Inspection on 14/06/05 for The Mayfield

This inspection was carried out on 14th June 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 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 12/04/06

The Mayfield 03/11/05

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 Richard Adkin Unannounced 14 June 2005, 11:50h00 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 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 G62-G11 S17548 The Mayfield V233134 140605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Mayfield Address 6 Alicia Avenue, Kenton, Harrow, Middlesex, HA3 8AL. Telephone number Fax number Email 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 Kiren Nathwani Vacant CRH PC Care Home only 23 Category(ies) of OP Old Age registration, with number of places The Mayfield G62-G11 S17548 The Mayfield V233134 140605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 3 December 2004 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 of mixed gender. There were two 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 two further homes nationally. The new manager has just commenced (Patrice Martin) and is undergoing a period of induction. The home is located in a residential area of Kenton, fifteen minutes walk from the underground station. Nearby on the main Kenton Road there are parades of small shops, hairdressers, cafes and pubs, churches, a temple, and bus routes. There is unrestricted parking access outside of the home. The home is a large, converted and extended house. Accommodation for the service users is provided on the ground and first floor. Access upstairs is by stair-lift or stairs. All the bedrooms, except one, are single occupancy, most with en-suite facilities, and all fully-furnished. Communal toilets are located close to the two separate lounge areas. The home has one bathroom upstairs, and a little-used shower room downstairs. At the rear there is a patio and a large garden. The Mayfield G62-G11 S17548 The Mayfield V233134 140605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Unannounced Inspection took place on a mid-week day in June with the intention of primarily looking at the requirements and recommendations that arose from the previous inspection of 3 December 2004. The Inspector spent time looking at records and procedures. The Inspector also spent time talking with residents and this was facilitated by an interpreter for some of the Asian residents. Feedback was also received from staff members and a relative visiting the home at the time of the inspection. The area manager kindly made herself available throughout the inspection as the new manager was undertaking her induction. The Inspector thanked everyone at the home for their help with the inspection. What the service does well: What has improved since the last inspection? A new manager has just commenced at the home. The Managment of continence issues has improved through detailed recording and follow-up taking place with the Continence Advisory Service. The handover information from each shift has improved. A reasonable time is allowed for handover. Recording has improved and is more upto date. Ongoing improvements are taking place in the decoration of the home. The Mayfield G62-G11 S17548 The Mayfield V233134 140605 Stage 4.doc Version 1.30 Page 6 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 G62-G11 S17548 The Mayfield V233134 140605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection The Mayfield G62-G11 S17548 The Mayfield V233134 140605 Stage 4.doc Version 1.30 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 standard(s) 2, 4 Progress has been made to adhere to the admission procedure and to ensure there is an assessment prior to people moving into the home. There is now more assurance that the care needs of residents will be met. EVIDENCE: Evidence was seen on files looked at by the Inspector of residents’ care plans being in place and assessments taking place prior to admission. Signing and dating needs to be tightened up for documentation as this was not complete on some of the records looked at by the Inspector. Thought also needs to be given to targeting training for staff in areas of specific needs for service users such as dementia care. The Mayfield G62-G11 S17548 The Mayfield V233134 140605 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 Some progress has been made on improving arrangements to ensure that the healthcare needs of residents are identified and met. The lack of full risk assessments however places residents at potential risk. EVIDENCE: Individual service user plans of care and supporting records have been improved upon since the last inspection; daily and monthly updates are taking place and are more detailed to enable staff to provide appropriate support for each resident. Some of the records viewed were not