Inspection on 21/12/06 for Mayo House

This inspection was carried out on 21st December 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mayo House 27/03/08

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Mayo House Lodge Road Yate South Glos BS37 7LE Lead Inspector Odette Coveney Key Unannounced Inspection 21st December 2006 09:30 Mayo House DS0000067615.V316266.R01.S.doc Version 5.2 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 Mayo House DS0000067615.V316266.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 Adults 18-65. 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. Mayo House DS0000067615.V316266.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mayo House Address Lodge Road Yate South Glos BS37 7LE 0117 970 9300 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) admin@aspectsandmilestones.org.uk Aspects and Milestones Trust Mr Alan Nuttall Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Mayo House DS0000067615.V316266.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection This is a new service and therefore this was the first inspection. Brief Description of the Service: Mayo House was registered with the Commission for Social Care Inspection in 2006. The home is operated by Aspects and Milestones Trust a ‘not for profit’ charitable Trust. The home is purpose built and the accommodation is of a high standard. Each individual has a small independent living area, which comprises of a sleeping, lounge and kitchen area. Each individual has their own bathroom with bathing and showering facilities. This promotes individual’s independence and rights of privacy and choice. Additional communal accommodation is available for individuals use. Accommodation is also available should friends or relatives wish to stay over. The home is located within the residential area of Yate and blends in well with the local community and is within close proximity to good transport links such as public transport and the M5 and M5 motorways. The home is able to accommodate six individuals with learning disabilities aged 18-65.Current fees charged is £2076.65 per week. Mayo House DS0000067615.V316266.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the visit was to establish if the home is meeting the National Minimum Standards and the requirements of the Care Standards Act 2000 and to review the quality of the care provision for the individual’s living in the home. This inspection employed key elements of the national inspection methodology with the objectives of focusing on outcomes for the individual’s. This is evidenced through evaluation of key standards and verification through a surveying and case tracking approach that included talking with and the observation of individuals who live at the home and the views of the staff on duty. As this service was registered with the Commission in June 2006 this was the homes first inspection. An opportunity was taken to view the home and a number of the records relating to the management of the home and plans of care for two of the individuals were reviewed. A high number of comment cards were received prior to the inspection, three were from service users, two were from relatives of those who live at the home, six from health/social care professionals who have supported individuals at the home and one card was received from general practitioners who visits individuals at the home. Comments made were reviewed during the inspection visit and comments, maintaining individuals confidentiality were shared with the senior member of staff involved with the inspection and these have been incorporated within this inspection report. Staff was informative and engaged fully with the inspection process. What the service does well: The home has detailed information about service users prior to admission in order to establish if the home can meet that persons needs. Once the service user is admitted the home have developed well-written plans of care that are tailored to ensure that individuals needs, wishes and aspirations are recorded and take into account risks and individuals complex needs. These plans ensure that staff are provided with information that helps them meet service users needs safely and consistently. The staff team are committed, caring and respectful at all times, this was observed throughout the inspection. Service users use the local and surrounding areas to access a variety of activities and leisure pursuits. Mayo House DS0000067615.V316266.R01.S.doc Version 5.2 Page 6 Staff are recruited appropriately and received training appropriate to meet service users needs and protect their safety and welfare. The home is well managed and is run in the best interests of the service users. The manager monitors the quality of care and there are sound systems in place to underpin this. What has improved since the last inspection? What they could do better: In order that service users are fully aware of the fees per week and any additional costs that they may incur it is required that additional information is added to individuals ‘licence agreements’ in order that they have been provided with accurate information. In order to fully demonstrate that individuals have been supported appropriately and safely it is required that the home must notify The Commission of any incident that affects the wellbeing of those individuals who live at the home. In order to ensure that individual’s wishes and choices will be respected and adhered to it is recommended that the home seek and record the end of life choice off the individuals who live at the home. Mayo House DS0000067615.V316266.R01.S.doc Version 5.2 Page 7 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. Mayo House DS0000067615.V316266.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mayo House DS0000067615.V316266.