meals were served in the dining area of each lounge. The meal provided buy the kitchen staff was very well presented and wholesome. The evening meal is made by the staff on each unit and consists of sandwiches, cakes etc. One unit had a birthday tea so the kitchen had made and provided the food for this. Some of the residents spoken with were unable to remember what they had eaten for lunch but others said that they had really enjoyed it. One gentleman knew what he had had for lunch but could not find the word to say it. However, when prompted he was able to recall it. The manager should consider having photographs of each meal taken so that a photographic menu can be placed in a prominent position in each wing. This would help residents to make a choice of meal but would also act as a reminder and visual prompt throughout the day. (See recommendation 11) The kitchen staff have achieved a gold award for cleanliness and maintenance from the environmental health department for the second year running. Mayfields DS0000006684.V294356.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence, including documentation and a visit to the service. Staff training in adult abuse awareness and the protection of vulnerable adults will ensure that all forms of abuse or bad practice are recognised and reported. EVIDENCE: Mayfields has a written complaints procedure, which includes contact details for the Commission for Social Care Inspection (CSCI). Information regarding how to make a complaint has been given to all residents or their relatives and was also displayed prominently. There had been one complaint made since the last inspection. The manager had met with the complainant and the social worker the matter had been resolved to their satisfaction. Although a record of complaints is kept by the manager there should be a recording system devised so that complaints can be tracked through to completion with dates, the action taken, by whom and how the complainant was informed of the outcome. In the same way a book could also be devised for comments made by relatives or professionals on the quality assurance questionnaires. This would show what action had been taken to resolve issues that had not been made as a complaint but were of sufficient concern to relatives. (See recommendation 12) Mayfields DS0000006684.V294356.R01.S.doc Version 5.1 Page 17 The manager has developed a compliments book to record when compliments are made to individual staff. The manager verbally informs the staff when a compliment has been received. Written adult protection procedures had been compiled by the home and a copy of the local authority’s procedures and protocols were also available. Some staff members spoken with said they had not received any adult protection training and there were also a number of new staff working at Mayfield who would be requiring the training. The staff were aware of the Whistle Blowing policy and the homes Abuse of Vulnerable Adults policy and said they would report anything they suspected as abuse to the manager or senior on duty. The registered manager had not received training in this area but had recently received the training material, which was seen. It consisted of a video and workbook. The manager and assistant managers would also need to know what their role would be should an allegation be reported to them. All staff must receive training on the protection of vulnerable adults from abuse. (See requirement 4) Mayfields DS0000006684.V294356.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence, including documentation and a visit to the service. The openness and brightness of Mayfield provides the residents with a comfortable and calm atmosphere where they are free to move around and spend time in all areas of the home. EVIDENCE: A tour of the premises showed that the home is spacious, well decorated and well equipped. There is a programme of routine maintenance to keep it in good order. Residents have a choice of shared spaces in which to sit and there is good access for people who use wheelchairs. All bedrooms are single occupancy and have en-suite toilets and washbasins, which promote individual privacy. There are landscaped gardens that are accessible and secure and these provide residents with safe areas in which to walk or sit. There are plans and funding in place to further develop the garden area to provide sensory areas. Mayfields DS0000006684.V294356.R01.S.doc Version 5.1 Page 19 Locks are fitted to all bedroom doors. Many residents are unable to use these. This does, however, mean that some residents who have the ability to walk freely around the home sometimes wander into other people’s bedrooms and encroach on their privacy. The manager should discuss with residents and their relatives whether or not they would like their bedroom doors locking during the day to prevent inadvertent access by other residents who walk about the home. (See recommendation 13) During the inspection one member of staff was heard asking an assistant manager for the keys. A resident who chooses to lock her door was not responding when the staff knocked on the door and there was no immediate override facility on the lock. The type of locking system should be risk assessed to ensure suitability in the event of an emergency. (See recommendation 14) The individual wings have a small kitchen area attached to each lounge. Some of the residents, particularly those who have lost an awareness of danger or who will pick things up randomly, may be at risk from kitchen items. The manager said that they try to have a member of staff in each unit at all times and when the staffing is reduced at night the kettle is stored away in a cupboard underneath the sink. However, it is important that residents have a risk assessment completed in relation to their safety, and that of others, in and around the kitchen area. (See requirement 5) A bell is in operation for access to the building and all visitors are asked to sign the visitors’ book when they enter and leave. The alarm system is also activated at night for the safety of both staff and residents. There is a maintenance man employed by the home who makes weekly safety checks on the fire, alarm, lighting, heating and water systems. These are recorded in separate folders and any problems are then dealt with immediately. The home is clean and free of unpleasant odours, making it a pleasant environment for residents and their visitors Mayfields DS0000006684.V294356.