signed by a senior staff member or the resident or their representative. There was a shortfall on some files inspected of a general assessment of risks and how these will be addressed. The assessments need to include what the home will do to reduce the risks, noting when each aspect of this is being achieved. The individual toileting needs of residents is now being more proactively followed up with the involvement of the continence advisory service and record keeping is up to date. The Mayfield G62-G11 S17548 The Mayfield V233134 140605 Stage 4.doc Version 1.30 Page 10 A ‘pressure relief policy’ that addresses how staff will support residents in respect of pressure relief, before the involvement of district nurses takes place, needs to be produced. The report of the CSCI pharmacy inspector was not accessible and it was not clear if the remaining requirements were being fully met. The Mayfield G62-G11 S17548 The Mayfield V233134 140605 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and 15 Social activities are in place but should be further developed for Asian residents. Meals are nutritious and balanced and offer a healthy and varied diet for residents. EVIDENCE: Some residents kindly showed the Inspector around the home and seemed proud of the establishment. Activities in the home should be more readily advertised in the home. The manager must ensure that more cultural activities involving external organisations are set up for Asian service users. Bajans, however, are now happening with tapes and there is a dedicated area for Hindu religious items. A system of providing a choice of meals before meals are served, is being considered. The quality of food provided for residents at lunchtime looked good, varied and nutritious. Positive comments were received from residents about the food particularly around the Asian vegetarian option. The Mayfield G62-G11 S17548 The Mayfield V233134 140605 Stage 4.doc Version 1.30 Page 12 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 standard(s) 18 Residents do not have adequate protection from harm due to the lack of staff training on protection of vulnerable adult. EVIDENCE: Adult Protection Training is planned for 2 seniors in the next month. However, this training needs to be followed through for all staff members at the earliest opportunity. There was no evidence seen to show how adult protection issues are included within the home’s induction training record, which needs to be addressed within future induction records. The Mayfield G62-G11 S17548 The Mayfield V233134 140605 Stage 4.doc Version 1.30 Page 13 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 standard(s) 19 and 25 Some improvements to the fabric of the home have been made. There are some matters outstanding that put residents at risk of serious harm particularly around access to the garden. EVIDENCE: Improvements to the home are ongoing and a plumber was present during the inspection undertaking maintenance work. The Inspector went into the back garden with a resident who struggled to gain access to the garden from the main lounge. A number of areas require attention. In particular: • • • The garden furniture must be replaced with sturdier equipment that supports service users with getting up from a seated position. Doors need to be on restrictors to avoid excessive slamming noise. Consideration should be given to fencing off the far corner of the garden which is uneven. G62-G11 S17548 The Mayfield V233134 140605 Stage 4.doc Version 1.30 Page 14 The Mayfield • • • • • • • The hallway carpets must be thoroughly cleaned to get rid of any staining and paint marks or be replaced. Bedroom (No 9) has a hand-sized hole in the flooring near the sink and has some remaining boxing of pipes near the hole that requires tiling over. Carbon monoxide detectors must be fitted next to the boilers, particularly in the lounge used by Asian residents. The boiler in that lounge must be boxed in and decorated The back area must be tidied up where there has been a bonfire. The disused items, namely the oven, fridge, broken chairs, boxes and metal should be removed and disposed of. A grab rail must be reinstalled by the back door to facilitate access to and from the back garden. Work has commenced on fitting guards to radiators but needs to be completed and the risk assessment needs to be reviewed in this area. Bars that are broken off and covered with tape on the fire escape at the back of the home should be replaced. The Mayfield G62-G11 S17548 The Mayfield V233134 140605 Stage 4.doc Version 1.30 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28 and 30 Training needs to be improved in the home for care staff in order to ensure that the standard of care provided is raised to better meet the needs of residents. EVIDENCE: Training records were looked at by the Inspector. The new