Inspection on 27/03/08 for Mayo House

This inspection was carried out on 27th March 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mayo House 21/12/06

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 Unannounced Inspection 27th March 2008 08:30 Mayo House DS0000067615.V361792.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.V361792.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.V361792.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.V361792.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th February 2008 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.V361792.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience Good quality outcomes. This visit to Mayo House was unannounced and took place over one day; time was spent examining a number of records including care documentation, health records and health and safety documentation. Staff training and supervision records were reviewed. Since the last key site visit to the service, which was undertaken on 21st December 2006 we undertook a random visit to the service, this was undertaken on 8th February 2008. The purpose of this visit was to review the health, safety, care and welfare pertaining to two individuals who lived at the home following a protection of vulnerable adults strategy meeting. Prior to the site visit we received from the home a completed an annual quality assurance assessment (AQAA). The annual quality assurance assessment is a new process that is being used for all regulated services from April 2007. Individuals living at Mayo House have some complex communication methods with spoken language not always used. We spent some time in communal and individual’s private flats. We observed staff interaction with individuals throughout the day and comments about this are recorded within this report. What the service does well: People who live at Mayo House are supported through individualised care planning and staff are provided with comprehensive information in order to meet their assessed needs. Those living at Mayo House have some complex support needs and these are well managed at the home and individuals are supported well with full access to specialist services such as psychology and speech and language therapy. Those who live at Mayo House are well supported by staff to live a varied and fulfilling life in and out of the home. There is an established group of people who live and work at Mayo House. Those who live at Mayo House benefit from a competent team who have a good understanding of individuals support needs Mayo House DS0000067615.V361792.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: In order that those living at the home are living in a well maintained environment it is required that attention must be given to repair the plaster around doorframes. In order that those living at the home can feel confident and safe it is required that the home records and undertake risk assessments in the following areas: The use of lighter fuel and a risk assessment for those who administer their own medication. Also in respect of medication it is required that medication records must correspond with medication, which has been given. Furthermore to ensure that staff have been provided with current information in respect of the protection of vulnerable adults it is recommended that the home obtain a copy of the safeguarding procedure for South Gloucestershire’s housing and community care department. In order that clear information is maintained at the home it is recommended that the session feedback records in relation to activities better maintained. Mayo House DS0000067615.V361792.R01.S.doc Version 5.2 Page 7 In order that those living at the home can be confident that all staff are treated equitably it is recommended that agency and bank staff that are used at the home to support the permanent staff team are given formal supervision. 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.V361792.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.V361792.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. Clear information is in place in order that individuals can make an informed choice about where to live, individual’s aspirations and needs are fully assessed. Clear contracts are in place for those who live at the home. EVIDENCE: The Statement of Purpose for Mayo House contained the aims and objectives of the home and recorded that Aspects and Milestones mission is: ‘To enable people with learning disabilities, mental health needs and physical abilities to develop a fulfilling life in the community’. At our last visit to the service undertaken in February 2008 we reviewed this document and we said that the Statement of Purpose did not fully reflect the complex level of need and support, which is in place at the home. We made a requirement that the Statement of Purpose must fully reflect the range of needs that the home intends to meet. A review of this document found that this had been met, the document had been updated and this was found to be Mayo House DS0000067615.V361792.R01.S.doc Version 5.2 Page 10 fully comprehensive and contained all of the relevant information required as stated in Schedule 1, Regulation 4(1)(c). There is a well-established process for the assessment of prospective residents. People are referred to Mayo House through Aspects & Milestones Trust. This referral includes a detailed care management assessment, risk assessments and where present, details of supportive agencies that are involved. During this time prospective residents are invited to visit the house for meals and overnight stays in order to meet the other people who live at Mayo House and staff. They can then decide if they wish to move in or not. These visits also allow staff to further assess the needs and goals of the individual, and to assess whether the home might be able to help with these. There had been no new admissions recently and there is currently one vacancy at the home. We saw that each individual had in place a ‘licence agreement’ that outlines the rights and responsibilities of all parties and also the terms and conditions of the placement. These documents had been produced in pictorial format with the use of easy to use phrases. These documents, where possible, had been explained to individuals who had signed to confirm this. The document had also been signed by a representative of the home and dated. Mayo House DS0000067615.V361792.