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager ensures that the home are able to meet service users needs prior to their admission to the home. There is clear information about the services and facilities provided at the home and this is available on request. Minor attention is needed to individual ‘licence agreements’. EVIDENCE: The home has a Statement of Purpose that provides prospective service users, their relatives and professionals with information about the home. The Statement of Purpose was found to be fully comprehensive and contained all of the relevant information required as stated in Schedule 1, Regulation 4(1)(c). The Statement of Purpose contained the aims and objectives of the home and the philosophy of the home is firmly rooted in the principles of ‘O Brians’ five accomplishments, these are about enabling community presence, supporting people to make choices, it spoke of treating individuals with dignity and respect, to promote independence and encourage individuals to make choices with aspects of their lives. The home also has a service users guide that has been enhanced by the use of pictures and gives information about the service specification for the home. The brochure in place provides meaningful information for prospective service users to the home about information that would be of interest to them such as Mayo House DS0000067615.V316266.R01.S.doc Version 5.2 Page 10 ‘what’s around and about’, ‘how we will help you to keep healthy and safe’, how we support you to find out about the things to do outside of the home within the local community’. This brochure incorporates the use of photographs and is a useful guide. The home is registered to accommodate six service users, at the time of the inspection two individuals were living at the home. Prior to the inspection the inspector received a comment card from a health care specialist who recorded that for the two individuals who were admitted into Mayo House; ’The assessment and transition went very smoothly and at the present time both service users are making good progress’. Information seen within care files evidenced that no person is admitted into the home without having their needs assessed and that they have been assured that these will be met. The senior member of staff on duty was able to inform the inspector of those needs, which would not be able to be met at the home, and was able to demonstrate the homes capacity to meet the assessed needs of individuals admitted into the home. Individuals who had been referred to the home through the care management process had a full assessment of need recorded within their care plan. The inspector saw that each person’s admission into the home had been tailored to their specific requirements and at a pace appropriate to them. There are individuals living at the home who do not use full spoken language as their main method of communication. Information seen in service users care records clearly showed that staff have established professional caring relationships with individuals and have recorded the complex indicators that individuals use such as body language and behaviour, this demonstrates a commitment from the staff team to ensure that the needs of individuals are met. Information seen in care records showed that when specialist advice had been required in order to fully support clients this had been sought; examples of external support included care mangers, consultant psychiatrist and the community learning disabilities team. The inspector saw that each individual had a ‘licence agreement’ this outlines the terms and conditions of the occupancy. This ensures that service users and their representatives know what services will be provided within the fee structure. It was found that full information about costs per week or additional costs had not been fully recorded it is required that this is completed in order that service users are provided with accurate information. During the inspection staff were observed interacting with individuals, using appropriate language and tone of voice. Mayo House DS0000067615.V316266.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 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. Care planning documentation at the home contains clear, detailed information to enable individual’s personal, emotional needs to be well met, with individuals being supported and encouraged to make decisions that affect their life. EVIDENCE: Both services users living at the home have diverse and complex needs. Information held for individuals was extremely detailed and it was evident that full consultation had taken place in order to ensure that all areas had been considered; Essential Lifestyle information was in place and all of the individuals records had been written in a person centred way and had been tailored to the specific requirements of individuals. It was clear that information had been gathered through observation of individuals and that their preferred lifestyle had been well documented. Information recorded in care plans covered areas such as personal, physical, healthcare and emotional areas of support with guidelines in place to direct and guide staff practice. Records are monitored closely by the home and any changes are well recorded and any new plan of support is implemented. Mayo House DS0000067615.V316266.R01.S.doc Version 5.2 Page 12 There is a high level of training within the home that is arranged in relation to service users needs, ensuring they are met and individuals are supported appropriately. The inspector saw that individuals had risk assessments in place. Each assessment is tailored to the individual and the factors affecting their well being had been considered. All were dated and signed and there was evidence in place to show that assessments are reviewed on a regular basis. Information seen in comment cards from the individuals who live at the home indicated high levels of satisfaction about their decision to move into Mayo House, they said they were able to make choices and decisions, that staff treated them well and