Inspection on 30/05/07 for Maynell House

This inspection was carried out on 30th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

Maynell House 18/09/09

Maynell House 01/03/06

Maynell House 29/09/05

Maynell House 30/03/05

Maynell House 30/09/04

Maynell House 17/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Maynell House High Road East Felixstowe Suffolk IP11 9PU Lead Inspector Julie Small Unannounced Inspection 30th May 2007 10:20 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 Maynell House DS0000024444.V341837.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Maynell House DS0000024444.V341837.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Maynell House Address High Road East Felixstowe Suffolk IP11 9PU 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) 01394 272731 01394 272731 maynell@pri-med.co.uk Pri-Med Group Ltd. Ms Wendy Jacqueline Patient Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Maynell House DS0000024444.V341837.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st March 2006 Brief Description of the Service: Maynell House is a care home registered to provide accommodation and personal care for up to 25 older people. The home is part of the Pri-Med Group Ltd and is one of the organisations’ three care homes for older people in Felixstowe. It stands back from the main road in it’s own extensive grounds. The house was once part of the independent boarding school for girls and it retains many of it’s original features, but has been extended to provide additional accommodation, including a pleasant veranda where residents can sit in warm weather. The home is on three floors and access to all but one room is either by staircase or a passenger lift. All rooms are tastefully decorated and furnished. There are two lounge areas and a dinning room. Interesting gardens surround the house, which includes a water feature complete with mature fish. Bedrooms are equipped with a single bed, wardrobe, chest of drawers, bedside cabinet and an easy armchair. With the exception of two rooms all have en suite facilities providing either a bath or a shower. Many of the bedrooms have views over the gardens. Residents are encouraged to bring their own personal possessions into the home, including small items of furniture. There is an emergency call bell system in operation situated in each bedroom and bathroom. The home is staffed 24 hours a day, with two waking night staff. The company has achieved Investors in People Award, initially in 1995 and has subsequently been re-accredited three times. The pre-inspection (PIQ) questionnaire received 14th February 2007 stated that fees at the home range from £440 to £660, additional charges are made for hairdressing and chiropody services. Maynell House DS0000024444.V341837.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on Wednesday 30th May 2007 from 10.25 to 16.45. The inspection was a key inspection which focused on the core standards relating to older people and was undertaken by regulatory inspector Julie Small. The report has been written using accumulated evidence gained prior to and during the inspection. The home’s manager and the deputy manager were present during the inspection and provided the requested information promptly and in an open manner. During the inspection a tour of the building and observation of work practice was undertaken. Six residents and three staff members were spoken with. Records viewed included three residents, three staff recruitment, training, fire safety and accident records. Further records viewed are detailed in the main body of this report. Prior to the inspection a pre-inspection questionnaire (PIQ) and staff, visitors and residents surveys were sent to the home. The PIQ was returned to CSCI (Commission for Social Care Inspection), sixteen service user and fifteen relative/visitor surveys were returned. What the service does well: What has improved since the last inspection? Maynell House DS0000024444.V341837.R01.S.doc Version 5.2 Page 6 There had been a new shower installed. There was work being undertaken on the exterior of the building and a new wooden balcony barrier had been built The manager said that external painting was being undertaken the week following the inspection. There had been new ‘sit on’ scales purchased at the home, to replace a broken set. A regular check of individual service users weight was being undertaken. During the last inspection a requirement was made which identified that wheelchairs or equipment stored in corridors, which were, routes leading to a fire exit were removed. During a tour of the building it was noted that the requirement had been actioned. 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. The summary of this inspection report can be made available in other formats on request. Maynell House DS0000024444.V341837.R01.S.doc Version 5.2 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 Maynell House DS0000024444.V341837.