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, 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those who live at Mayo House are supported to make their own decisions about their lives with assistance where needed. All individuals have a plan of care in place that has been developed with them. Individuals are supported and encouraged to risks as part of their independent lifestyle. EVIDENCE: Those living at Mayo House indicated they were happy at the home and appeared well cared for. A number of comment cards were received from visiting professionals and relatives of those living at the home and these said that individual’s needs were being well met by a caring and supportive staff team. Relationships between individuals and staff are well established and effective methods of communication both verbal and non-verbal have been developed. Mayo House DS0000067615.V361792.R01.S.doc Version 5.2 Page 12 Information held for those living was extremely detailed and it was evident that the information in place had been gathered over a period of time; all of the 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 talking with individuals, asking them what they wanted. Individual’s wishes and choices and their views for 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 excellent guidelines in place to direct and guide staff practice. When we visited the service earlier in the year we found that care plans and some risk assessments had not been reviewed and had not been updated when needed and therefore were not fully comprehensive or reflective of individuals needs. We made a requirement that care-planning documents must be kept under review and updated when required. A review of these documents during this visit found that the requirement had been met, furthermore, we saw some excellent records which evidenced to us that people living at the home have been fully consulted about what they want and what they need with further information to show how people were being supported to meet and exceed their expectations. The home operates a key working system whereby each person has a ‘circle of support’ in which a few named members of staff who play a key role in coordinating the services they receive. The manager completes regular reviews for funding authorities and forwards a copy of his review to them in order to inform placing authorities of any changes to individuals care needs. The staff were observed going about their duties in a friendly and calm manner and responding to those living at the home in a familiar style. There was friendly banter between individuals and the staff Those who live at Mayo House are supported to take risks in their daily lives by staff. These were detailed written risk assessments that were linked to the care plan. They demonstrated actions are taken to ensure the home is safe for those who live and work at the home. Risk assessments also demonstrated people are encouraged to live an independent and fulfilling life and take part in varying activities. Mayo House DS0000067615.V361792.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): 12, 13, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for meeting the social and recreational needs of individuals are good and there are opportunities for those living at Mayo House maintain links with family, friends and the local community. The home’s practice and routines are flexible and enable individuals to exercise choice and have control over their lives. EVIDENCE: Staff enable those who live at the home to have opportunities to maintain and develop social, emotional, communication and independent living skills. On the day of the visit those who live at Mayo House were busy partaking in activities of their choosing and were being supported by both staff at the home and staff from external agencies. Activities seen within records showed that individuals are involved and supported with on a regular basis included attending church, Mayo House DS0000067615.V361792.R01.S.doc Version 5.2 Page 14 visiting their local community centre and playing pool, shopping and visiting family. The home have also consulted with those who live at the home and have developed action plans for developing new skills and for looking into future projects and aspirations. In order to monitor the effectiveness of activities the home record activity feedback sessions, however we found that these are not always completed. In order that clear information is maintained at the home it is recommended that the session feedback records in relation to activities better maintained. Family and friends are welcomed to the home and those who live at Mayo House can choose whom they wish to see; they can see visitors in their flat in private. Comment cards were received from relatives of those who live at the home and all confirmed they are welcomed at the home at any time, that they are kept informed of important matters affecting their relative and that they are satisfied with the overall care provided at the home. It should also be noted that those who live and work at the home took part in a sponsored walk in order to raise funds for leisure ‘extras’. From photographs seen and through talking with service users and staff this was clearly a rewarding event. One of the individuals works for a local company and is supported by the home to maintain this independence. From our discussion with the individual, the manager and staff at the home it is evident that this individual is valued and respected for the work they do. The manager and another individual at the home confirmed that job opportunities for them were also currently being actively explored. Mayo House DS0000067615.V361792.