Inspection on 12/04/06 for The Mayfield

This inspection was carried out on 12th April 2006.

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

Other inspections for this house

The Mayfield 14/01/08

The Mayfield 03/11/05

The Mayfield 14/06/05

The Mayfield 03/12/04

The Mayfield 14/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE The Mayfield 6 Alicia Avenue, Kenton Harrow Middlesex HA3 8AL Lead Inspector Clive Heidrich Unannounced Inspection 12th April 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 The Mayfield DS0000017548.V289467.R01.S.doc Version 5.1 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. The Mayfield DS0000017548.V289467.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Mayfield Address 6 Alicia Avenue, Kenton Harrow Middlesex HA3 8AL 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) 020 8907 7908 020 8907 5777 Mr Kiran Nathwani Mr Paren Nathwani ** Post Vacant *** Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places The Mayfield DS0000017548.V289467.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 3rd November 2005 Brief Description of the Service: The Mayfield is a care home providing personal care and accommodation for up to 23 older people. The group of people living at the home at the time of the inspection were mixed gender. There were no vacancies at the time of the inspection. The home is owned by Messrs Nathwani of Farrington Care Homes Ltd. The organization owns two other homes in the local London region, and is expanding nationally. The home is located in a residential area of Kenton, fifteen minutes walk from an underground station. Nearby on the main Kenton Road there is a parade of small shops, with a hairdresser, cafes, pubs, churches, and a temple. There is a bus route close by. There is unrestricted parking outside of the home. The home is a large converted and extended house. Accommodation for service users is provided on the ground and first floor. Access upstairs is by stair-lift or stairs. All of the bedrooms, except one, are single occupancy. Most of the bedrooms have en-suite facilities and are fully furnished. Communal toilets are located close to the two separate lounge areas. The home has one bathroom upstairs and a newly-refurbished shower room downstairs. At the rear of the house is a patio and a large garden. The current scale of charges, as of 15/3/06, is £485 to £505 a week. Additional charges include for the hairdresser, and private chiropody and dentistry. The home did not have a registered manager at the time of writing. A manager, Ms Martin, has been employed at the home since the summer of 2005, but it remains for the CSCI to receive an application for her registration in this role. This is referred to further under standard 31. The Mayfield DS0000017548.V289467.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place across one and a half days in early April. It lasted ten hours and twenty minutes. Its focus was on inspecting all of the key standards, and with checking on compliance with requirements from the last inspection report. The inspection process involved meeting with a number of service users individually to discuss the services provided in the home. For service users whose first language is not English, the use of an independent interpreter was acquired. The inspector also discussed aspects of the service with the few visitors present during the visits, with staff who were working during the visits, and with the manager. Additionally, care practices were observed across the first day, aspects of the environment were checked on, and a number of records were sampled. A few months prior to the inspection, the manager was requested to send out comment cards to involved people, and to complete an inspection questionnaire. She promptly undertook this. Consequently information from eight service users’, nine friend/relatives/visitors’, and six health & social care professionals’ comment cards, along with the inspection questionnaire, have been included in this report. Feedback was mainly positive. The inspector thanks all involved in the home for the patience and helpfulness before, during, and after the inspection. What the service does well: What has improved since the last inspection? A number of requirements from the previous inspections have been addressed. Complaints from service users and visitors are now dealt with appropriately. A first Service Users’ Meetings was held just before the inspection. Service users’ The Mayfield DS0000017548.V289467.R01.S.doc Version 5.1 Page 6 views about the home were also formally audited at the end of 2005. These all help the service to be run in service users’ best interests. Ongoing improvements are taking place in the decoration of the home. The shower room downstairs has been re-tiled and expanded, and is now used as a walk-in or wheel-in facility, which improves services to service users. Radiator covers have also been fitted in many areas, to reduce scalding risks. Staffing levels have slightly improved. There is now a second cleaner working during the week along with a new part-time activities worker. There is now an organised and established system of staff managing the medication administration. This helps to ensure that medication is distributed correctly to service users, although there remain some concerns. 