Inspection on 03/11/06 for Mayott House

This inspection was carried out on 3rd November 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Mayott House 18/09/07

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 Jane Handscombe Unannounced Inspection 3rd November 2006 10:00 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.V317959.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.V317959.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 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.V317959.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. 6th February 2006 Date of last inspection Brief Description of the Service: Mayott House is a home for older people based near the centre of Abingdon, close to several local shops and amenities with good bus routes. The home can accommodate a maximum of 43 older people. The home provides 24-hour support for all the service users accommodated at the home. The home does not provide nursing care. The Home is 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 was purchased from Oxfordshire County Council in 2002, and there have been significant changes to the structure and organisation of the home since the transfer. The Home has not been identified as a priority for redevelopment by OSJCT, although the organisation has undertaken a programme of refurbishment, and has made a commitment to maintain the fabric of the home to a good standard. The fees for this service range from £491.00 - £650.00 per week Mayott House DS0000013160.V317959.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 10:10 hours and was in the service for 8.5 hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s owner or manager, and any information that CSCI has received about the service since the last inspection. 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. Of these 6 relatives/visitors comment cards, 7 “Have your say about Mayott House”, and 3 GP and 4 Health and Social Care professionals comment cards were received by the Commission. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. The inspector was given a warm welcome by both the staff and the residents. Care plans were examined followed by meeting with the individual residents to see if the care needs were being met. Discussion took place with the registered manager, activities co ordinator, resident’s and staff. The medication system was examined as was a sample of staff files, including evidence of training and development that had taken place. Resident’s, files were examined and a sample of records required by regulation were examined. A tour of the premises took place and the inspector spent time speaking with those who use the service. The inspector would like to thank all the staff who assisted in this inspection in any way for their cooperation. What the service does well: Mayott House DS0000013160.V317959.R01.S.doc Version 5.2 Page 6 Residents reported that they are happy with the provision of care they receive and find the manager and staff to be very approachable. Service users feel confident in using the complaints procedure if the need arose. Any concerns or complaints are acted upon appropriately and in a timely manner. The staff were observed to treat residents with dignity and respect throughout the inspection offering help discreetly and sensitively where necessary. Whilst the home is beginning to look ‘tired’ the manager works very hard to ensure that the home presents as homely and welcoming redecorating and refurbishing where necessary. A very good rapport was observed to take place between the service users and staff. What has improved since the last inspection? What they could do better: Whilst service users spoke highly of the care they receive at Mayott House and of the staff who deliver the care, there are a number of areas highlighted within this report that the home could improve upon. Areas in which improvement needs to be made is namely that of accurate, detailed record keeping to ensure the health, safety and welfare of service users in their care. Poor recording procedures were found within the assessment of needs, care plans and the recording of medication that has been administered. An assessment of residents’ nutritional needs should be done on admission and regularly thereafter, using a recognised, evidence-based method, so that any residents at risk from poor diet will be identified and action taken to improve their nutrition and health. Mayott House DS0000013160.V317959.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. Mayott House DS0000013160.V317959.R01.S.doc Version 5.2 Page 8 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.V317959.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 5. Standard 6 does not apply to this home. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides prospective service users with information about the home and its services and undertakes an assessment of needs which allows them to make an informed choice. The home does not offer intermediate care. EVIDENCE: The home provides prospective service users and/or their representatives comprehensive information about the home and the services it offers. The registered manager or care leader, who is qualified to undertake such a task, undertakes an assessment of needs and invites them to spend a day with fellow service users and staff members to gain a ‘feel’ of the home prior to a service being offered. Mayott House DS0000013160.V317959.R01.S.doc Version 5.2 Page 10 This ensures that prospective service users are able to make an informed choice when deciding upon a home suitable to meet their needs. The sample of assessments examined did contain some gap; one failed to include any details of the service users’ hobbies and interests, their social aims and objectives whilst another failed to note within the medical history section that the service user was a diabetic. It was noted that within the file it stated to offer a diabetic menu, yet the assessment of needs and relevant part of the care plan stated ‘normal diet and is able to choose from daily menu’. Discussions with staff members evidenced that they were aware of this clients dietary needs and the needs were met appropriately. However the