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. Individuals are supported appropriately in all aspects of their life. Generally medication practices are good, however, recording in this area must be improved. 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. It was also clear that staff consulted with individuals, asked them their opinion and this opinion was listened to and valued. One person we spoke with said that they got on well with all of the staff and said ‘they are all sound’, this person also went onto to tell us about a special medical condition they have and in their view they felt their health had improved since being at the home and they also said that they were confident in the staff ability to support them with their healthcare. Mayo House DS0000067615.V361792.R01.S.doc Version 5.2 Page 16 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. We saw that clear information and protocols were in place to support individuals in specialist areas of their care such as epileptic seizures and behaviour, which could impact on others. The home’s medication storage systems were in good order. All staff receive full induction training regarding medication administration, and policies and procedures were current and up to date. A check was done on some of the medication in the storage cupboard and this was found to be all correct. When we reviewed controlled medication in the home it was found that medication had been given yet it had not been fully recorded in all areas and had the potential for error. In order to ensure that medication is given as prescribed it is required that medication records must correspond with records maintained within the home. There is an individual who is being well supported by the staff to retain their independence and this person is able to manage their own medication with support, in order that this person is safe and supported appropriately to maintain their independence it is required that a risk assessment this area is completed, involving the service user. We recommended during our visit to the home last year that the home should seek and record the wishes of individuals in the event of their death. This is to ensure that individual’s wishes are respected. (This was not reviewed at this site visit). Therefore we will ensure that this area is fully covered during our next visit to the home. Mayo House DS0000067615.V361792.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. Those living at the home are protected from the potential of abuse and complaints are dealt with appropriately due to staff training and understanding in this area. Staff demonstrated a clear understanding in this area with clear policies and procedures in place. EVIDENCE: The home has a procedure, which outlines the steps to take if there are any complaints, and all individuals have a copy of this in their care file, these are available in an accessible format. They are also aware of how to contact the Commission for Social Care Inspection (CSCI). A complaints book is kept in the office, and any complaint would be recorded there. No complaints have been received either by the home or to CSCI. All living at Mayo House are encouraged to air their views, and both care staff and the manager are keen to hear any suggestion from people about how the service could be improved. One of the people we spoke with who lives at Mayo House told us that they were happy at the home and that if they had any complaints they would “go straight to speak with the manager”. Due to peoples varied communication, both the staff and families advocate for individuals and care files held well documented information regarding how those who live at Mayo House communicate and express their emotions. The home has good relationships and ongoing communication with families. This helps ensure that staff would be told of any concerns that families may have regarding their relatives care. Mayo House DS0000067615.V361792.R01.S.doc Version 5.2 Page 18 There are organisational policies and procedures in place relating to the issue of protection of vulnerable adults from abuse. Since the last key site visit to the service, which was undertaken on 21st December 2006 we undertook a random visit to the service, this was undertaken on 8th February 2008. The purpose of this visit was to review the health, safety, care and welfare pertaining to two individuals who lived at the home following a protection of vulnerable adults strategy meeting. This situation was fully examined and some lessons have been learnt to ensure the safety and wellbeing of those living at Mayo House. Some discussion took place with the manager of the home about their responsibility in respect of the protection of vulnerable people who live at Mayo House, the manager is very aware of their role in this area and is committed in ensuring the safety of those living at the home. Aspects and Milestones Trust have clear policies and procedures in this area and staff we spoke with were fully aware of these. We did note that the home did not have a copy of the local authorities guidance for this and a recommendation was made that a copy of South Gloucestershire’s Safe Guarding Adults Policy to be obtained by the home for reference Mayo House DS0000067615.V361792.