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 Mayfield DS0000017548.V289467.R01.S.doc Version 5.1 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 The Mayfield DS0000017548.V289467.R01.S.doc Version 5.1 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 4. Quality in this outcome area is adequate overall. Strengths are with the updated information provided about the home’s services, and in usually ensuring that the home can meet service users’ needs to their satisfaction. Key improvements are needed to ensure that detailed written information about the home is provided, that assessment processes acquire all relevant information, and that the home consequently does not admit service users whose specialist needs are too great. The home does not provide intermediate care. EVIDENCE: Work has been undertaken to update the home’s Statement of Purpose and Service User Guide. Copies of final drafts were supplied to the inspector after the inspection. They were seen to include appropriate information. No service users spoken with had received any written information about the home’s services. Work now needs to be undertaken to ensure that all service users and their representatives are personally supplied with a copy of the The Mayfield DS0000017548.V289467.R01.S.doc Version 5.1 Page 9 Guide, including in Gujarati and Hindi where applicable, to enable them to be clear as to the services offered by the home. Additionally, the Statement of Purpose must also be translated and made available. Visitors’ comment cards included that 3 out of 9 are not aware of the complaints procedure, and that 6 do not have access to inspection reports about the home. Whilst these documents were seen to be available in the entrance hall, distribution of the new Service User Guides will help to clarify this information to visitors. Checks were made of the assessment processes for three service users who had been admitted within the previous nine months. A standard assessment procedure is used by the home, and these were in place in each case. Two assessments were dated from the day of the admission into the home. Key information was partially captured through this process, but there were blank spaces in some areas, such as with the person’s religious needs and with profiling key aspects of their life history. Obtaining this information helps to provide a better overall chance of meeting all of the service user’s needs, and so ought to be obtained. Only one of the above cases had supporting documentation from the funding authority about the service user’s needs. This was previously required for all funded service users, as it provides independent information about the service user’s needs and can highlight needs that may not be apparent from the home’s assessment. For instance, the manager noted that the wandering tendency of one service user, a significant support need, had not been apparent at their assessment, and no other assessment had been acquired. The manager must ensure that care management documentation about a potential service user’s needs is acquired, where available, in advance of agreeing to a placement. The home was found to have recently admitted two service users who have significant dementia care needs. The home is not registered in this respect. Staff do not have specific training about dementia. One service user’s care plan showed little awareness of dementia needs despite clearly aiming to support where possible. Ongoing records also raised concerns about the appropriateness of the service user’s placement, in terms of their and other service users’ safety. In conjunction with acquiring the care management assessment, the manager must ensure that service users who have significant dementia care needs are not admitted into the home unless the home successfully applies for registration in this respect. The home provides specialist care for service users of an Asian origin. Feedback from these service users found that most felt that there are enough staff who can speak their native language, and that their needs are met by the home. Observations and other feedback concurred with this, for instance in terms of the meat and vegetarian Asian menus cooked in the home, the The Mayfield DS0000017548.V289467.R01.S.doc Version 5.1 Page 10 weekly temple visits provided, and the provision of the Sony television channel in the smaller lounge. Feedback from other service users, and from comment cards, found that people are overall happy with the care provided. For instance, one visitor noted that since admission, their relative looks like a new person and hence they no longer have to worry about their well-being. The Mayfield DS0000017548.V289467.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All of them Quality in this outcome area is adequate overall. The home provides generally good standards of health-care support, and adequate standards of personal care and treatment of service users. Despite improvements, standards of medication are poor. Improvements are mainly needed to ensure that suitable records of service users’ support needs are in place, that medication procedures are always followed, and to address a few shortfalls in treating service users respectfully. EVIDENCE: Plans of care were in place within all care files checked. Three such plans were inspected in detail. Key points from these are that: • Plans are set up within two weeks of the service user moving in, which is reasonable. In one case, the plan was set up on the day of moving in. • Plans cover many areas of service users’ needs, such as with personal care, nutrition, and orientation. Other relevant needs, which may include clothing, finance, daily living routines, continence, and night care, were absent in the majority of cases. Some needs, such as with a service user’s nutrition, generalised too much (e.g. “eat healthily”) rather than stating