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users can expect to be provided with the information they need to make an informed choice about where to live and that their needs are assessed before they move into the home. The home does not provide an intermediate care service. EVIDENCE: Three service user’s records viewed contained needs assessments which had been completed prior to them moving into the home. The manager confirmed that the prospective service users were visited in their home, or alternative placements, such as hospital, and the assessments were undertaken prior to them moving into Maynell House. The needs assessments included details of mobility, reasons for requiring accommodating at the home, personal care needs, interests and hobbies, allergies, medication and health care needs. Maynell House DS0000024444.V341837.R01.S.doc Version 5.2 Page 9 The service user’s surveys asked if they had received a contract. Fourteen answered yes, one answered no and one did not answer the question. The surveys asked if they were provided with information about the home before they moved in. Twelve answered yes, two answered no and one did not respond to the question. Comments made on the surveys included ‘my relative chose the home…’ and ‘very thorough interview on both sides, matron most helpful’. The home’s statement of purpose was viewed and contained information on the provision of care which included rights, privacy, dignity, independence, security, choices, daily, life in the home, social activities, complaints, religion and worship, protection, staffing details, the organisation structure and procedure for evacuation of the home in the event of a fire. The statement of purpose had recently been amended to show that there had been a change of company, which was Healthcare Homes. The home still operated as part of the Pri-med Group Ltd. The service user’s guide was viewed and included information which service users could expect living at the home. Information included the aims and objectives of the home, arrangements for visitors, equality, civil rights, advocacy services, personal care, meals, insurance of the home, confidentiality, complaints and social activities. Maynell House DS0000024444.V341837.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can expect that their needs are met and set out in an individual plan of care. Service users can expect that they are treated with respect and that they are protected by the homes medication procedures. EVIDENCE: Three service user’s care plans were viewed and included details of support they required and preferred in their daily living in areas such as mobility, personal care and socialising. There was an assessment of need and preadmission assessment in each service users records and the care plans were generated from the needs assessments and identified how each need should be met. The care plans and assessments were signed by the service user and the staff member at the home. Maynell House DS0000024444.V341837.R01.S.doc Version 5.2 Page 11 Service user’s records included details of the name that each service user wished to be called, their specific dietary requirements, their religion and their preferences for worship, allergies and their final wishes if death occurred. The service user’s care plans identified their preferences with regards to the ways of bathing and the frequency of bathing. There was documentation in each service user’s records which identified when they had been supported to bathe, wash their hair and/or shave. One comment in a relative/visitor survey was that the routine of the home was one bath a week. This was discussed with the manager who said that each service user had their individual preferences and needs regarding the frequency of bathing and their preferences were supported. A staff member who had recently been employed at the home was spoken with and said that they found the care plans useful and descriptive. They said that they had read service user’s care plans prior to working with them and that they provided the information they required to support each service user. A staff member spoken with said that they used the care plans for reference and always ensured that they also asked the service users what they preferred. The service user surveys were asked if they received the care and support they needed. Eleven answered yes, three answered usually and one did not respond. Comments included ‘staff very aware of needs’ and ‘sometimes carers seem to take a long time to respond to the call bell’. During the inspection call bells were observed to be responded to promptly and the manager confirmed that staff respond to them as soon as they were able. The service user surveys asked if staff listened and acted upon what they said. Thirteen answered yes, one answered yes usually, one sometimes and one did not respond. Service user’ records included risk assessments on areas such as manual handling, pressure sores, nutritional screening and falls. The assessments included scores for each area, which indicated if the service user’s needs were high, low or medium. There was information provided in further risk assessments, which identified how the risks could be minimised. The service user’s records included weight charts, which evidenced that service users weight was regularly monitored. There was a comment in a service user and relative/visitor survey which stated that a service user had not had their weight monitored. The manager and deputy manager was spoken with and said that the previous set of weighing scales had broken and a new set was ordered, which left the home without ‘sit on’ scales for approximately one month November 2006. They confirmed that service users weight was monitored on a weekly basis. The new scales were seen during a tour of the building. Maynell House DS0000024444.V341837.R01.S.doc Version 5.2 Page 12 Service user’s records provided clear details