that carers listen and act on what they say. The inspector received two comment cards from the relatives of those who live at the home, both said that they are made welcome and that they are kept informed of important matters affecting their relative and that they were satisfied with the overall care provided at the home. Additional comments were; ‘very satisfied with overall care and staff, very pleased with the progress that has been made by my relative since living at the home’. The staff were observed going about their duties in a friendly and calm manner and responding to the residents in a familiar style. There was friendly banter between the residents and the staff, evidencing that the home is a good place to live. Records are stored safely and are able to be locked away. The home has a clear confidentiality policy that covers aspects of written and verbal information and the importance of confidentiality is also incorporated within staff contracts, is covered during supervision and also is discussed at staff meetings. Mayo House DS0000067615.V316266.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from accessing the local community and taking part in appropriate activities. Service users rights are respected at all times. EVIDENCE: Information seen by the inspector, and confirmed by staff, and information seen recorded within individuals’ care records showed that those living at the home are offered a variety of social activities. Individuals are able to participate or not, this is dependent on the individual’s choice. Time was spent with the activities coordinator for this home who spoke with great enthusiasm about his role and how he has been actively involved in future planning meetings with individuals at the home in order to support them on a one to one basis. This has involved looking at activities, social events, further education and possible job opportunities as well as ensuring that individuals can be active participants within their community such as supporting the local football club and attending matches, using public Mayo House DS0000067615.V316266.R01.S.doc Version 5.2 Page 14 transport, visiting local shops, post offices, banks and public houses. The Coordinator has developed individual’s choices board and activity sheets that have been tailored around individual’s choices. These demonstrate a commitment to working in an individualised person centred manner ensuring that individuals rights and wishes, likes and dislikes are obtained, listened to and acted upon. Those who live at Mayo House have opportunities for personal development. Within the home staff enable individuals to have opportunities to maintain and develop social, emotional and practical life skills. Individuals are supported to attend visit their families and participate in these activities on a regular basis. All individuals who are able, and who choose to, are supported to participate in activities of daily living such as light housework, tending to their own laundry and making drinks and snacks. Staff support individuals to participate in the local community in accordance with their assessed needs and individual care plans. Staff ensure that information is given to individuals about local activities and staff support individuals both in and out of the home to participate in activities of their choosing such as visiting places of local interest, meals out, shopping. The high levels of staffing enable service users to be supported individuals to gain access to the community and to attend activities chosen by them and are suited to their needs. During the inspection one of the service users went shopping, the other person Through observation of staff when talking and supporting service users they were seen to be respectful, kind and very relaxed and gentle in their manner. Staff were patient and considerate at all times. Individuals were spoken to as adults. Observations, daily records seen and discussion staff evidenced that the daily routines and house rules promote independence, individual choice and freedom of movement’. It was clear that staff had an excellent understanding of service users communication needs and worked hard to ensure that service users were understood and that their needs and requests were listened to and met. The home has an open visiting policy and visitors can come in at any reasonable time. Discussions with staff evidenced that the home has very good relationships with the families of those who live at Mayo House. Comment cards received from relatives prior to the inspection confirmed that staff support service users to maintain contact with them through visits and the manager keeps them informed of any changes or concerns. Mayo House DS0000067615.V316266.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users physical, emotional, medication and healthcare needs are well met. Service users dignity and privacy is respected. EVIDENCE: Staff described how they monitored an individual’s wellbeing and much was done via observations, as individuals did not always articulate their needs coherently and logically. This further evidenced that staff had a good awareness of the needs of those individuals with communication differences. The health needs of individual’s are well met with evidence of good multi disciplinary working taking place on a regular basis. All of those living at the home are registered with a general practitioner; evidence was in care records to confirm that individuals are supported with their primary healthcare needs such as optician, dentist and chiropody and that specialist advice is obtained when needed. Prior to the inspection a comment card was received from a general practitioner and six comment cards were received from health/social care professionals who visit services users at the home. All the feedback received was consistent in that all agreed that the home communicates clearly and Mayo House DS0000067615.V316266.R01.S.doc Version 