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Inspection on 28/11/05 for Mayflower Court

Also see our care home review for Mayflower Court for more information

This inspection was carried out on 28th November 2005.

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The care home has comprehensive and relevant documentation for both residents and staff. Documents reviewed on the day of the inspection demonstrated that residents care plans, risk assessments, and daily health records were up to date and had been reviewed on a regular basis by the senior carers in the home therefore ensuring the residents needs are met. Staff in the home are friendly and have a good rapport with all residents.

What has improved since the last inspection?

All newly recruited staff have up to date CRB/POVA enhanced certificates, before commencing work in the home. This helps ensure that residents are safeguarded.

What the care home could do better:

The homes kitchen needs to be redecorated and screens fitted to the exterior window. The main ground corridor floor needs to be replace/retiled, where the present floor covering is damaged. This will enhance the environment within which residents have to live.

CARE HOMES FOR OLDER PEOPLE Mayflower Court 8 Waterford Road Birkenhead Wirral CH43 6UT Lead Inspector John McCabe Unannounced Inspection 28th November 2005 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 Mayflower Court DS0000040989.V269215.R01.S.doc Version 5.0 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. Mayflower Court DS0000040989.V269215.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Mayflower Court Address 8 Waterford Road Birkenhead Wirral CH43 6UT 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) 0151 652 8810 Mayflower Care Homes Ltd Monica Mary Wilson Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Mayflower Court DS0000040989.V269215.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th September 2005 Brief Description of the Service: Mayflower care home is an Edwardian house with three floors registered for personal care for twenty residents; a lift is available to access all floors of the home. The home is in a quiet part of Birkenhead close to all amenities including rail and bus stations. There are two communal lounges and a dining room, furnishings and decoration give a homely appearance to the home. Most of the residents have their own bedrooms; those who share bedrooms have verbally consented to do so. The home has a well cared for garden with seating for residents in the summer months. All residents have their own GP; specialist health professionals visit residents in the home when ever necessary. Mayflower Court DS0000040989.V269215.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 28/11/04 at 0930 hours. The registered manager of the home was present throughout the inspection. Files and documents relating to residents and staff were reviewed, and a full tour of the building took place. The inspection was done over a period of 3 hours. The home was clean, tidy and adequate numbers of staff were on duty to care for the residents. Staff and residents told the inspector that the home is a happy place to live and work in. What the service does well: The care home has comprehensive and relevant documentation for both residents and staff. Documents reviewed on the day of the inspection demonstrated that residents care plans, risk assessments, and daily health records were up to date and had been reviewed on a regular basis by the senior carers in the home therefore ensuring the residents needs are met. Staff in the home are friendly and have a good rapport with all residents. Mayflower Court DS0000040989.V269215.R01.S.doc Version 5.0 Page 6 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 contacting your local CSCI office. Mayflower Court DS0000040989.V269215.R01.S.doc Version 5.0 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 Mayflower Court DS0000040989.V269215.R01.S.doc Version 5.0 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): 1,2,4,5. The Homes Statements of Purpose is up to date and ensures that the home stays within the category of resident agreed with the commission, and prospective residents have some knowledge of the home before they decide to move in on a permanent basis. The resident’s pre-admission assessment documentation is robust and comprehensive; this ensures that the skill mix of the workforce in the home can meet the residents identified care needs. EVIDENCE: All residents in the home are provided with a statement of terms and conditions, plus a contract when they move in to the home on a permanent basis. Residents are able to visit the home or have an overnight stay before they move in to allow them the opportunity to make a more informed choice. Mayflower Court DS0000040989.V269215.R01.S.doc Version 5.0 Page 9 The homes senior carers undertake a pre-admission assessment on residents before they are admitted to the home, to ensure care needs are identified. Other health care professionals known to the resident are also involved in the assessment. Care staff in the home undertake specialist care training in areas such as dementia, cognitive impairment, diabetes and stroke. This is ongoing, to ensure that the assessed and changing care needs of the residents are met by suitably trained staff. Mayflower Court DS0000040989.V269215.R01.S.doc Version 5.0 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. Resident’s individual health, personal and social care needs are clearly recorded, and this provides care staff with the information they need to meet the residents care needs. EVIDENCE: All residents in the home have an individual care plan, which is formulated on admission to the home, and reviewed by the senior carers on a monthly basis. Residents and family also contribute the formulation of the plan. Daily health records are documented for each resident, this also includes any critical incidences plus any visits from GPs, specialist nurses etc. No resident in the home self medicates, all medications for residents are administered by the carers in the home. The protocols for the receipt, storage, disposal, and documentation of medications in the home are in accordance Mayflower Court DS0000040989.V269215.R01.S.doc Version 5.0 Page 11 with the National Minimum Standards (NMS) and therefore help to ensure that residents are safely administered medication. Currently, there are no pressure sores on any of the residents. All residents in the home can access their NHS entitlements, which include dentists, opticians and chiropodists. This ensures that their overall health needs are regularly reviewed by independent practioners. Mayflower Court DS0000040989.V269215.R01.S.doc Version 5.0 Page 12 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. Residents are encouraged to exercise choice and flexibility about how they spend their day in the home. They can also pursue leisure and educational activities according to their choice and preferences. This encourages independence and individuality for each resident. Residents