what this meant in terms of supporting the individual. The Mayfield DS0000017548.V289467.R01.S.doc Version 5.1 Page 12 • Improvements are needed in these respects, to help staff to support each service user more individually. Plans are signed by service users or their representatives in some cases. This reflects service user feedback, and represents improvements on the last inspection. Risk assessments that covered actions to reduce risks, in respect of manual handling and some areas of individual need, were in place within individual files. Assessments in respect of falls, dependency, and nutrition, were not being used. Their use would allow for preventative action to be taken to reduce risks to individual service users in these respects. The manager must address this. It was positively noted that there are few accident records for service users in 2006. The records were appropriately detailed. Relatives’ and GP comments cards raised no concerns about health support in the home. Service users commented positively about healthcare support. Their comments included that they get appropriate support for their diabetes, that they kept their GP upon moving into the home, that the home responded promptly to an urgent health deterioration, and that chiropody is acquired every three to four months. Individual service users’ summary healthcare records were not up-to-date relative to the feedback received, such as with a lack of recording about chiropody input. The manager must address this, to help oversee the professional health support each service user is receiving. Checks of a sample of service users’ weight records found no concerning trends. One person’s low weight had risen well in the previous six months. Service users commented positively about how medication is given and handled in the home. The inspector observed no concerns about how staff organised the lunchtime medications. An improvement on the last inspection is that there is now an organised and established system of staff managing the medication administration. Checks were made of the medicine management of three service users. Whilst it was evident that medicines are given appropriately in many cases, the following issues were identified for improvement: • There were occasional missing signatures for medications that had been given, which can put service users at risk of receiving incorrect medications. The Mayfield DS0000017548.V289467.R01.S.doc Version 5.1 Page 13 • • • Two cases of changing the time of administering were identified. The manager agreed that this needs to be following discussion with the GP, to ensure that the change is appropriate. Movicol sachets were being used for all applicable service users from one person’s prescribed supply. This puts service users at risk of receiving incorrect doses and prevents straightforward stock control. Some liquid medications lacked a date of opening. This is necessary to prevent use established medication deterioration periods. There was individual guidance, signed by the GP, for each established service users about the circumstances for homely remedy use. It was found during this visit that homely remedies are also being used for one new service user, despite individual guidance not being established. A remedy had been used for twelve days, despite the guidance for other people stating a maximum of three days before consultation with the GP. This puts the service user at risk of inappropriate and potentially dangerous healthcare treatment, and fails to involve the GP appropriately. The manager must ensure that homely remedies are only offered following GP agreement, and that GP involvement is acquired after a suitable time period. Feedback from service users and relatives was very positive in respect of being well-treated by staff and receiving appropriate levels of privacy. The inspector observed appropriate staff treatment of service users during the inspection. Examples include staff taking time to provide a service user with support to drink, staff exchanging smiles and chat with service users, staff responding to requests such as for sweeteners in tea, and staff encouraging service users to use the toilet but accepting clear refusals. There were however occasional observations of disrespectful behaviour from staff and the manager. For example, dependent service users occasional had their mouths wiped without preceding verbal or eye-contact, bedroom doors were sometimes not knocked on before entry, and confused service users were sometimes ignored after repeated requests. These behaviours can cause upset and frustration to service users. The manager must ensure that these employee behaviours are eliminated. Service users’ standards of appearance was overall positive. People had for instance, well-fitting and clean clothing, and well-kept hair and nails. The Mayfield DS0000017548.V289467.R01.S.doc Version 5.1 Page 14 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): All of them. Quality in this outcome area is good overall. The home provides generally good standards in respect of service users’ daily lives and social activities. Improvements are being made to consult with service users more. Improvements are needed in respect of providing activities more consistently. EVIDENCE: Through comment cards, 5 out of 8 service users noted satisfaction with the activities provided in the home. One person was unsatisfied. This reflected comments from discussions. The new activity co-ordinator, who works in the afternoons half the week, was appreciated by some, including for the exercises provided. The manager noted that this