manager and registered people must ensure that at least 50 of care staff employed at the home have qualified at NVQ Level 2 in Care. This is not the case at the moment. One family member visiting the home did comment that the experience and more training of staff could be raised a further level. First aid training is planned and the manager must ensure that all staff have undertaken this essential training. Food hygiene training needs to be undertaking if a staff member is handling food. Likewise a foundation programme (as per the National Training Organisations) must be set up and used for new staff within their first 6 months at the home as this has not happened. The Mayfield G62-G11 S17548 The Mayfield V233134 140605 Stage 4.doc Version 1.30 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33 and 38 It is positive that there is a new manager in post and registration should be applied for the earliest opportunity to ensure continued leadership in the home and improve quality assurance. Risk assessments in several areas need improving to protect residents and safeguard their health, safety and welfare. EVIDENCE: The new manager had just started at the home and was going through an induction programme of the working operations of the home. The new manager needs to be registered with CSCI at the earliest opportunity. The manager is trained nurse, must also gain a Certificate in Management. The Mayfield G62-G11 S17548 The Mayfield V233134 140605 Stage 4.doc Version 1.30 Page 17 Quality assurance needs to be improved involving residents, carers and stakeholders. Consideration should be given to holding service user and family meetings as a means of assessing quality and providing opportunity to feedback, in order to develop quality assurance and continue to involve stakeholders in raising standards in the home. The manager and area manager must strengthen risk assessments for any service user at risk in the home and the new keypad system installed by the front door must be in working order. Communication systems and the handover of information have improved since the last inspection with daily verbal handover taking place. Constructive information was also seen in the handover book by the Inspector. Some health and safety aspects have been addressed such as fire drills, however the testing of the water systems for legionella was out of date. The Mayfield G62-G11 S17548 The Mayfield V233134 140605 Stage 4.doc Version 1.30 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 x 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 1 x x x x x 2 x STAFFING Standard No Score 27 x 28 2 29 x 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 2 x 2 x x x x 1 The Mayfield G62-G11 S17548 The Mayfield V233134 140605 Stage 4.doc Version 1.30 Page 19 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation Requirement Timescale for action 1/8/05 2. OP7 13(4) 14(2) 15(2) 17(1)(a) Schedule 3 Part 3 Individual plans must be dated and signed by a senior staff member and the resident or a representative. (previous timescale not met) A general assessment of risks, 1/9/05 and how these will be addressed, must be in place on each residents file. This might include depending on likelihood and severity, falls, nutrition, wandering, absconding, aggression, vulnerability, pressure sores, and language-barriers. The assessments must include what the home will do to reduce the risks, noting when each aspect of this has been achieved (Previous timescale not met). A pressure relief policy, that addresses how staff will support residents in this respect before district nurses become involved, must be written and used. A copy should be sent to CSCI. (Previous timescale not met). The registered people must 3. OP8 13(1) 18(1)c 1/9/05 4. OP9 13(2) 1/8/05 Version 1.30 Page 20 The Mayfield G62-G11 S17548 The Mayfield V233134 140605 Stage 4.doc 5. OP12 16(2)(m) 16(3) 12(1) 6. OP18 7. OP18 13(b) 18(1)c(i) 8. OP19 23(2)(bd) 9. OP19 13(4) ensure that the remaining requirements of the CSCI Pharmacy Inspectors report are met in a timely manner. - Report not available. (Previous timescales not met). The manager must ensure that more cultural activity involving external organisations is set up for Asian service users. The registered people must provide training on Adult Protection. Training is planned for 2 seniors in July and this needs to be followed through for all staff members. (Previous timescale not met). There was no evidence to show how adult protection issues are included within the homes induction training record. This must be addressed within future induction records. (Previous timescale not met). The following minor maintenance issues were identified during the inspection. They must be addressed: 1. The hallway carpets must be thoroughly cleaned to rid of any staining and paint marks or replaced. 