of their health needs and visits to and from medical and healthcare professionals such as dentist, optician, district nurse, chiropodist and doctor. One service user survey stated that ‘local GP/district nurse not always keen to do home visits…’ The manager reported that there were no issues with GP or district nurse visits, and records viewed showed that visits were made when required. The service user surveys asked if they received medical support when they needed it. Nine answered always, five usually, one sometimes and one did not respond. Part of the lunchtime medication administration was observed. The home used the MDS (monitored dosage system) and medication was removed from the blister pack directly into a small pot which was given to the service user. The staff member signed the MAR (medication administration record) chart when the medication had been provided to the service user. The MAR charts were viewed and it was noted that there was one incident where not all medication administered on one shift had been signed for. There were records of a medication audit which had identified that the MAR charts had not been signed. The manager was spoken with and explained that they were on duty at this time and were aware of the incident, they said that the audit of medication had evidenced that the medication had been provided but not signed for. The MAR charts viewed did not have any further discrepancy and it was noted that the incident was a ‘one off’. The MAR charts included photographs of each service user who has prescribed medication and signatures of each staff member who administered medication. The medication was securely stored and the controlled medicines were stored in a secure container. In the medication room there was a medication fridge and the records of regular temperature checks were viewed. The controlled drugs record was viewed and was a bound book and two staff members had signed for the administration and receipt of controlled medicines. There was a balance kept of the medication. Records for the disposal of medicines were viewed. The service user’s records which were viewed included details of their prescribed medication. Two staff members spoken with, who administered medication, said that they had been provided with medication training, the training records which were viewed confirmed this. During the inspection staff were observed knocking on bedroom doors before they entered them. The manager asked for service users permission for the inspector to enter their bedroom. Maynell House DS0000024444.V341837.R01.S.doc Version 5.2 Page 13 They were observed ensuring that bedroom and toilet doors were closed when they were assisting the service users. The interaction between staff and service users during the inspection was observed to be friendly, professional and respectful. Service users spoken with said that the staff always treated them with respect. The service users guide explained that residents would be provided their mail unopened. Maynell House DS0000024444.V341837.R01.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, 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users can expect that they are provided with the opportunity to participate in activities, that they maintain contacts of their choice, that they have choice and control over their lives and that they are provided with an appealing and balanced diet. EVIDENCE: Service user’s records viewed identified what their interests were and their daily records evidenced what activities they had participated in. There was a separate record of provided activities and a resource file of services who provided activities, such as musical and comedy entertainers and a pat the dog service, which is a service which brings a dog into the home and service users could stroke if they wished to. During the afternoon of the inspection service users were heard participating in exercise, the manager said that a visiting physiotherapist facilitated the exercise activities. Service users were observed watching television, completing puzzles and reading books in various areas of the home. A service Maynell House DS0000024444.V341837.R01.S.doc Version 5.2 Page 15 user spoken with said that there was a visiting library service who supplied larger print books, and that they enjoyed reading in their bedroom and the communal areas of the home. Service users were observed having their hair done in the hairdressing room in the home by a visiting hairdresser. Staff were observed asking several service users if they wished to use the hairdresser. A service user spoken with said that the hairdresser came to the home regularly and was very good. There was a very good and varied range of activities provided by the home, the manager said that the home did not employ an activities co-ordinator and that staff managed activities well. Further activities provided included art class and pottery and there were several items such as a clock and pottery made by service users displayed in the home. There were photographs of service users enjoying outings and information about future activities, such as theatre trips, displayed in the home. The manager said that the weekend following the inspection the home had a garden fete which had been organised to fund raise for a charity. The manager and service users were observed discussing the upcoming fete. The service user survey asked if there were activities provided in the home. Four answered always, seven usually, two sometimes, one never and two did not respond. Comments included ‘Enjoy minibus outings when available.’ ‘There is always plenty going on.’ ‘…Enjoys large print library books, keep fit, hairdressers, chiropodist and church service – holy communion available’. One service user had a pet cat in their bedroom and there were two budgerigars in a cage in the small lounge. The manager said that the service users had bought the cage and the budgerigars. Service user’s records provided details of family and friend contacts who they maintained contact with. Daily records viewed evidenced that service users enjoyed regular visits from family and friends. During the inspection several visitors were observed in the home visiting friends and relatives. Service users spoken with said that their visitors were welcomed into the home by staff. Two service users spoken with said that their family often visited and they were welcomed at the home and often enjoyed a meal while visiting. They said that they were surprised that their family which included children would be made so welcome. A relative/visitor survey stated ‘Living close to Maynell House I visit often and always receive a friendly welcome. I notice the attention and care given to the people in the home. Additionally I always accompany my relative at social events’. Service user’s records and observation of work practice evidenced that service users were provided with choice in their daily living, including food and drinks Maynell House DS0000024444.V341837.R01.S.doc Version 5.2 Page 16 and what they wished to participate in throughout each day. The records identified service user’s likes and dislikes regarding food and specific dietary requirements. Minutes of a service user meeting were viewed and they had discussed their preferences with regards to food and activities. The menu was viewed which was varied and nutritious and there was a choice of meals. The menu provided a good range of cultural foods which included Indian, Chinese, Italian and Mexican. There were fresh vegetables and fresh fruit provided on the menu for each day. The cook was spoken with and said that they tried to keep the menu varied and offered service users items of food they may not have tried before moving into the home. They said that service users were consulted with on the menu and that they were provided with food items they had requested. Records were viewed of service user consultation regarding meals, which included a form for their likes, dislikes and specific requests. Service users were observed to be offered hot and cold drinks throughout the day. The service users made their choice of meals on the same day. The manager said that they had previously done this the day before, however, they found that service users preferred to make their choices on the same day. During a tour of the building it was noted that there was a choice of two dining rooms and some service users were observed to be provided with their meal in their bedroom. Lunch looked and smelled appetising, and service users appeared to enjoy their meal. There was a range of soft drinks which service users could choose from. The dining tables were attractively laid and provided attractively folded napkins and small vases of flowers. The food store was viewed and there was a good range of fresh fruit and vegetables and the food was mostly branded types. Staff food and hygiene training certificates were displayed on the wall near to the kitchen. Service users spoken with said that the food was very good. The service user survey asked if they liked meals in the home. Eight answered always, seven usually and one sometimes. Comments included ‘generally the meals are very good.’ ‘Excellent food especially at Christmas.’ ‘Dietary needs and special dishes make all the difference’. ‘The bakewell tart is the best I have ever tasted’. Maynell House DS0000024444.V341837.R01.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, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can expect that their complaints will be listened to and acted upon and that they are protected from abuse. EVIDENCE: The home’s complaints procedure was viewed, which included contact details of CSCI (Commission for Social Care Inspection). Details of the procedure were included in the statement of purpose and service users guide. Staff spoken with were aware of actions they should take if a service user or visitors to the home wished to make a complaint. Complaints records were viewed and all concerns and actions taken were recorded. The records included complaints made by service users when there had been power cuts in the area. The records identified that staff had ensured that service users were made as comfortable as possible and were provided with torches. All concerns and complaints had been dealt with within twenty eight days. Maynell House DS0000024444.V341837.R01.S.doc Version 5.2 Page 18 The service user survey asked if they knew who to speak to if they were not happy. Eleven answered always, three usually and two did not respond. The survey asked if service users knew how to make a complaint. Thirteen answered always, two answered usually and one did not respond. Staff training records were viewed and evidenced that staff were provided with POVA (protection of vulnerable adults) training. Two staff members spoken with confirmed that they had been provided with POVA training