person provides activities in bedrooms as well as the lounges. Plans are in place to advertise activities in advance, which will help service users to make decisions about involvement. Service users spoke of external activities. A number of Asian service users are supported by staff and the manager to visit a local temple weekly. Other service users noted that requests for trips out were made at a recent service user meeting, and that they are awaiting news on this. A few service users also confirmed that they go out by themselves. The Mayfield DS0000017548.V289467.R01.S.doc Version 5.1 Page 15 The home provides newspapers and television, including a dedicated Asian channel within a separate lounge. One service user noted that they can watch this channel from the early morning. It is required for activities provision to take place across the week, to ensure that appropriate activities are offered to service users at all reasonable times. Whilst there has been improvements in this respect, through the hiring of an activity person and the discussion with service users about activities, the inspector observed potentially-active service users sitting around a great deal, and notes that there is half a week when no dedicated activities take place. One visitor comment card also noted that the home made more effort to stimulate service users under previous ownership. There was positive feedback, from service users and visitors, about visitors being welcomed into the home. This matched observations during the inspection. There was positive feedback from service users about being able to exercise choice and control over their lives. One person noted that they can get up at an early hour to follow their religion, nobody mentioned about restrictions in their lifestyles, and no-one wanted to be more involved in the decision-making processes in the home. Inspection observations matched this, noting for instance that service users’ choices are respected, and walking frames are left within easy reach to allow self-mobilization. Service users’ comments about the food was mainly positive. Asian service users were entirely satisfied, which was found from some people to be due to consultation about the menu and having the menu easily available. The home employs a separate cook in this respect, and provides meat and vegetarian options. Some service users noted that the menu on display on a board in the main lounge is not always accurate. This should be addressed. The lunch, a roast dinner, was sampled during the inspection, and was found to be of a clear and pleasant taste. This reflects the cook’s experience and the use of fresh food as found in the kitchen. The inspector observed that meals are given to service users based on asking each service user as to what and how much they would like. This enables individual choices. A choice of similarly-styled meals is now also provided. Service users were given time and support to finish meals. Menu records showed sufficient nutritional provision. The Mayfield DS0000017548.V289467.R01.S.doc Version 5.1 Page 16 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 and 18. Quality in this outcome area is adequate overall. The home has good standards of accepting and addressing complaints, but poor standards of protection from abuse. Improvements are needed in respect of appropriate recruitment checks, appropriate notification to the CSCI of incidents, and an appropriate policy. EVIDENCE: Service users commented positively about the complaint processes in the home, including that it is effective. One person cited a recent issue that they were awaiting feedback from the manager. Staff showed awareness of noting and addressing complaints from service users. The complaints book showed six complaints since the last inspection, from both service users and relatives. Records showed prompt responses and that outcomes included learning for the service. This represents a significant improvement on the last inspection. Visitors’ comment cards showed that most are aware of the complaints procedure and that few have had to complain. An updated complaints summary was available, at the start of the inspection, in the entrance hall. A copy was seen to be available in one service user’s room. The manager noted that a translation for Asian service users is being addressed. Service user feedback included that they feel safe in this home. One person noted that they are not rushed, as was also observed. The Mayfield DS0000017548.V289467.R01.S.doc Version 5.1 Page 17 Training records showed that some staff have received training on the prevention of abuse. Feedback and records showed that all staff, including cooks and cleaners, are to receive refresher training in this respect by midsummer, which is a positive commitment. The adult protection policy was checked. Whilst relevant, it was found to need adjustments in respect of: • Referring to and working within the local borough’s adult protection guidance, • Informing the relevant social work department of abuse allegations, • Noting common forms of abuse, and • The organisation’s procedures in respect of suspending accused staff and safeguarding involved people in the event of an allegation. Two issues arose from this inspection that the inspector judges to have potentially put service users at unnecessary risk of abuse. One is referred to under standards 31-36 in respect of recruitment checks. The other refers to poor formal reporting procedures in respect of a night-time incident. The manager explained how appropriate actions to minimise further risk have been taken. She must ensure