receive a balanced diet offering variety whilst at the same time reflecting resident’s personal preferences. EVIDENCE: Residents in the home are asked on admission, about their lifestyle, choice of foods, and choices and preferences of the social activities that they would like to participate in. On admission to the home the resident with help from a family member completes “Getting to know you” questionnaire, which is a “Work life History” of the resident. This includes the residents experiences of schooling, work, hobbies, as well as food likes and dislikes etc. This information is used to facilitate organised activities for the resident, to formulate care plans and to implement activities for the residents. Mayflower Court DS0000040989.V269215.R01.S.doc Version 5.0 Page 13 Visitors are allowed in the home at any reasonable time of day and residents may entertain their visitors, in the communal lounges, or in their own bedroom. This helps to maintain contact with significant people in the residents lives. Residents told the inspector that they enjoyed the variety of food in the home and were looking forward to chicken pie and chips with vegetables. Some of the residents prefer to take their meals in their own room rather than go to the dining room and this choice is supported whenever possible. Mayflower Court DS0000040989.V269215.R01.S.doc Version 5.0 Page 14 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): 16,17,18. The home has a satisfactory complaints system with evidence that residents feel their views are being listened to and acted upon. The homes policy and training programmes for POVA, and Whistle blowing, ensure that the homes residents are protected from any abuse. EVIDENCE: There have been no internal complaints, or complaints to the commission since the last inspection. The home has robust complaints procedures, which are documented in the residents guide and the staff handbook. Many of the residents use their postal votes in the Local Elections and are encouraged to do so. This supports their individual right to express their political preferences. The care home has up to date information on the Protection of Vulnerable Adults (POVA). This information is communicated to new employees on their induction course. There was evidence that many of the staff in the home have undertaken training on POVA protocols, and the Whistle Blowing Policy. This assists in safeguarding residents by ensuring all staff know how to respond to concerns they may have about the welfare of a resident. Mayflower Court DS0000040989.V269215.R01.S.doc Version 5.0 Page 15 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): 19,20,21,22,23,24,25,26. The standard of decor within this home is good, with evidence of some continuing improvements, through maintenance and planning. The home does present as a homely, safe and comfortable environment for the residents. Mayflower Court DS0000040989.V269215.R01.S.doc Version 5.0 Page 16 EVIDENCE: The home is well maintained and decorated and is suitable for its stated purpose. The premises are safe and comfortable. The homes kitchen needs to be redecorated, and the cupboard door,( which is situated on the kitchen floor), needs to be refitted to the cupboard. The floor tiling immediately outside the kitchen door entrance needs to be replaced. In its present state it compromises health and safety regulations. A chair belonging to a resident is damaged and the manager is to speak to the resident and his family to ascertain whether the chair can be repaired or replaced. The communal lounge and dining room is furnished in a homely way, with domestic lighting, a television and radio as well as a number of library books. The front and rear gardens are well cared for and tended and offer seating for the residents and their visitors. Most of the residents have personalised their own bedrooms with photographs and memorabilia thus presenting as a more homely environment in which to live. Mayflower Court DS0000040989.V269215.R01.S.doc Version 5.0 Page 17 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. The standard of vetting and recruitment practices is safe and ensures that appropriate checks are being carried out on all new staff. This means that the residents are not put at unnecessary risk. EVIDENCE: Staff personal files were reviewed. All staff working in the home have up to date CRB/POVA enhanced certificates. All staff has signed their induction document to confirm they have all been instructed on Adult Protection protocols and during conversation with the inspector those spoken to were able to demonstrate a satisfactory awareness of this important aspect of their work. Mandatory and specialist training for staff is ongoing as evidenced from the personal files of the staff. Mayflower Court DS0000040989.V269215.R01.S.doc Version 5.0 Page 18 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): 31,32,33,34,35,36,37,38. Staff morale is high in the care home, resulting in an enthusiastic workforce that works positively with residents to improve their whole quality of life. Staff are well supervised and the health and safety of the residents and staff is promoted and protected. EVIDENCE: The homes manager has over ten years experience in home care management. She has successfully completed an NVQ Level4 management programme. All staff in the home have documented supervision six times per year, this ensures that all staff have the opportunity to discuss with the manager, and other senior nurses, any issues that can effect or improve the care for the residents. Documented supervision of all staff also gives the staff and managers opportunities to discuss their own /or identified training needs. Mayflower Court DS0000040989.V269215.R01.S.doc Version 5.0 Page 19 Where possible residents look after their own financial affairs. The home doesn’t hold any bank accounts for individual residents. The homes certificates of insurance and worthiness for machines, gas, electricity, fire equipments, lift, hoists were in date and valid. The Employers Liability Insurance Certificate which is displayed in the main hall of the home, the certificate was also valid and in date. Mayflower Court DS0000040989.V269215.R01.S.doc Version 5.0 Page 20 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 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 18 3 2 3 3 3 3 3 3 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 3 3 3 3 3 Mayflower Court DS0000040989.V269215.R01.S.doc Version 5.0 Page 21 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 OP19 Regulation 23 Requirement The registered person must ensure that the homes kitchen is redecorated and properly maintained, and floor tiling at the entrance to the kitchen door is replaced. Timescale for action 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Mayflower Court DS0000040989.V269215.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Mayflower Court DS0000040989.V269215.R01.S.doc Version 5.0 Page 23 - 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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