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence, including documentation and a visit to the service. The recruitment policies and procedures being followed by the home, together with the training provided to the staff will further ensure that the residents are supported and protected. EVIDENCE: There have been a number of new staff recruited since the last inspection, this includes three assistant managers, three care workers and administrative assistant. The assistant managers were spoken with together and individually throughout the inspection. They all agreed that they had received adequate training to help them to fulfil their work. They said they had found it difficult at first as the manager was also relatively new when they started working at the home but now feel that they have a good understanding of the ethos of the home and their role within it. The new member of staff was spoken with and confirmed that she had received a three-day induction programme. However, when asked how she had done with the questions in the workbook she said that she did not know as it had not been checked and she had not received feedback. The new staff’ knowledge and understanding of topics covered in their induction should be explored and any areas of concern or uncertainty clarified. (See recommendation 15) Mayfields DS0000006684.V294356.R01.S.doc Version 5.1 Page 21 Staff rosters confirmed that previously agreed staffing levels were being maintained and the use of agency staff had not been necessary for some time. The file for a new member of staff was checked and included all of the documentation required for the safe recruitment of staff and protection of the residents. The homes recruitment policy and procedure was being followed. There are over 50 volunteers who work into Mayfield at some point throughout the week. The manager said that all of the volunteers had had a police check carried out with the Criminal Records Bureau. Five volunteers were spoken with throughout the inspection and all confirmed this. Staff spoken with included longer serving staff, a number of whom had completed NVQ level 2. However, this had been between 5 and 6 years earlier. They said they had asked to do NVQ level 3 but were told that it would not be funded at this time. The manager explained that the policy of Methodist Homes was to fund NVQ level 2 until all staff across their services had completed it. Other training had been provided, which included dementia training called Yesterday, Today and Tomorrow. All of the staff had participated in this and said that they really enjoyed it and learned a lot from it. Mayfields DS0000006684.V294356.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence, including documentation and a visit to the service. The methods taken to seek the views of the residents, relatives and others involved in the service ensures that the home continues to practice in the residents best interest. EVIDENCE: The manager has been registered with The Commission for Social Care Inspection since the last inspection. She has worked in care services for many years and has achieved NVQ level 4, Registered Manager’s Award. She has also periodically updated her training, specific to the client group. The manager is fully aware of her role and duties to residents and is familiar with the conditions and diseases associated with old age. Mayfields DS0000006684.V294356.R01.S.doc Version 5.1 Page 23 Methodist Homes conducts an annual quality assurance exercise, which includes sending questionnaires to relatives and other professionals who have involvement in the home. A suggestion box is also available in the foyer. Relatives meetings are held three monthly and the minutes of these are recorded. The manager has identified an assistant manager who has identified 5 other staff within Mayfield to seek the views of the residents on the service at Mayfield. The staff will all be attending audit training in preparation for this. Staff receive regular formal supervision which is recorded. The registered manager supervises the assistant managers and senior staff. The assistant managers supervise the care support staff, although some of the staff said they felt this creates a ‘them and us’ environment. The residents’ finances are managed either by their family, Social Services, Power of Attorney or through Court of Protection. The manager is not responsible for the finances of any of the residents. The allowances held for residents to cover some spending at the shop or visits from the hairdresser are held in the safe and receipts are kept and recorded appropriately. The health, safety and welfare of residents and staff is promoted through safe working practices and the training of staff in areas such as moving and handling, first aid, food hygiene, infection control and COSHH (Control Of Substances Hazardous to Health). Mayfields DS0000006684.V294356.R01.S.doc Version 5.1 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 X 3 2 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 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 2 3 3 3 X X 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 Mayfields DS0000006684.V294356.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 2 Standard OP3 OP7 Regulation 14 15 Requirement All residents must have a completed assessment prior to them moving into Mayfield. All residents must have a detailed care plan when they move into the home, devised from the information gathered at the assessment. Previous date of requirement,01/03/06, not met. The plan must 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. All staff must receive training on the protection of vulnerable adults from abuse Residents must have a risk assessment to assess their safety and that of others in and around the kitchen area of each wing. Timescale for action 01/09/06 01/09/06 3 OP7 15 01/09/06 4 5 OP18 OP25 12 & 13 13 01/09/06 01/09/06 Mayfields DS0000006684.V294356.R01.S.doc Version 5.1 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. Risk assessments should to be held on individual files. The manager should consider carrying out regular full audits of the care files. Staff should state the section where the care plan had been altered on the behaviour analysis form so that it can be clearly identified. The manager should source recording with care training for care staff. Staff should check the MAR sheets when they come in and ask the pharmacy to correct any mistakes. The manager should explore a more secure system of filing the MAR sheets. The manager should consider having a photographic menu, placed in a prominent position in each wing. The manager should devise a recording system for complaints so that they can be tracked through to completion and any pattern developing can be identified. 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 must ensure door-locking systems on bedrooms can be easily opened by staff in the event of an emergency. 5 6 7 8 9 10 11 12 13 OP7 OP7 OP7 OP7 OP9 OP9 OP15 OP16 OP24 14 OP24 Mayfields DS0000006684.V294356.R01.S.doc Version 5.1 Page 27 15 OP27 Induction work should be checked and feedback given. Mayfields DS0000006684.V294356.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mayfields DS0000006684.V294356.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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