that any further incidents that put any service user at significant risk are reported without delay to the CSCI. The Mayfield DS0000017548.V289467.R01.S.doc Version 5.1 Page 18 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, 23, 24, 25 and 26. Quality in this outcome area is good overall. Gradual improvements continue to be made, in particular on this occasion with making the shower room more easily usable. Some minor improvements are needed, particularly with fitting fire-release mechanisms on bedroom doors where needed. EVIDENCE: Service users’ comments about the environment were positive. Comments included that the home is kept clean, that the home is kept warm enough, and that bedrooms are fine. One person noted grills have been placed over many radiators. This minimises risks of accidents from the radiators. A tour of communal areas and a few bedrooms found no significant concerns. Improvements have been made to the décor of some corridors. The entrance hall has new, tiled flooring. The shower room downstairs has been re-tiled and expanded, and is now used as a walk-in or wheel-in facility, which improves services to service users. The manager also pointed out that previouslyslamming doors have been adjusted, and cushioned, to prevent excess noise. The Mayfield DS0000017548.V289467.R01.S.doc Version 5.1 Page 19 The laundry area has two industrial washing and drying machines. Systems are in place to ensure that service users’ clothing is returned to them. Maintenance issues in this room have been addressed. There were no concerns with standards of cleanliness and infection control from this inspection. The minutes of the last staff meeting showed detailed attention to infection control management. There are a couple of issues that must be addressed: • The toilet seat in the main toilet next to the lounge must be prevented from wobbling, to minimise risks of accidents. • Some bedroom doors are wedged open, at the preference of service users who are using the room. This however presents a possible fire risk. Management must install door-release mechanisms where the risk is significant, with the approval of the fire authority. The inspector also notes that some areas of the home are quite cramped. For instance, the dining area has tables close together, which some service users need staff support to negotiate, and that there is no easily-accessible storage area for hoists. This should be addressed. The Mayfield DS0000017548.V289467.R01.S.doc Version 5.1 Page 20 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): All of them. Quality in this outcome area is poor overall. The home provides adequate standards of staffing that is let down by poor recruitment practices and insufficient NVQ training. Improvements must be urgently made in these respects. EVIDENCE: There were reasonable comments made about staff by service users, visitors, and health professionals. A few people commented that communication amongst staff can be an issue. The manager explained how this is being addressed, including through the use of an assessor of English communication needs who will shortly be visiting the home. There were no concerns about staffing levels from the inspection. Cover for absence is organised within the staff team, as observed during the visit. Service users’ and visitors’ feedback found that there are enough staff always working in the home. Rosters confirmed this, with levels found to have slightly increased since the last inspection. The increase is that there is now a second cleaner working during the week along with the part-time activities worker. The inspector checked through the recruitment files of three recentlyappointed staff members. Checks of these found that all had completed application forms. All had two written references that pre-dated their start dates, as is appropriate. The Mayfield DS0000017548.V289467.R01.S.doc Version 5.1 Page 21 Issues arose with the Criminal Record Bureau (CRB) disclosures. A formal letter was sent, shortly after the inspection, to the directors after it was found that one staff member had been employed despite concerns being raised from their CRB disclosure. Their employment potentially put service users at risk of abuse. Appropriate action was consequently and promptly taken by management. Another staff member’s CRB was dated after their start date, whilst there was only evidence of CRB application in the third staff member’s case. The former case was found to be an administrative error. Management must ensure that CRB disclosures are received before the employment of new staff, and that appropriate actions are taken if any concerns arise from the disclosure information. Induction records were seen for two new staff members. The records were ongoing and within the timescales of the home’s policies. The process showed evidence of conforming with the national induction standards. The manager noted that she is due to attend a workshop hosted by the national induction body shortly, to ensure that the processes are fully up-to-date. The training certificates for four staff were checked through for attendance of key courses. It was found that all received moving & handling training in 2005, and that two had training in food hygiene. One had up-to-date 1st aid training. The manager explained that she is planning to update staff in key training areas, for which some documentation was in place. The manager must ensure that this training occurs where needed, and that training records in this respect are kept up-to-date. This was also required from the previous inspection. The manager stated that three