Inspection on 05/10/05 for Mayott House

This inspection was carried out on 5th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 18/09/07

Mayott House 03/11/06

Mayott House 06/02/06

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 5th October 2005 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.V259716.R01.S.doc Version 5.0 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.V259716.R01.S.doc Version 5.0 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 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.V259716.R01.S.doc Version 5.0 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. 24th February 2005 Date of last inspection Brief Description of the Service: Mayott House is a home for older people based near the centre of Abingdon. The home can accommodate a maximum of 43 individuals. 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 now 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. Mayott House DS0000013160.V259716.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, lasting 6.5 hours, which took place on the 5th October 2005. The purpose of the visit was to see how the home is meeting the National Minimum Standards. The visit involved speaking to residents in order to ascertain their views upon the care and the services they receive at the home, the staff members and the manager, viewing care plans and assessments, whilst observing the general day to day operation of the home. At the time of inspection the service users were busy going about their daily activities and there was a calm relaxed atmosphere. The inspector was warmly welcomed, by both the staff and residents. Much of the inspection focused upon life from the service users point of view. Comments received from residents during the inspection included: ‘It’s a nice home’ - ‘we have all the conveniences’ - ‘nice people living here’ and ‘we are all well looked after’. Comments received from staff included: ’nice place to work’ - ’I’m really happy here’ and ‘best boss I’ve had, she really is’. The inspector would like to thank the residents, staff and family members for their assistance during the inspection. What the service does well: The home has a very welcoming homely atmosphere and the service users rooms had a real sense of ‘home’ about them. Residents spoken to during the inspection were complimentary of the staff and the care they receive at the home and spoke positively with regard to the way in which the home was managed. Both the residents and staff were of the opinion that the manager runs the home in an open and inclusive manner. A varied programme of activities to suit all abilities is offered on a daily basis and staff liaise with residents regarding their likes and dislikes on both a one to one basis and through regular resident meetings. Mayott House DS0000013160.V259716.R01.S.doc Version 5.0 Page 6 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. Mayott House DS0000013160.V259716.R01.S.doc Version 5.0 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.V259716.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 The home provides prospective service users with appropriate information to allow them to make a choice about where to live. Generally, service users do not move into the home before their needs are assessed and both parties are confident that these needs will be met. In instances where emergency admissions take place, the system of assessing the service users, needs to be addressed as poor practices were observed. EVIDENCE: All prospective service users undergo an assessment of needs, are provided with a Service Users Guide and the homes Statement of Purpose. They are invited to visit to gain ‘a feel’ of the home and to meet fellow residents and staff to allow them to make an informed choice when deciding upon a care home suitable for them. Mayott House DS0000013160.V259716.R01.S.doc Version 5.0 Page 9 Each service user is provided with a statement of terms and conditions. The inspector found no evidence of one service users’ assessment of needs, who was admitted to the home as an emergency admission some 13 days prior to the inspection. A recommendation that the manager considers needs assessments for emergency admissions and undertakes these as a matter of priority has been made within this report. Mayott House DS0000013160.V259716.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 8 The organisation has produced new care plan templates to allow a more concise and accessible form of care planning and assessment procedure, although there is still much work to be done to ensure these are detailed and appropriate to the service users needs. The lack of important information could lead to missing a vital part of an individuals care. EVIDENCE: The inspector was informed that no resident moves into the home before an initial assessment of needs has been undertaken. A detailed care plan is then drawn up from the initial assessment, to inform staff what the residents needs may be and how to address them. However the inspector asked for 4 named residents files, picked randomly, 3 of which were produced and the 4th was being worked upon. Mayott House DS0000013160.V259716.R01.S.doc Version 5.0 Page 11 The Inspector reminded the manager that in cases where residents are admitted in an emergency, a full care plan should produced within 48 hours. The file failed to contain any admission details; details omitted included the date of admission, next of kin, GP details, a personal inventory, details around diet, no baseline weight or height had been recorded and no risk assessments had been undertaken. Whilst the resident had been admitted to the home, some 12 days prior to the inspection the care plan was of a poor standard and an immediate requirement was made in which a detailed care plan and risk assessment was to be put in place immediately, whilst the inspector was on the premises. A further requirement was made in which the manager is to complete emergency admission details as required by the National Minimum Standards and to forward a copy to the CSCI by 6th October 2005. Of the further three care plans viewed, there was evidence of risk assessments either not having been undertaken or those that had been, the updating of these assessments were found to be inconsistent and not being updated on a monthly basis and the files failed to contain up to date information or evidence that there had been appropriate consultation with the service user or their representative. Requirements have been made within this report to address the omissions. Mayott House DS0000013160.V259716.