registered manager must ensure that information within the care plans and assessment of needs are clear and contain no conflicting information in order that the residents’ needs can be met appropriately by any member of staff including agency staff who may be unfamiliar with the clients. All the assessments viewed failed to contain the service users’ or their representatives’ signature to evidence that they had been included and agreed to the assessment. Furthermore, one of these failed to contain the signature of the person who had undertaken the assessment. From evidence seen by the inspector, it is considered that this service is able to meet the needs of individuals of various religious, racial or cultural needs. Mayott House DS0000013160.V317959.R01.S.doc Version 5.2 Page 11 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, 89, 9, 10 and 11 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. All residents have a care plan detailing their needs which is regularly reviewed. The residents are well cared for, and feel that they are treated with dignity and respect, and know that their wishes regarding the end of their life will be carried out. There are clear and effective procedures in place for those who wish to maintain responsibility for their own medication. EVIDENCE: All residents have an individual care plan drawn up from their initial assessment of needs, which is regularly reviewed and updated as necessary. However, the assessment of needs, in one file viewed (See section headed Choice of Home) failed to contain important medical history and therefore was not clear within the care plan resulting in conflicting information regarding the residents’ dietary needs. Mayott House DS0000013160.V317959.R01.S.doc Version 5.2 Page 12 Nutritional screening is minimal and it would be a good practice recommendation to use an evidence-based tool such as MUST (Malnutrition Universal Screening Tool) for all residents on admission. Whilst the care plans give staff details of the care to be provided, it is recommended that the daily reports within these be written in a more person centred way i.e. holistically. There are good communications between the staff and the GP’s and the District Nursing staff, although care does need to be taken to ensure that the health professionals visiting residents write up their reports in the correct service users care plan. It was noted that a GP had written up notes on a visit to one service user in the wrong care plan. The home has access to other health care services such as specialist nurses, pharmacy, opticians, dieticians, and chiropodist. Three GP’s responded to the commission’s comment cards and four Health and Social Care Professionals who have contact in the home, all of who were satisfied with the overall care provided to residents. The inspector examined the medication systems within the home and found some shortcomings. It is required that when medication has not been given, or refused that this be entered on the medication administration record (MAR) using a coding system and the staff member sign the relevant MAR sheet. Likewise the MAR sheet should not contain crossing out, but the coding system to be used. The systems in place to record medications into and out of the home were in good order and all medication was stored appropriately. There are clear and effective procedures in place for those who wish to maintain responsibility for their own medication within a risk management process. Throughout the inspection it was evident that staff understood issues about privacy and dignity; the residents were seen to be assisted in a kindly and respectful manner, and staff were observed to knock on doors prior to entering a residents private room, or the bathrooms and toilets. The inspector noted that there was information in the individual care plans about the resident’s wishes concerning terminal care and arrangements after death. This information is usually gained during the initial assessment in order that the home handles their wishes accordingly. Mayott House DS0000013160.V317959.R01.S.doc Version 5.2 Page 13 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 good This judgement has been made using available evidence including a visit to this service. EVIDENCE: The activities co-ordinator keeps a record of the activities each individual service user has taken part in and these are discussed and reviewed to ensure that the programme is meeting their needs. Activities include both one to one sessions and group activities to suit the residents’ wishes which include; bingo, karaoke, quizzes, model making, visiting entertainers, manicures, film shows and trips to places of interest. One resident told the inspector ‘we went out to the circus last night, it was very good’, whilst another spoke of his interest in music and explained that ‘we had some boys in from Radley College playing their instruments, they are very good’. It was mentioned from a few residents that they used to enjoy undertaking exercises, which were no longer offered. This was mentioned to the activities co coordinator who explained that she is to undertake training in this area in order that the exercise activities could again be offered to those who required. Mayott House DS0000013160.V317959.R01.S.doc Version 5.2 Page 14 Whilst spending time with residents and touring the home, there was very little evidence of staff spending quality time with residents on a one to one basis. Although daily activities are offered to residents, the inspector noted no activities taking place during the afternoon. With this in view, the delivery of activities are not as individualised as they could be and therefore the inspector has made a recommendation to include individualised person centred activities for those who require them and deliver these on a one to one basis or in small groups, during the quieter afternoons, so as to address everyone’s individual needs. Meals and mealtimes are an important part of the resident’s day and those spoken to were complimentary regarding the food and welcomed the choices available, that they enjoy the meals offered and could choose what they have. Residents generally take their meals in the dining rooms