care staff have relevant NVQ qualifications. Other care staff are being enrolled as required. This is a long-standing requirement that must be promptly addressed. The Mayfield DS0000017548.V289467.R01.S.doc Version 5.1 Page 22 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, 33, 35, 37 and 38. Quality in this outcome area is adequate overall. There are adequate and improving standards of management and administration in place in the home. Further improvements are particularly needed in respect of the manager applying for CSCI registration, with upholding confidentiality of records, and with acquiring a gas safety check. EVIDENCE: The manager has worked at this home in this role since the summer of 2005. She has two years’ nursing experience. She used to work in another of the organisation’s homes. She explained that she is currently undertaking the relevant management qualifications (NVQ4 and RMA), which should finish by the summer. It remains for the manager’s application for registration with the CSCI to be submitted. This is necessary to enable the CSCI to formally judge the appropriateness of the manager in her role. This must be promptly addressed. The Mayfield DS0000017548.V289467.R01.S.doc Version 5.1 Page 23 There was some feedback received about the manager. One service user noted that the manager discusses issues with him, whilst another stated that she deals with issues when asked to. Staff noted that the manager provides support. Recent staff meeting minutes show that the manager leads staff in terms of health and safety and about how to treat service users. Feedback from service users was positive in respect of whether or not the service is run in their best interests. The recent service users’ meeting was cited as an example. The manager noted that family members were also invited to this, but none attended. She is planning further meetings, including for Asian service users. The manager had clear ideas on how the service needs to develop. She uses staff meetings and supervisions to gain staff feedback, and showed the November 2005 service user surveys in respect of auditing service users’ opinions. She noted that individual feedback about this was provided to service users and their representatives. She will develop the necessary written report on this process in due course. A development plan is additionally recommended. The manager stated that monthly proprietors’ visit reports are fedback to her, although she is not shown the reports. These reports must be additionally sent to the CSCI for consideration. The service looks after the money of two service users based on their specific needs. Other service users look after their own money, or have representatives who do this for them. Suitable records and receipts in respect of the lookedafter money were seen. One improvement is needed with the records kept in the home. The complaint book was left available in the hallway, which prevents complainants from making complaints confidentially. This was discussed with the manager, who agreed to implement a system of confidentiality without withdrawing complaint forms from being available for use. The home has systems in place to uphold suitable standards of health and safety. These were seen to include a monthly health and safety audit, risk assessments for the building and against fire, and regular internal tests of water temperatures and fire systems. Fire training and drill records are also in place. The manager had identified further training needs in this area. One improvement with health and safety is needed, in respect of there being no professional gas safety certificate that is up-to-date. The Mayfield DS0000017548.V289467.R01.S.doc Version 5.1 Page 24 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 2 X 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 2 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 X 18 1 2 3 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 1 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X 2 2 The Mayfield DS0000017548.V289467.R01.S.doc Version 5.1 Page 25 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 OP1 Regulation 4, 12(4)(b) Requirement The statement of purpose needs to be translated into a relevant language so that the information can be given to service users and their representatives whose first language is not English. Previous timescale of 15/1/06 not met. The service users guide needs to be translated into a relevant language so that the information can be given to service users and their representatives whose first language is not English. Previous timescale of 15/1/06 not met. Information about how to contact the local office of the Commission for Social Care Inspection and local Social Services and health care authorities needs to be translated into a relevant language for service users and their representatives whose first language is not English. Previous timescale of 15/1/06 not met. DS0000017548.V289467.R01.S.doc Timescale for action 01/06/06 2 OP1 4, 12(4)(b) 01/06/06 3 OP1 12(4)(b) 01/06/06 The Mayfield Version 5.1 Page 26 4 OP3 14(1)(b) For the individuals referred to the home through Care Management arrangements, the home must obtain a summary of the care management assessment and a copy of the care plan in advance of the placement, where available, to help establish whether the home can meet the potential service user’s needs. Previous timescale of 15/1/06 not met. The manager must ensure that service users who have significant dementia care needs are not admitted into the home unless the home successfully applies for registration in this