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, 26, 28, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those living at Mayo House live in a homely and comfortably furnished environment, although there were areas in need of attention. The home is clean and hygienic. EVIDENCE: There have been no changes in the services and facilities provided at the home since our previous visit. The location and layout of the home is suitable for its intended purpose. Mayo House is a spacious purpose built building which opened in 2006. Mayo House is furnished to a good standard. The home is situated in Yate and blends in with the local community. At the time of our visit all areas seen were clean, tidy and odour free. All of those living at the home have access to their personal space within their own private one bedded flats, each of these flats has their own bathroom and kitchen and those on the ground floor have a small private garden area for their use. Communal space is also provided at the home such as a lounge and Mayo House DS0000067615.V361792.R01.S.doc Version 5.2 Page 20 gardens. The home has a very pleasant rear garden; this was seen to be well tended It was noted during our visit that there were a number of door frames on the ground floor which had cracks around doorframes within the plaster, the manager explained that the contractors involved with the building of the home had been contacted in order to rectify the problem, consultation has also taken place within the organisations maintenance departments and works to improve these areas had been agreed. It is required that attention must be given to repair the plaster around doorframes to ensure that the building is a pleasant area in which to live. Mayo House DS0000067615.V361792.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. Those living at Mayo House can be confident that staff are effective and competent and have been provided with training needed to fulfil their role. EVIDENCE: The manager was able to demonstrate that he 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. Individuals we spoke with indicated that relationships with staff were good, one person told us that they got on really well with staff, they listened and were good at their job. 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 us to be good listeners, effective communicators and were interested and motivated in meeting the needs of those living at the home. Mayo House DS0000067615.V361792.R01.S.doc Version 5.2 Page 22 At our last visit to the service in February 2008 training records for staff were not clear and it was difficult to ascertain what training staff had received, this was in respect of both permanent and agency and bank staff. Two recommendations were made. These were that a record of training undertaken by agency/bank staff should to be available and also that the training records of permanent staff at the home should to be reviewed and updated. A review of these training records showed us that the home had improved upon this area and recording in this area had much improved. At our last visit to the service it was clear that there are individuals living at the home with complex and specialised needs and although some training had been provided there were areas of deficit in areas such as fragile X syndrome. At our last visit we made a requirement that specialised training must be provided for staff. Mr Nuttall and Jeff Parry told us that training sessions for staff had been a priority and Mr Nuttall confirmed that staff would be undertaking training in fragile X syndrome and that refresher training in positive response training was being provided in order that staff have the skills to deal with potentially difficult situations effectively. Following our visit to Mayo House 0n 8th February 2008 it was recommended that in order that those living at the home can be confident that all staff are treated equitably it was recommended that agency and bank staff that are used at the home to support the permanent staff team are given formal supervision. Mr Nuttall and the area manager Jeff Parry agreed that this is an issue for the organisation and that the manager will look at processes to ensure that this recommendation is met. We will review this at our next visit to the service. During a discussion with a staff member it identified their previous relevant experience and their duties and responsibilities as a support worker. They indicated those areas covered during their induction process were clear and that they had sufficient information to support those who live at Mayo House consistently. The staff member also said that the staff team worked well together and that there were good communication processes in place in order to share information with each other. The home follows the organisational recruitment policy and procedures in place. New applicants undergo interview processes and appropriate checks to help ensure that those living at Mayo House are kept safe. An agreement is in place between the Trust and the Commission for Social Care Inspection for staffing records to be held at the Trust’s Headquarters and to be inspected periodically, some records were seen and the manager keeps an employee records checklist that includes dates of police checks with the Criminal Records Bureau. Mayo House DS0000067615.V361792.