and clearly explained actions they would take if they had concerns about a service user being abused. The home had the POVA guidelines for Suffolk, which was stored in the office and available for staff reference. There had been one POVA referral made, regarding a staff member. The home had acted in an appropriate manner and informed the appropriate bodies and the staff member was referred to the POVA list following theft from a service user. A copy of the letter confirming this from The Department of Health was provided with the PIQ. Maynell House DS0000024444.V341837.R01.S.doc Version 5.2 Page 19 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, 20, 21, 24, 25, 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users can expect that they live in a safe, well maintained environment which is clean, pleasant and hygienic. Service users can expect that they live in comfortable bedrooms with their own belongings around them. EVIDENCE: The home was clean, well maintained and comfortable. Residents spoken with were complimentary about the cleanliness and comfort of the home and their bedroom. There were various communal areas which residents could use, which included a choice of dining areas and lounges. During the inspection several residents were observed participating in exercise in a communal lounge. Maynell House DS0000024444.V341837.R01.S.doc Version 5.2 Page 20 During a tour of the building it was noted that the home had made efforts to ensure the environment was homely. There were framed paintings, mirrors, dried flowers, photographs of residents, lamps and ornaments in the communal areas. The home was attractively furnished and decorated. Service users bedrooms were attractively decorated and the manager and service users confirmed that service users had chosen the décor of their bedroom. There were personal items in service users bedrooms including items of personal furniture, photographs and memorabilia. The grounds were well maintained and the external balcony barrier had recently been replaced. The manager said that painting of the exterior of the house was planed for the week following the inspection. A previous requirement was made during the last inspection which identified that no wheelchairs or equipment stored in corridors which were routes leading to a fire exit. During a tour of the building it was noted that the requirement had been actioned. There was hand washing facilities including hand wash foam and disposable paper towels in each bathroom, toilet and the laundry. The majority of bedrooms were provided with en-suite facilities which included a bath or shower. There were communal bathrooms and toilets for service users use. One bathroom had an assisted bath and there was a newly installed shower on the first floor of the home. A downstairs bathroom was decorated with sea themed pictures and ornaments. The PIQ stated that a new electronic bath had been installed in March 2006. During the inspection it was observed that the visiting hairdresser was working at the home. There were three service users having their hair styled in the hairdressing room, which had been decorated to resemble a salon and had black and white pictures of film stars of the 1940’s and 1050’s. The laundry was viewed and there was a sluicing programme on the washing machine. There was a stock of disposable aprons and gloves for staff use. There were no offensive odours in the home. The service user survey asked if the home was fresh and clean. Fourteen answered always and two answered usually. Comments included ‘The home has a very high standard’ and ‘Bins are not emptied over the weekend, includes soiled pads in bathrooms/toilets’. The manager and the deputy manager was spoken with and said that they did not have a weekend domestic staff, however, staff had been instructed to empty the bins at weekends. Maynell House DS0000024444.V341837.R01.S.doc Version 5.2 Page 21 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): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can expect that trained and competent staff meets their needs and that they are protected by the home’s recruitment procedures. EVIDENCE: Three staff recruitment records were viewed and all held the required information which included a photograph, identification such as a copy of a passport, application form, POVA check, CRB (Criminal Records Bureau) check and two written references. Staff spoken with had a clear understanding of their roles and responsibilities in the home. Interaction between staff and residents during the inspection was observed to be friendly, professional and respectful. The staffing rota was viewed which indicated the actual staff working at the home for each shift. The manager was spoken with and said that they did not have any issues with staffing at that time and that there was sufficient staff to meet the needs of residents. Maynell House DS0000024444.V341837.R01.S.doc Version 5.2 Page 22 There had been some moves in staffing to accommodate maternity leave and a day staff moving from days to nights. They said that they were advertising for day staff. The manager said that they rarely used agency staff but when they did they used the same agency who provided regular staff. A staff member reported that the home’s training programme was good and that they were provided with sufficient training to enable them to do their job. They said that they were provided with regular updates on their training. A newly recruited staff member was spoken with and they explained the training they had received since commencing their role, which included Skills for Care Induction. They said that they had shadowed experienced staff in the initial period of their employment. Training records viewed evidenced that staff were provided with regular and updated training such as food hygiene, POVA, care planning, manual handling, fire safety and dementia. Training records evidenced that staff were provided with Skills for Care induction. The PIQ stated that there were fifteen staff working at the home and six had achieved a minimum of NVQ level 2. The home had not yet met with the target of 50 of staff to have achieved a minimum of NVQ level 2 by 2005. Maynell House DS0000024444.V341837.