although these may be taken in their own rooms if required. One resident told the inspector ‘I had my flu jab this morning, I wasn’t’ so good, so I had my breakfast in my room’. Staff informed the inspector that residents are encouraged to maintain contact with their families, friends, representatives and the local community as they wish and support is given if required. Residents verified this and informed the inspector, that visitors and friends are welcomed at any reasonable time, and are able to entertain them in the communal lounges or their own bedrooms. One service user told the inspector ‘I go out with my brother. Last Wednesday we went to the over 60’s club and then I went shopping with him………he can come in at any reasonable time…’ and another explained that the home has a bar facility and ‘when my son comes to see me we usually have a drink’. There is a visiting hairdresser who visits the home twice a week and a local chaplain who holds a service each Sunday, offering communion to those who wish. Mayott House DS0000013160.V317959.R01.S.doc Version 5.2 Page 15 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, 17 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a clear complaints procedure in place should a resident or their family members and friends need to access. All residents are given information on advocacy services available to them and if required, staff will support residents to access the service. Service users are protected from abuse. EVIDENCE: There is a complaints procedure should any residents have any concerns. Residents spoken to during the inspection confirmed that they would take any concerns to the manager and her staff if they had the need and felt that their concerns would be listened to and acted upon appropriately. Residents meetings are also a means in which any concerns may be voiced. The complaints logged were examined highlighting that one complaint had been brought to the attention of the manager and had been dealt with appropriately. There have been no complaints brought to the attention of the commission since the last inspection. Mayott House DS0000013160.V317959.R01.S.doc Version 5.2 Page 16 The home has in place robust procedures in circumstances where there are any suspicions concerning possible abuse. Staff are all aware of the procedures and have attended training on the protection of vulnerable adults and are clear on the procedures to follow. The home facilitates access to advocacy services and takes steps to ensure that residents are enabled to take part in the local and national elections if they require. Mayott House DS0000013160.V317959.R01.S.doc Version 5.2 Page 17 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, 21, 22, 23, 24 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 provides comfortable surroundings, which are equipped to meet the residents differing needs. EVIDENCE: On the day of the inspection, the home was generally clean and tidy with a homely atmosphere. However there was one room, which contained an offensive odour, which the manager assured would be deep cleaned so as to rectify the odour. Residents are enabled to access to all their communal and private space, through the provision of specialist equipment which include ramps and a passenger lift. Mayott House DS0000013160.V317959.R01.S.doc Version 5.2 Page 18 The home provides grab rails in corridors, bathrooms and toilets and hoists and assisted toilets and baths are available to meet the residents’ needs. The home has sufficient toilet, washing and bathing facilities, all of which were accessible and clearly marked. Accommodation for each resident is furnished and equipped to ensure them the right to comfort and privacy. The manager informed the inspector that the home always encourages residents to bring small items of furniture and memorabilia to personalise their rooms to their own liking, which was evident on touring the home. Residents spoken to on the day informed the inspector that they were very happy with their rooms and found them to suit their needs. Whilst touring the home, the inspector spoke to a couple who were very happy with their room, in that it allowed them to remain together and suited their needs. Another resident told the inspector that her room was ‘lovely and comfortable’. Residents are provided with a key to their room if they wish allowing them privacy, and lockable storage is also provided. All rooms have call system with an accessible alarm facility, which allows residents to call staff in the case of an emergency. Residents spoken to informed the inspector that in situations where they have had to use this alarm they had been answered swiftly and appropriately. Whilst the building is looking ‘tired’ some redecoration within the home has recently taken place which includes new carpets in all the main corridors, new furniture has replaced that in the Victoria lounge, new worktops have been provided in the kitchenettes, a new oven has replaced that in the kitchen and most kitchen equipment is being replaced. Mayott House DS0000013160.V317959.R01.S.doc Version 5.2 Page 19 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. Mayott House operates a recruitment procedure that ensures the protection of the residents in their care. The numbers and skills of staff ensure that the resident’s needs are met appropriately. All staff are provided with training to ensure they have the knowledge and skills to undertake their roles competently. EVIDENCE: The staffing levels on the day of inspection were sufficient to meet the needs of the residents. The recruitment systems in place are of a good quality; a selection of staff files were sampled for inspection all of which contained the relevant pre employment checks, references and their relevant qualifications. There was one instance in which there was no recent photograph held on the staff members personnel file and a further file in which some mandatory needed updating; both of which the manager assured would be addressed. Future Mayott House DS0000013160.V317959.R01.S.doc Version 5.2 Page 20 training has been identified and planned for, which includes the updating of mandatory training. All members of staff undergo induction