respect. The manager must ensure that each service user’s individual plan of care includes all relevant care needs, and that it states what the individual support the service user needs is. Plans lacked sufficient details in these respects. The manager must ensure that written assessments in respect of falls, dependencies, and nutrition, are used for applicable service users. Individual service users’ summary healthcare records must be kept up-to-date. Medicines must be administered as prescribed. Previous timescale of 16/11/05 not met. The manager must ensure that all medications are signed for when administered. The manager must ensure that service users are only given the specific medication that is DS0000017548.V289467.R01.S.doc 01/06/06 5 OP4 14(1)(d) 15/05/06 6 OP7 15 01/08/06 7 OP8 13(4), 15 01/08/06 8 9 OP8 OP9 17(1)(a) s3 pt 3(m) 13(2) 01/06/06 01/06/06 10 11 OP9 OP9 13(2) 13(2) 01/06/06 01/06/06 The Mayfield Version 5.1 Page 27 12 13 OP9 OP9 13(2) 13(2) 14 15 OP10 OP11 12(4)(a) 17(1)(a) sch 3 prescribed to them, and not any identical medication from another service user’s supply. The manager must ensure that all liquid medications have a recorded date of opening. The manager must ensure that homely remedies are only offered following GP agreement, and that GP involvement is acquired after a suitable time period. The manager must ensure that service users are treated respectfully at all times. The service user and their family’s wishes in relation to illness and death must be recorded in their care plan. Previous timescale of 15/1/06 partially met. It is required for activities provision to take place across the week, to ensure that appropriate activities are offered to service users at all reasonable times. The adult protection policy must be adjusted in respect of: • Referring to and working within the local borough’s adult protection guidance, • Informing the relevant social work department of abuse allegations, • Noting common forms of abuse, and • The organisation’s procedures in respect of suspending accused staff and safeguarding involved people in the event of an allegation. The manager must ensure that any further incidents that put any service user at significant risk are reported without delay DS0000017548.V289467.R01.S.doc 01/07/06 01/06/06 01/06/06 01/08/06 16 OP12 16(2)(m, n) 01/07/06 17 OP18 13(6) 01/08/06 18 OP18 37 01/05/06 The Mayfield Version 5.1 Page 28 19 OP18 12(1), 13(6), 18(1c) to the CSCI. The registered people must provide training to all staff not just seniors for adult protection. Previous timescales of 31/1/04, 1/4/05, 1/9/05 and 15/1/06 partially met. The toilet seat in the main toilet next to the lounge must be prevented from wobbling, to minimise risks of accidents. Management must install doorrelease mechanisms to bedrooms doors, where the risk from propping open the doors is significant, with the approval of the fire authority. The registered people must ensure that at least 50 of care staff have qualified at NVQ level 2 in care. Previous timescales of 1/1/05, 1/12/05, and 15/3/06 not met. Management must ensure that Criminal Record Bureau disclosures are received before the employment of new staff, and that appropriate actions are taken if any concerns arise from the disclosure information. The manager must ensure that all staff have attended the planned first aid and food hygiene training. Previous timescales of 1/10/04, 1/3/05, 1/9/05 and 15/2/06 partially met. The training needs of the service users must be documented and the documentation kept up to date. All staff must have relevant training that is up to date. DS0000017548.V289467.R01.S.doc 15/04/06 20 OP19 23(2)(b) 15/05/06 21 OP19 13(4), 23(4) 01/08/06 22 OP28 18(1)(c) 15/04/06 23 OP29 10(1), Msc Amd Rgs 2 01/05/06 24 OP30 13(4), 18(1)(c) 15/04/06 25 OP30 18(1)(c) 01/09/06 The Mayfield Version 5.1 Page 29 26 OP31 8(2)(a, b) Previous timescales of 15/1/05 partially met. The new manager of the home must apply for registration with CSCI as soon as possible. Previous timescale of 15/1/06 not met. The manager must ensure that a report, that summarises audited people’s views about the care provided in the home, is produced and circulated following each quality assurance audit. Copies of monthly proprietors’ reports must be sent to the CSCI shortly after the production of each report. The manager must implement a system of keeping complaint records confidential, without withdrawing complaint forms from being available for use. An up-to-date professional gas safety certificate must be in place within the home. 01/06/06 27 OP33 24 01/09/06 28 OP33 26 01/06/06 29 OP37 12, 22 01/06/06 30 OP38 13(4), 23(2)(c) 01/06/06 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 Good Practice Recommendations The manager should ensure that the home’s pre-admission assessment forms are always fully completed, and that the assessment takes place well in advance of offering a placement. The manager should ensure that menus in the lounge are kept up-to-date. Management should address the low space issues in some areas of the home. It is recommend that all cooks attend the thorough, 4-day, DS0000017548.V289467.R01.S.doc Version 5.1 Page 30 2 3 4 OP15 OP19 OP30 The Mayfield 5 OP33 food hygiene training. A development plan for ongoing service improvements in the home is recommended. The Mayfield DS0000017548.V289467.R01.S.doc Version 5.1 Page 31 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 The Mayfield DS0000017548.V289467.R01.S.doc Version 5.1 Page 32 - 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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