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users can expect that the home is managed by a person who is fit to be in charge, that the home is run in their best interests, that their financial interests are safeguarded and their health, safety and welfare is protected. EVIDENCE: The manager was spoken with and provided information of their qualifications and experience. The manager had achieved a nursing and management qualification. They had a range of experience, which supported them in their role and had a good clear knowledge of their roles and responsibilities as the Registered Manager of the home. Maynell House DS0000024444.V341837.R01.S.doc Version 5.2 Page 24 There was evidence in the training records, which were viewed, which identified that the manager had undertaken several training courses and was undertaking a distance-learning course on dementia, which was also provided to the staff team. The manager was receptive to the inspection process. The manager had some period absence from work since the last inspection and the deputy manager had undertaken the management responsibilities of the home. Relative/visitor surveys made several complimentary comments regarding the homes manager and the deputy manager and their work during the manager’s absence. The quality assurance report following satisfaction questionnaires completed in 2005 was viewed and available for service users and those who have an interest in the home. The manager said that a recent report had recently been undertaken and this would be forwarded to CSCI when senior management had provided the home with it. Regular Regulation 26 visit reports were undertaken and the reports were available in the home. Service user’s records of their personal monies were viewed and were clear and well maintained. It is recommended that the receipts of personal transactions were numbered and cross-referenced to the records which provide an audit trail. The records which evidenced that daily fridge, freezer and food temperatures were undertaken. The records indicated any issues which had arisen and any cleaning which had been undertaken in the kitchen. Staff training records viewed evidenced that staff had been provided with health and safety related training such as manual handling, food hygiene, appointed person first aid, COSHH (control of substances hazardous to health) and fire safety. Newly appointed staff had been provided with a Skills for Care induction which included information of safe practices. Fire safety records were viewed and evidenced that regular fire safety checks were undertaken. The home had a fire risk assessment. Health and safety records viewed indicated that regular checks and servicing was routinely undertaken such as with electrical appliances, gas safety, hoists, fire alarm system, fire extinguishers and water was tested for legionella. This was also confirmed in the PIQ. A copy of the safer food better business and hazard analysis food hygiene inspection report by Suffolk Coastal District Council November 2006 was forwarded with the PIQ. Maynell House DS0000024444.V341837.R01.S.doc Version 5.2 Page 25 The home stated that they had actioned the two points on the report, which were that the window frames required redecoration and the fly screens required cleaning. Accident records were viewed. Environmental risk assessments were viewed and were made for all aspects of the environment to minimise risks to staff, visitors and service users in the home. All cleaning materials and substances were stored securely when not in use. Maynell House DS0000024444.V341837.R01.S.doc Version 5.2 Page 26 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 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 3 X X 3 X 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 X 3 X 3 X X 3 Maynell House DS0000024444.V341837.R01.S.doc Version 5.2 Page 27 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. Standard Regulation Requirement Timescale for action 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. Refer to Standard OP9 OP35 Good Practice Recommendations The home should continue with the monitoring of the administration of medication processes which would ensure service users receive their appropriate medication Receipts of personal transactions should be numbered and cross-referenced to the records which would ensure a clear audit trail of service users monies. Maynell House DS0000024444.V341837.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Maynell House DS0000024444.V341837.R01.S.doc Version 5.2 Page 29 - 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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