training, upon appointment to their posts, and are offered ongoing training, which equips them to meet the assessed needs of the residents within the home. The Trust has just introduced an “E Learning “ induction training, which is being rolled out across the Trust. The manager informed the inspector that three care leaders are currently undertaking their NVQ level 3 in care, a further 8 carers are being registered for the NVQ level 2 and one carer on the NVQ level 3. Whilst speaking to carers, one mentioned how she had enjoyed the course and how useful it had been. Recent training over the past 12 months has included; Safe handling of medication, fire training, dementia care, COSSH and abuse training. All staff undergo an appraisal once a year and regular supervision takes place both formally and informally. Mayott House DS0000013160.V317959.R01.S.doc Version 5.2 Page 21 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, 32 33, 35, 36, 37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Mayott House is a well managed home, run in the best interests of the residents, using the service. Safeguards are in place to protect their health, safety and welfare although poor recording practices could compromise this. EVIDENCE: Residents and members of staff reported that the manager runs the home in an open, positive, inclusive way and they would have no worries approaching her if they had any concerns and were confident that they would be listened to and dealt with appropriately. Mayott House DS0000013160.V317959.R01.S.doc Version 5.2 Page 22 Since the last inspection held in February 2006, the registered manager has continued in broadening her skills and knowledge and has completed the Registered Managers Award and NVQ level 4 in care – a formal qualification for her role within the home. The Trust has introduced a quality assurance system that requires managers to continually audit, monitor, and report on all of the key management systems on a regular basis. An Annual quality survey has just recently taken place within the home It is recommended that a copy of the summary of the annual quality survey should be supplied to the commission when completed. Regular residents’ meetings take place monthly, in which open discussions and suggestions take place around issues regarding the home, the care provided, meal provision, entertainment etc and any points that the residents would like placed on the agenda. These meetings are minuted and accessible to all service users and their families. Feedback from one relative/visitors comment card suggested that similar meetings for relatives would be very useful. The manager discussed the procedures that are in place to safeguard the resident’s financial interests and explained that the same accounting and auditing system is used in all the OSJCT homes. The system ensures that residents’ personal allowances and small amounts of cash are safely managed and there are receipts and records for all transactions. The home’s fire safety record was checked and was up to date, with evidence of regular fire safety training for staff and maintenance of the fire fighting equipment and alarms being routinely undertaken. On the whole, the home is run in the best interests of the service users with safeguards in place to protect their health safety and welfare. Some failings in the record keeping (See sections headed Choice of Home and Health and personal care) could compromise the health safety and welfare of the residents and it is recommended that residents care plans and assessment of needs be monitored regularly to ensure that policies and procedures are being adhered to. Mayott House DS0000013160.V317959.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X 3 3 3 3 X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 2 3 Mayott House DS0000013160.V317959.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES 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 OP3 Regulation 14 and 15 Requirement Timescale for action 31/12/06 2 OP3 OP7 14 The registered manager must ensure assessment of needs and reviews of care are dated and gain the assessors and service users/advocate signature to evidence their part in the process. The registered manager must 31/12/06 ensure that information within the care plans and assessment of needs are clear and contain no conflicting information in order that the residents’ needs can be met appropriately. The registered manager must ensure that staff adhere to the procedures for the recording and administration of medicines The registered manager must ensure that the home is kept free from offensive odours All staff personnel files must contain a recent photograph This remains outstanding from the previous inspection held in February 2006. 31/12/06 3 OP9 13(2) 4 5 OP26 OP29 16 19(b) schedule 2 31/12/06 31/12/06 Mayott House DS0000013160.V317959.R01.S.doc Version 5.2 Page 25 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 OP3 OP7 OP9 Good Practice Recommendations It is recommended that residents care plans, assessment of needs and Medication Administration Records be monitored regularly to ensure that policies and procedures are being adhered to. It is a good practice recommendation care plans, be more person centred than they are at present It is recommended that nutritional screening be undertaken for all residents on admission and subsequently on a periodic basis, using an evidence-based tool such as MUST (Malnutrition Universal Screening Tool). It is a good practice recommendation to include individualised person centred activities on a one to one basis or in small groups, at varying times of the day, so as to address everyone’s individual needs. It is recommended that a copy of the summary of the annual quality survey should be supplied to the commission. It is recommended that residents meetings be more inclusive and consider inviting family members and representatives to attend. 2 3 OP7 OP8 4 OP12 5 6 OP33 OP32 Mayott House DS0000013160.V317959.R01.S.doc Version 5.2 Page 26 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.V317959.R01.S.doc Version 5.2 Page 27 - 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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