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, 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those who live at Mayo House benefit from a well run home that is managed with a clear sense of direction. There are formal quality monitoring systems in place in order to measure the aims and objectives of the home. There are procedures and protocols in place in order to ensure the health, safety and welfare of those who live and work at the home. EVIDENCE: The manager has many years experience of working with people with learning disabilities and is committed to providing a good service for those who live at Mayo House, to ensure that they have positive outcomes and are supported to Mayo House DS0000067615.V361792.R01.S.doc Version 5.2 Page 24 achieve aims and goals they have set for themselves with support from others. Mr Nuttall has recently achieved a BSC in learning disabilities studies and should be commended for this. Since our last key inspection Mr Nuttall has also completed training in the areas of safeguarding adults protocols, Mental Capacity Act and a re accreditation courses for those who train others in positive response training. Mr Nuttall 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. The manager has a very “hands-on” approach and is very involved and aware of the needs of those who live and work at the home. Staff meetings are held on a regular basis and there was evidence that everyone is encouraged to make suggestions about how the home is run and what happens, staff spoken with also confirmed this. From talking with staff it was evident that they felt supported in their role by the manager. 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, clients and other stakeholders to voice concerns and to affect the way in which service is delivered. These included staff supervision, review meetings, quality assurance, and an open and approachable management approach. It was also reported that the representative of the responsible individual Mr Jeff Parry visits the home on a regular basis, spends time with those who live at the home, 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. Prior to the site visit we received from the home a completed an annual quality assurance assessment (AQAA). The annual quality assurance assessment is a new process that is being used for all regulated services from April 2007. This had been fully completed by the home and recorded areas of improvement over the past twelve months and identified areas of future improvement plans to ensure positive outcomes for those who live and work at the home. The daily records, care plans and accident/incident records were viewed at this visit, it was found that records are well maintained. Following our random visit to the service that was undertaken on 7th February 2008 a requirement was made that the home must ensure that The Commission is notified of incidents that affect the wellbeing of those living at the home. This was due to records we saw, which at the time, showed that significant incidents had not been reported to us. At this visit we found that the home had introduced a new protocol which provided clear guidance for staff as to what should be reported to us, furthermore prior to our visit the area Mayo House DS0000067615.V361792.R01.S.doc Version 5.2 Page 25 manager had contacted us and had agreed a reporting protocol with us. Between our random visit to the service and this visit the home have reported all incidents as required. There are health and safety procedures in place for those who live and work at the home to follow; records identified that are procedures in place to monitor all aspects of the health and safety of the home including audits being carried out. An annual health and safety appraisal of the home is also completed as part of a Quality Assurance process. During our visit it was noted that one individual smokes and provision for this has been made, however it was also noted that this individual uses lighter fuel, with a number of these being located around their flat. In order that this is dealt with in a safe manner for the individual who lives in the flat and others who live and work in the building it is required that a risk assessment is completed in relation to the issues surrounding this flammable material. The fire logbook record showed that the range of required fire safety checks were being carried out and were up to date helping to ensure the safety of people inside the building is maintained. All staff have attended both fire training and regular fire drills. Mayo House DS0000067615.V361792.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 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 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 X 28 3 29 X 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 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 2 X Mayo House DS0000067615.V361792.R01.S.doc Version 5.2 Page 27 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. 2. 3. Standard YA42 YA24 YA9 Regulation 13 (4) b 23 (2) b 13 (4) b Requirement Timescale for action 27/05/08 A risk assessment in respect of combustible materials must be completed. Attention must be given to repair 27/06/08 the plaster around doorframes. A risk assessment to be completed in respect of individuals who self medicate 27/06/08 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. (This was not reviewed at this site visit). The home to better maintain session feedback reports following activity sessions. Agency/bank staff to receive formal recorded supervision. A copy of South Gloucestershire’s Safe Guarding Adults DS0000067615.V361792.R01.S.doc Version 5.2 Page 28 2. 3. 4. YA13 YA36 YA23 Mayo House Policy to be obtained. Mayo House DS0000067615.V361792.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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.V361792.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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