2. Bedroom (no 9) has a handsized hole in the flooring near the sink and has some remaining boxing of pipes near the hole that requires tiling over. (Previous timescale not met). Carbon monoxide detectors must be fitted next to boilers, particularly in the lounge for Asian residents. 1/9/05 1/9/05 1/8/05 1/9/05 1/8/05 10. OP19 13(4) The boiler in that lounge must be boxed in. Bars that are broken off on the 1/9/05 fire escape must be replaced. Version 1.30 Page 21 The Mayfield G62-G11 S17548 The Mayfield V233134 140605 Stage 4.doc 11. OP19 23(2)(b) 12. 13. OP19 OP25 13(4) 13(4) The back area must be tidied up 1/9/05 where there has been a bonfire. The disused oven, fridge, chairs, boxes and metal must be removed. A grab rail must be reinstalled by 1/9/05 the back door to facilitate access to and from the back garden. The manager must ensure that 1/10/05 radiators either have a guaranteed low surface temperature or are fitted with guards. Work has commenced but needs to be completed. (Previous timescales not met). 14. OP25 15. OP28 16. OP30 17. OP30 18. OP30 The risk assessment in this area, last reviewed in 6/10/03, must also be updated. 23(2)(c, The flow of hot water to the bath e) in Room 13 must be improved upon, both in terms of water volume and the time it takes for the water from the hot tub to come out as hot. (Previous timescale not met). 18(1)c The registered people must ensure that at least 50 of care staff have qualified at NVQ Level 2 in care. (Previous timescale not met). 17(2) The manager must ensure that Schedule induction records for all future 4 part 6(f) staff include their names. 18(1)c(i) (Previous timescale not met). 18(1)c A foundation training programme as per the National Training Organisations guidance, must be set up and used for new staff within their first six months at the home. (Previous timescale not met). 13(4) The manager must ensure that 18(1)c all staff have attended the planned first aid and food hygiene training. (Previous timescale not met). G62-G11 S17548 The Mayfield V233134 140605 Stage 4.doc 1/9/05 1/12/05 1/9/05 1/9/05 1/9/05 The Mayfield Version 1.30 Page 22 19. 20. OP31 OP33 24(2) 21. OP38 13(4) 14(2) 15(2) 22. OP38 13(4) 23(1)(b)( 4) 23. OP38 12(1) 13(4) 24. OP38 13(4) The new manager in post must be registered with CSCI at the earliest opportunity. General quality reviews at the home must result in a report which is made open to service users, carers and representatives and the inspecting authority. (Previous timescales not met). A written risk assessment of the residents needs, including actions for staff to take to minimise risk, must be completed for any resident at risk of leaving the home without being considered safe to do so. (Previous timescale not met). A keypad system has been installed at the front door to prevent vulnerable residents from leaving the home alone without appropriate notification or support. However it is not functioning and needs repairing. The general risk assessments on file for the home remain dated from June 2003. They require reviewing and updating. (Previous timescale not met). The testing of the water systems for legionella are out of date and needs to be updated. 1/9/05 1/9/05 1/8/05 1/8/05 1/9/05 1/8/05 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 OP2 OP4 OP12 Good Practice Recommendations The Manager should ensure that, if used, the homes service user assessment forms are dated, and signed. Improvements could be made by targeting training for staff in the specific needs of some service users (eg dementia care). Activities in the home should be advertised in advance. G62-G11 S17548 The Mayfield V233134 140605 Stage 4.doc Version 1.30 Page 23 The Mayfield 4. 5. 6. 7. 8. 9. OP15 OP19 OP19 OP19 OP33 OP33 The system of providing a choice of meals before the meals are served is being explored and should be adopted. The garden furniture should be replaced with sturdier equipment that supports service users, with getting up from a seated position. Doors need to be on restrictors to avoid excessive slamming noise. Consideration should be given to fencing off the far corner of the garden which is uneven. Consideration should be given to holding service user and family meetings as a means of assessing quality and providing feedback forums. The manager and area manager are advised to make records of any time that either visits the home out of hours, as part of the general records of when they are working at the home. The Mayfield G62-G11 S17548 The Mayfield V233134 140605 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection 4th Floor, Aspect Gate 166 College Road Harrow, Middlesex 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 G62-G11 S17548 The Mayfield V233134 140605 Stage 4.doc Version 1.30 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. 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