Inspection on 18/09/07 for Mayott House

This inspection was carried out on 18th September 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

Mayott House 03/11/06

Mayott House 06/02/06

Mayott House 05/10/05

Mayott House 24/02/05

Mayott House 09/08/04

Mayott House 16/03/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Mayott House Ock Street Abingdon Oxfordshire OX14 5DH Lead Inspector Kate Harrison Unannounced Inspection 18th September 2007 9:15 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 Mayott House DS0000013160.V344716.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. Mayott House DS0000013160.V344716.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mayott House Address Ock Street Abingdon Oxfordshire OX14 5DH 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) 01235 521959 01235 536515 manager.mayotthouse@osjctoxon.co.uk www.oxfordshire.gov.uk The Orders Of St John Care Trust Ms Jayne Trinder Care Home 43 Category(ies) of Past or present alcohol dependence over 65 registration, with number years of age (3), Dementia - over 65 years of of places age (17), Learning disability over 65 years of age (3), Old age, not falling within any other category (43), Physical disability over 65 years of age (20) Mayott House DS0000013160.V344716.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of persons that may be accommodated at any one time must not exceed 43. 3rd November 2006 Date of last inspection Brief Description of the Service: Mayott House is a home for older people based near the centre of Abingdon, owned and managed by The Orders of St John Care Trust (OSJCT), which is a charitable organisation that also runs homes in Wiltshire, Lincolnshire and Gloucestershire. The home is close to several local shops and amenities with good bus routes, and can accommodate a maximum of 43 older people. The home provides 24-hour support for all the individuals living at the home, and does not provide nursing care. There are no en-suite bedrooms, and a passenger lift is available to the first floor. The home provides a suitable outdoor area with garden furniture for people to safely walk and sit to enjoy the garden. The fees for this service range from £495.00 - £680.00 per week, and the home can be contacted for detailed information about fees. Mayott House DS0000013160.V344716.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 09.15 hours and was in the service for 4 hours. This inspection was a thorough look at how well the service is doing. It took into account detailed information already provided by the service’s manager, and any information that CSCI has received about the home since the last inspection. The inspector saw all areas of the home and looked at records and documents relating to the care of the residents. The inspector asked the views of the people who use the services and other people seen during the inspection or who responded to questionnaires that the Commission had sent out, 10 people living at the home and several relatives responded through the Commission’s questionaires. Their views are included in this report. The inspector looked at the way this service is meeting standards set by the government, and in this report has made judgements about the outcomes for people living in the home. The home’s approach to equality and diversity was considered throughout the inspection process. From the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs, and of different physical ability. What the service does well: The environment is homely and comfortable, and people made comments such as: ‘its always fresh and clean’, ‘its very clean and tidy’ and ‘couldn’t be better’. People living at the home are confident that their health and personal care needs are met, in a respectful way. Individuals enjoy the activities, and find new skills through the support provided. People said of the food provided: ‘always very tasty’, ‘good’, ‘very good’. The home’s garden provides a focal point for people living at the home, and people enjoy walking, sitting and working in the garden. Mayott House DS0000013160.V344716.R01.S.doc Version 5.2 Page 6 People know how to make complaints and are confident that their concerns will be heard. People living in the home say that the staff members are ‘very caring’, ‘good’, skilled and reliable, and that they have time to talk with them. People have confidence in the home’s management, and feel the home is well run. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Mayott House DS0000013160.V344716.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 Mayott House DS0000013160.V344716.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): 3 and 6. The home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care needs of individuals are assessed to make sure that the home can properly look after the individual. EVIDENCE: A senior member of the care team usually conducts the pre-admission assessment, and individuals are able to visit the home with their relatives before deciding to come to live there. The Orders of St John Care Trust (OSJCT) who manage the home has reviewed all the documentation used to record care at the home, and improved documents are being introduced. The inspector saw the new pre-admission assessment documentation for one individual and all the information was available, so that the home could decide if the individual’s needs could be met. Information included referral information from the care manager and health information from the individual’s general practitioner. Mayott House DS0000013160.V344716.R01.S.doc Version 5.2 Page 9 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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home are confident that their health and personal care needs are met, in a respectful way. EVIDENCE: The majority of the individuals who responded to the Commission’s questionnaire said that they ‘always’ received the care and support they needed, and that they ‘always’ received the medical support they needed. Relatives who replied said that their relative ‘always’ or ‘usually’ received the care they expected. The new documentation is gradually being introduced, and the expectation is that it will make planning an individual’s care easier and be more person centred. The care plans seen contained all the necessary information to enable carers to look after the individuals, including specific details about how to make communicating with the individual easy. The new documentation includes a care plan about decision-making, and this is good practice. Mayott House DS0000013160.V344716.R01.S.doc Version 5.2 Page 10 The evidence base of the new nutritional tool used at the home was not known, and it is recommended that the home use a nationally evidenced based nutritional risk assessment tool, such as the Malnutrition Universal Scoring Tool (MUST), that includes a body mass index score. This was a recommendation at the last inspection. The home has a medication policy and only carers trained in the management of medicines are responsible for the administration of medicines at the home. The medication administration records seen by the inspector were appropriately completed and systems are in place, including regular audit checks by the supplying pharmacist and by the home, to make sure that people living at the home receive their medication safely. The inspector observed care practice during the inspection visit, and saw that carers showed respect for people living at the home. All of the people living in the home who responded to the Commission’s questionnaire said that the staff members ‘always’ listen and act on what they said. Mayott House DS0000013160.V344716.R01.S.doc Version 5.2 Page 11 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 and 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living at the home are able to live in the way they want to, and are supported by the home’s staff to try to achieve their potential. EVIDENCE: The home encourages a homely, open