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 15 The social activities available to the service users provide stimulation and interest. Service users are encouraged to maintain contact with family and friends and the local community as they so wish, to ensure continued social contact. There is a choice of meals offered at the home which are varied, nutritious and alternatives may be requested. EVIDENCE: Service users confirmed that organised activities are provided regularly, which includes keep fit, arts and crafts, bingo, sing-along and trips. A visiting chiropodist and hairdresser are available for those who require the service and each Sunday evening, service users may attend a church service. It was evident during the inspection that service users experience and enjoy relaxed and unhurried conversations with the staff members and visitors are made welcome at the home at any time of their choosing. Mayott House DS0000013160.V259716.R01.S.doc Version 5.0 Page 13 During the inspection Service users were enjoying their lunch, which consisted of Roast Chicken, roasted or boiled potatoes, brussel sprouts, Swedes, stuffing and gravy, followed by apple pie and cream. An alternative is available for those who prefer and special diets are catered for. Menus are displayed upon notice boards within the home informing the residents of the choices available. After lunch, many were looking forward to attending the Link Club held in Headington. There are facilities for service users to make drinks and snacks if required. Mayott House DS0000013160.V259716.R01.S.doc Version 5.0 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 Service users, friends and relatives all have access to the homes complaints procedure and are confident that any concerns would act upon appropriately. Service users are referred to an independent advocacy service should they request this or should the need arise. All residents are on the electoral roll and may elect to take part in the local and national elections by means of a postal vote or visiting the local polling stations. There are policies and procedures in place to guide the manager and staff on how to respond to any suspicion of abuse. Training is provided to all members of staff to assist them in becoming aware of their own care practices, to recognise signs and symptoms of abuse and to emphasise each staff member’s responsibility to ‘whistle blow’ on any poor practice or concerns that come to their attention. EVIDENCE: On speaking to residents and family members during the inspection, it was apparent that they were aware of the complaints procedure, found in the service users guide and posted upon notice boards within the home, and would access this should the need arise. Regular meetings are held for residents to attend, where they are encouraged voice any concerns or complaints they may have. The meetings are minuted and distributed throughout the home. Where a complaint is received by the home, the matter is dealt with swiftly and appropriately. Mayott House DS0000013160.V259716.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 The home provides a safe, comfortable and friendly environment for all service users EVIDENCE: The residents have access to all their communal and private space, through the provision of specialist equipment There are grab rails in corridors, bathrooms and toilets. Sufficient hoists, assisted toilets and baths to meet the resident’s needs. The inspector was informed that all the main areas of the home and bedrooms are undergoing a decoration programme. Service users are encouraged to personalise their rooms with their own personal possessions and memorabilia, which was evident upon touring the home, where the inspector noted the service users individual rooms had a Mayott House DS0000013160.V259716.R01.S.doc Version 5.0 Page 16 noticeably homely feel. Likewise, service users rooms were seen to be equipped and fitted with appropriate furniture for their individual uses. All areas of the home were cleaned to a high standard. However, one bedroom presented as odorous, which when discussed with the manager, it became evident that she was aware of this, and was dealing with this matter appropriately. There is adequate provision of toilets, washing and bathing facilities throughout the home. The inspector noted soap bars were in use in a couple of the bathing/washing facilities and paper towels were not readily available in all. One was found to contain a broken soap dispenser. The manager informed the inspector that new liquid soap dispensers were to be fitted within a couple of weeks. A recommendation has been made to ensure that liquid soap is used so as to protect residents from the possibility of cross infection. A call system with an accessible alarm facility is provided in all rooms, in order that residents can call upon staff in the case of an emergency. Feedback from residents informed the inspector that staff were very quick to answer when the alarm is used. The gardens and patio area were neat and tidy and residents informed the inspector that during the warmer months the gardens are enjoyed by all. The inspector reminded the manager that the health and safety risk assessment with regards to the security of the home was due for a review, which the manager agreed to undertake. A resident’s personal possessions were found to be stored in a cupboard within one of the communal areas and it was recommended that this be stored in the resident’s own room. Mayott House DS0000013160.V259716.