5.2 Page 16 works in partnership in order to ensure the needs of individuals are met, that the staff demonstrate a clear understanding of the care needs of the service user, that management/staff ensure that any specialist advice is incorporated into the service users plan. All also said that they were satisfied with the overall care provided to service users at the home. Additional comments were: ‘I have been very impressed with this new service, the manager and his team are striving to create a person centred home where people are able to develop their skills’. ‘I always receive a warm welcome at the home and have been impressed at how quickly new ideas are implemented’. There were good records of individual’s healthcare needs and how they are monitored. Medication administration, recording and storage were accurate. Staff have all received training and have been deemed as competent Whilst reviewing the records of the individuals who live at the home it was clear that the home had not spoken with service users in order to ascertain their wishes in the event of their death. Some discussion also took place with staff members about this sensitive area and the reasons why it is important to obtain this information. It was recommended that the home seek and record individual’s wishes in the event of their death in order that their choices and rights are respected and adhered to. Mayo House DS0000067615.V316266.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their representatives can be confidant that they are listened to and that any complaint would be responded to appropriately. Service users are suitably protected from abuse, however the home must ensure that The Commission are notified of incidents that affect the wellbeing of those living at the home. EVIDENCE: It was noted that care plans files contained a copy of the proceedure for making a complaint with evidence to show that this had been discussed with individuals. Comment cards received from service users recorded that individuals knew who to speak with if they had any concerns. Individuals who wanted it have been given a copy of the complaints proceedure. No issues of concern were raised during the inspection visit. Staff knew and understood the organisation complaints policy and demonstrated that they would respond appropriately. The home has a book in place to record and issues, concerns or complaints, there was nothing recorded at this current time. The policies and procedures relating to the Protection of Vulnerable Adults were in place. There was good evidence that the home systematically ensures that staffs is trained to enable them to identify abuse and follow correct procedures for reporting suspected or alleged abuse. A staff member told the inspector of the training they had undertaken and were able to describe all forms of abuse and also discussed subtle forms of abuse. During staff’s one to Mayo House DS0000067615.V316266.R01.S.doc Version 5.2 Page 18 one supervision sessions it is standard practice to discus protection and abuse awareness issues. Service users finances are well managed well and protects service users from potential financial abuse. Receipts are obtained and records are well maintained and audited. Mayo House DS0000067615.V316266.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30. Quality in this outcome area is Excellent. This judgement has been made using available evidence including a visit to this service. The home has been purpose built with specific consideration given to the needs and rights of those who would be supported at the home. The relationships between staff and those living at the home are good, and this creates a warm, supportive, safe environment, which promotes a good quality of life for the individuals living at Mayo House. EVIDENCE: Mayo House is a detached, two stored property situated in a quiet lane on the outskirts of Yates. There is a main bus route located nearby. The accommodation consists of four flats on the ground floor, each with living area, kitchen and en-suite bathing facilities, and a small private patio garden. Two flats located on the first floor are larger with separate bedrooms, living room, kitchen and en-suite bathing facilities. The private accommodation seen was well furnished and individuals had personalised their own areas according to their preferred tastes. Mayo House DS0000067615.V316266.R01.S.doc Version 5.2 Page 20 There are communal lounges, kitchens, and laundry facilities on both floors. The property has adequate storage space, and various rooms for use by the residents as determined by individual interests. A staff office, with adequate secure storage is located the first floor, and a staff sleep-in room with en-suite bathing facilities. There is an accessible garden area around the property. Furniture and fittings are domestic in style and are of a good standard. The property is purpose built and a site visit was conducted on the 2/6/06. The following documentation has been received to evidence compliance with necessary legislation in relation to the development: • • • • • • Building Completion Certificate - 5/6/06 Environmental Health Services report - 2/6/06 Fire Officers Report - 2/6/06 Electrical installation certificate - 22/5/06 Heating and Ventilation systems - 5/6/06 Employers Liability Insurance - expiry 27/9/07 The location and layout of the home is suitable for its intended purpose. Mayo House is a purpose built, spacious residential home and is furnished to a high standard is appropriately adapted to meet the needs of the current client group. Lighting within the home is domestic in style and of a good standard, emergency lighting is provided throughout the home, this is checked on a monthly basis. Mayo House DS0000067615.V316266.