Inspection on 07/09/05 for Mayflower Court

This inspection was carried out on 7th September 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.

Other inspections for this house

Mayflower Court 25/07/06

Mayflower Court 28/11/05

Mayflower Court 21/09/04

Mayflower Court 17/06/04

Mayflower Court 03/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Mayflower Court 8 Waterford Road Birkenhead Wirral CH43 6UT Lead Inspector John McCabe Unannounced 7 September 2005 1.00 p.m. th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Mayflower Court F52-F02 S40989 Mayflower V247787 070905 Stage 04.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Mayflower Court Address 8 Waterford Road, Birkenhead, Wirral, CH43 6UT Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0151 652 8810 Mayflower Care Homes Ltd Monica Mary Wilson PC Care home only 20 Category(ies) of OP Old Age - 20 registration, with number of places Mayflower Court F52-F02 S40989 Mayflower V247787 070905 Stage 04.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 21st September 2004. Brief Description of the Service: Mayflower care home is an Edwardian house with three floors registered for personal care for twenty service users, 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 service users 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 service users in the summer months. All service users have their own GP; specialist health professionals visit service users in the home when ever necessary. Mayflower Court F52-F02 S40989 Mayflower V247787 070905 Stage 04.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place with the registered manager of the home. 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 four hours. The home was clean, tidy and adequate 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: What has improved since the last inspection? What they could do better: Mayflower Court F52-F02 S40989 Mayflower V247787 070905 Stage 04.doc Version 1.40 Page 6 The recruitment and vetting of staff to the home must include CRB/POVA checks, before staff commence work at the home. 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 F52-F02 S40989 Mayflower V247787 070905 Stage 04.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Mayflower Court F52-F02 S40989 Mayflower V247787 070905 Stage 04.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5. 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 on a permanent basis. The homes senior carers undertake a pre-admission assessment on residents before they are admitted to the home, to ensure care needs are identified. Mayflower Court F52-F02 S40989 Mayflower V247787 070905 Stage 04.doc Version 1.40 Page 9 Other health care professionals known to the resident are also involved in the assessment. Care staff in the home undertakes special care training i.e. dementia, cognitive impairment, diabetes which is ongoing, to ensure that the assessed and changing care needs of the residents are met. Mayflower Court F52-F02 S40989 Mayflower V247787 070905 Stage 04.doc Version 1.40 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 standard(s) 7,8,9,10. Resident’s individual health, personal and social care needs are clearly recorded, and provides care staff 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 with the National Minimum Standards (NMS). Mayflower Court F52-F02 S40989 Mayflower V247787 070905 Stage 04.doc Version 1.40 Page 11 All residents in the home can access their NHS entitlements, which include dentists, opticians and chiropodists. Mayflower Court F52-F02 S40989 Mayflower V247787 070905 Stage 04.doc Version 1.40 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 standard(s) 12,13,14,15. Residents are encouraged to exercise choice and flexibility how they spend their day in the home. They can also pursue leisure and educational activities according to their choice and preferences. This allows independence and individuality for each resident. Residents receive a balanced diet offering variety while reflecting residents 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, and includes schooling, work, hobbies, food likes and dislikes etc. This information is used to facilitate organised activities for the resident, carers plan and implement the activities for the residents. Visitors are allowed in the home at any reasonable time of day, residents may entertain their visitors, in the communal lounges, or in their own bedroom. Mayflower Court F52-F02 S40989 Mayflower V247787 070905 Stage 04.doc Version 1.40 Page 13 Residents told the inspector that they enjoyed the variety of food in the home, and were looking forward to Friday, as they enjoy “fish and chips”. Some of the residents prefer to take their meals in their own room rather than go to the dining room. Mayflower Court F52-F02 S40989 Mayflower V247787 070905 Stage 04.doc Version 1.40 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 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 is documented in the residents guide and the staff handbook. Many of the residents used their postal vote in the Local Elections. 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 staffs in the home had undertaken training on POVA protocols, and the Whistle Blowing Policy. Mayflower Court F52-F02 S40989 Mayflower V247787 070905 Stage 04.doc Version 1.40 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 standard(s) 19,20,21,22,23,24,25,26. The standard of decor within this home is good, with evidence of continuing improvements, through maintenance and planning. The home does present as a homely, safe and comfortable environment for the residents. Mayflower Court F52-F02 S40989 Mayflower V247787 070905 Stage 04.doc Version 1.40 Page 16 EVIDENCE: The home is well maintained and decorated, suitable for its stated purpose. The premises are safe, comfortable and free from smells. There are grab rails throughout the house and ramps for wheelchair access. Some of the kitchen cupboard doors need replacing as they have been damaged and can no longer be safely cleaned; the manager said that the doors could be changed. The communal lounge, dining room is furnished in a homely way, with domestic lighting, television and radio, library books. The front and rear gardens are well cared for and tended and offer seating for the service users. The manager said that the side gardens are to be tidied up in the near future Most of the residents have personalised their own bedrooms with photographs and memorabilia. Mayflower Court F52-F02 S40989 Mayflower V247787 070905 Stage 04.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30. The standard of vetting and recruitment practices is not safe and does not ensure appropriate checks being carried out on all new staff. This means that the residents are potentially put at risk. EVIDENCE: Staff personal files were reviewed and it was noticed that a member of staff who had been employed recently, had no CRB/POVA enhanced certificate and was already working in the home. No person can be employed in a care home without an up to date CRB/POVA check, at the required level. The manager took immediate steps so as to comply with the regulations. All staff have signed their induction document to confirm they have all been instructed on Adult Protection protocols. Staff training is ongoing as evidenced from the personal files of the staff. Mayflower Court F52-F02 S40989 Mayflower V247787 070905 Stage 04.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 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, plus the turnover of care staff is low. 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 staffs have the opportunity to discuss with the manager, and other senior nurses, any issues which can effect or improve the care for the residents. Mayflower Court F52-F02 S40989 Mayflower V247787 070905 Stage 04.doc Version 1.40 Page 19 Documented supervision of all staff also gives the staff and managers opportunities to discuss their own /or identified training needs. 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 is valid and in date. Mayflower Court F52-F02 S40989 Mayflower V247787 070905 Stage 04.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 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 Standard No 16 17 18 Score 3 3 3 3 3 3 3 3 3 3 3 Mayflower Court F52-F02 S40989 Mayflower V247787 070905 Stage 04.doc Version 1.40 Page 21 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 29 Regulation 18 Requirement The registered person must ensure that all new employees have an enhanced CRB/POVA certificate, before they start work in the home. Timescale for action Immediate and ON Going. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Mayflower Court F52-F02 S40989 Mayflower V247787 070905 Stage 04.doc Version 1.40 Page 22 Commission for Social Care Inspection Liverpool Area Office 3rd Floor, 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 F52-F02 S40989 Mayflower V247787 070905 Stage 04.doc Version 1.40 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. 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