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The atmosphere of the home is friendly and welcoming. The manager is approachable to service users and staff and offers clear guidance and support. The home is staffed in accordance with the needs of the residents and staff undergo the appropriate training to meet the residents needs. EVIDENCE: Service users and staff spoke with high regard of the Manager one staff member said ‘I feel I can go and ask about anything’ and another stated ‘She keeps us updated on any courses available, it is a nice place to work, I am really happy here’. The inspector viewed a randomly chosen sample of staff files. The four files viewed, all failed to contain a recent photograph of the staff member and one further failed to contain the member of staffs’ birth certificate. A requirement has been made to ensure all relevant documentation as detailed in schedule 2 of the Care Homes Regulations 2001 is held on staff personnel files. There is a robust recruitment policy in place to ensure the suitability of new staff members and all undergo the necessary checks. Mayott House DS0000013160.V259716.R01.S.doc Version 5.0 Page 18 All new staff are provided with a copy of the General Social Council Code of Practice and a copy of the Oxfordshire Multi-agency Codes of Practice for the Protection of Vulnerable Adults and undergo an induction training period and shadow fellow colleagues until both parties feel they are competent to undergo this alone. Further training and updating of skills is offered to staff to ensure they are able to meet the resident’s needs. The manager informed the inspector that training in first aid was to be offered to staff members during the following month and a further 8 members of staff were undergoing an in depth training in medication. One member of staff commented that the ‘manager keeps us updated on any courses available. I’m really happy here…..a nice place to work’. Mayott House DS0000013160.V259716.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33 and 38 In view of the findings during the inspection around assessment of needs, risk assessments and care planning, the inspector is of the view that the home is not presently protecting the health safety and welfare of the residents appropriately. EVIDENCE: Whilst the manager has many years of experience in caring for older people and is undergoing the Registered Managers award NVQ level 4 which, she informed the inspector, she aims to finish by the end of the year, there are shortfalls around the issues of assessing residents needs and the care planning process. Mayott House DS0000013160.V259716.R01.S.doc Version 5.0 Page 20 It was reported to the inspector that a new care planning format has been introduced and training is to be undertaken by both the manager and a senior members of staff, who will be cascading the training to other staff members, which it is hoped will ensure that assessments, individual plans of care and reviews will be comprehensive and address the needs of the residents appropriately. Feedback from a Health and Social Care professional who is in contact with the home was very positive. The inspector was informed that the home communicates clearly and in partnership with them with regards to those in their care and that staff demonstrate a clear understanding of the care needs of the service users. Both the service users and staff were of the opinion that the manager runs the home in an open inclusive way, and would have no worries approaching her with any concerns that they may have. They were also confident that should the need arise, they would be listened to and their concerns would be dealt with appropriately. Regular residents meetings are held, which keep service users informed and allow for any concerns to be discussed. These meetings are minuted and distributed around the home. Policies and procedures are in place, to protect the resident’s health, safety and welfare and all staff receive mandatory training in moving and handling and fire safety. Mayott House DS0000013160.V259716.R01.S.doc Version 5.0 Page 21 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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 2 3 3 2 3 3 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X X X 3 2 Mayott House DS0000013160.V259716.R01.S.doc Version 5.0 Page 22 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. 1 Standard OP3 Regulation 14 and 15 Requirement The registered manager must ensure to assess the needs of the service user identified within this report. The registered manager must ensure the needs of a service user have been assessed, by a suitably qualified person, and appropriate consultation with the service user or their representative regarding the assessment takes place. The registered manager must set out a detailed individual plan of care for the service user identified within this report and forward to CSCI within 48 hours The registered manager must ensure that all risk assessments are undertaken and kept up to date to reflect the needs of the service users, and to provide staff with clear information as to the management of those needs. Information held on all staff personnel files must be as outlined in Schedule 2 of the Care Homes Regulations 2001 Timescale for action 05/10/05 2 OP3 14 05/10/05 3 OP7 15 and 17(1)a 05/10/05 4 OP7 24(1)a 05/10/05 5 OP29 19(1)b schedule 2 05/10/05 Mayott House DS0000013160.V259716.R01.S.doc Version 5.0 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP3 OP21 OP24 Good Practice Recommendations It is recommended that the manager considers needs assessments for emergency admissions and undertakes these as a matter of priority It is good practice recommendation to ensure hand towels and liquid soap are available to residents in all communal bathing and toileting facilities. It is recommended that resident’s personal possessions be stored appropriately. Mayott House DS0000013160.V259716.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: 0845 015 0120 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.V259716.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!