atmosphere so that individuals can feel at home. All of the people living at the home said that there were ‘always’ or ‘usually’ suitable activities for them to take part in, and some said that they preferred not to take part. The activities coordinator works 20 hrs a week, and uses individual history information to develop activity work. Staff members provide and manage the weekend activities. There are individual and group activities provided, and outings are arranged, including a Summer Fun Day. Some individuals have discovered new craft talents, and others are supported to grow flowers and vegetables, and in this way they are able to continue doing meaningful activities. The home has found ways of encouraging and supporting individuals to work towards achieving their potential, and this is commended. The inspector spoke to several individuals who said that they could do what they wanted to, and that staff helped them to be as independent as possible. A shop is open on the premises selling items most in demand by the individuals living at the home, and newspapers and magazines are delivered. Mayott House DS0000013160.V344716.R01.S.doc Version 5.2 Page 12 Some people go out to the nearby shops independently, and people can contact friends and family through the two public phones or through individual phones on private contracts. The home’s cook was not at the home on the day of the inspection, and an agency cook provided the meals on the day according to the menu. The organisation’s catering adviser is available to help improve the catering arrangements when necessary, and the catering staff members are included in the residents’ meetings to encourage feedback. The majority of people at the home said in the Commission’s questionnaire that they ‘always’ liked the food at the home, and individuals confirmed this on the day of the inspection visit. The ethos of the home promotes continued learning from daily experience, and an example was discussed during the inspection visit. An agency cook had provided a cooked breakfast for all the people living at the home, although all the individuals would not usually have chosen a cooked breakfast. When it was clear that all the individuals ate and enjoyed the breakfast, it was decided to review the current way of asking people to choose meals, so that a cooked breakfast is available to all. This incident demonstrates good reflective practice. Mayott House DS0000013160.V344716.R01.S.doc Version 5.2 Page 13 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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home are protected from harm, and their concerns and complaints are listened to. EVIDENCE: The home has an appropriate complaints procedure that is displayed in the home, and all the people living at the home have a copy. All of the people living at the home said that they knew how to make a complaint, and relatives also knew how to make their views known. Two complaints were received and addressed appropriately since the last inspection. No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. The home’s safeguarding policy includes information about the local authority’s contact details, and gives clear details about what to do in the event of an allegation of abuse. New staff members receive training on how to protect people living at the home from abuse during the induction period, and more training is provided following induction. Mayott House DS0000013160.V344716.R01.S.doc Version 5.2 Page 14 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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, safe and well maintained. EVIDENCE: The accommodation is arranged in four units, and this helps the home to be more homely and comfortable. There are systems in place to make sure that daily maintenance is carried out as required, and there is a development plan for the home, so that updating is carried out on a regular basis. Several individuals told the inspector how the garden enhanced the quality of life at the home, and provided a safe place to see and enjoy the outdoors. Individuals commented to the inspector that the home is always fresh and clean. The laundry room is spacious and is appropriately fitted to enable staff to manage the home’s laundry. The laundry room staff members confirmed that they had received training in the control of infection and in safe managing of the substances used in the laundry processes. Mayott House DS0000013160.V344716.R01.S.doc Version 5.2 Page 15 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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Trained and caring staff members support the people at the home, who have been properly vetted. EVIDENCE: The majority of the individuals who responded to the Commission’s questionnaire said that they ‘always’ received the care and support they needed, and several commented on the positive qualities of the staff. Staff members have bleeps so that they know who is in need of attention, and can quickly attend to individuals’ needs. There is a staff rota, showing which staff members are on duty over the 24 hours, and there were sufficient people working at the home on the day of the inspection to meet the needs of the individuals. The home is working towards having 50 of care staff trained to National Vocational Qualification Level 2 in Care. The home has a programme for staff training, and all the home’s staff members have either completed or are booked to go to the specialist dementia training provided by the Alzheimer Society. The inspector witnessed good practice in caring for people with dementia during the inspection visit. Mayott House DS0000013160.V344716.R01.S.doc Version 5.2 Page 16 The home provides dedicated resources for web-based learning for staff members, and all staff members are up to date in mandatory training, so that they are safe to care for the individuals in the home. The inspector saw three staff files to check the recruitment procedure, and was satisfied that all the necessary information was available. Mayott House DS0000013160.V344716.R01.S.doc Version 5.2 Page 17 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): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The best interests of people living at the home are protected by the home’s policies and procedures. EVIDENCE: The home’s manager is qualified and skilled and encourages people living at the home to make Mayott House their home. The majority of the people living at the home who spoke to the inspector praised her management of the home. The requirements from the previous inspection have been implemented. The home undertakes regular quality assurance exercises to assess the quality of the service, and one was carried out this year. The home follows the organisation’s procedures about managing petty cash, holds computerised records and keeps manual receipts of transactions. Mayott House DS0000013160.V344716.R01.S.doc Version 5.2 Page 18 The home has a named person who is responsible for health and safety and has a policy statement about health and safety regarding staff and people living at the home. A fire risk assessment is in place, and fire safety records are maintained. Mayott House DS0000013160.V344716.R01.S.doc Version 5.2 Page 19 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 X 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 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 Mayott House DS0000013160.V344716.R01.S.doc Version 5.2 Page 20 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 Refer to Standard OP8 Good Practice Recommendations It is recommended that the home should use an evidencebased tool such as MUST (Malnutrition Universal Screening Tool) to carry out nutritional screening. Mayott House DS0000013160.V344716.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Mayott House DS0000013160.V344716.R01.S.doc Version 5.2 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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