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected due to the robust recruitment and selection processes within the home. Staff are well training and have the right manner and approach to support individuals with complex and diverse needs. EVIDENCE: The senior member of staff on duty was able to demonstrate that she, the manager and the staff team have developed good relationships with those who live at the home and have a sound understanding of their needs, wishes and aspirations. These are well recorded in individual’s records. Staffing provision appeared to be consistent with levels and skills needed due to assessed care needs of the individual’s. The staff team have a varied range of knowledge and skills, they were observed by the inspector to be good listeners, effective communicators and were interested and motivated in meeting the needs of those living at the home. Information contained within individual staff files were all of a consistent standard. All staff had been issued with copies of their job description and had been given copies of the homes policies and procedures. Each staff member had recorded the induction they had completed at the start of their Mayo House DS0000067615.V316266.R01.S.doc Version 5.2 Page 22 employment, this was in depth and covered areas such as; protection of vulnerable adults, equal opportunities, statement of rights of those who live at Penleigh. Each staff member had also a copy of the code of conduct issued by the General Social Care Council. Staff had also undertaken core training such a Values awareness, basic first aid, manual handling and fire safety. The staff files for four individuals were reviewed; including the most recently recruited staff member all of the required documentation was in place in respect of robust recruitment and selection practices. The Trust has a dedicated learning and Development Department to ensure staff members are appropriately skilled to meet the diverse needs of the people accommodated. Staff spoken with and certificates seen in individuals files provided confirmation that the training had been undertaken and staff were positive about how training, including empowering practice and person centred planning, had influenced their practice and improved their skills in caring for people with individualised complex needs. Mayo House DS0000067615.V316266.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the service users. The home is well managed ensuring that individual’s interests and rights are promoted and protected by a knowledgeable and committed staff team. EVIDENCE: The Registered Manager Mr Alan Nuttall has over twenty years experience working in the care sector, with over 15 years management experience in different settings. The applicant has the following qualifications relevant to the position of registered manager: • • Registered Nurse Learning Disabilities Registered Manager Award NVQ Level 4 DS0000067615.V316266.R01.S.doc Version 5.2 Page 24 Mayo House • • NVQ Assessor Award Positive Behaviour Management Trainer. During his fit person interview conducted by Helen Taylor on 2/6/06 Mr Nuttall demonstrated a clear understanding of his responsibilities to ensure the home operates within the National Minimum Standards of the Care Homes Regulations 2000. The manager was not present at the inspection and the senior staff member on duty cooperated in the inspection process, and was able to locate all necessary information and documents easily. This evidences that the home has good systems in place and is well run. A comment card received from a health professional who has been involved with a person living at Mayo House commented ‘the manager Alan Nuttall is very highly spoken of by people I work with who have known him in a professional capacity have all said that they have found him easy to work with and that he is very committed in providing high quality care for those living at the home’. There are clear equal opportunities policies within the home and all staff are given copies of these. Staff meetings are held regularly and there are also other strategies for enabling staff, service users and other stakeholders to voice concerns and to affect the way in which service is delivered. These included staff supervision, client review meetings, quality assurance, and an open and approachable management approach. It was also reported that the area manager visits the home on a regular basis, spends time with service users, staff and the manager and oversees the service provided at the home. Staff spoken with said that he is approachable and committed in ensuring that the rights and choices of those living at the home are supported. The inspector viewed the fire logbook for the home. The home was completing the appropriate checks on the fire equipment and the recording of training, fire drills and the testing of equipment were satisfactory. The inspector saw the fire panel in working order. The Trust has well-established policies and procedures within the home and these are appropriate to the service provided and those who are being supported at the home and would provide information and clear guidance for those staff that work at the home. Mayo House DS0000067615.V316266.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 3 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 3 3 3 X Mayo House DS0000067615.V316266.R01.S.doc Version 5.2 Page 26 N/A 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 YA23 Regulation 37 Requirement The home must ensure that The Commission must be notified of incidents that affect the wellbeing of those living at the home. Licence Agreements must contain full information of fees charged. Timescale for action 21/12/06 2. YA5 5 (1) b 21/01/07 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 YA21 Good Practice Recommendations The home to seek and record the wishes of individuals in the event of their death. Mayo House DS0000067615.V316266.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Mayo House DS0000067615.V316266.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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