Inspection on 03/11/05 for The Mayfield

This inspection was carried out on 3rd November 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 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 Virginia Allen Unannounced Inspection 3rd November 2005 08:00 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.V263257.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. The Mayfield DS0000017548.V263257.R01.S.doc Version 5.0 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.V263257.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th June 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 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 (acting) 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 is a parade of small shops, with a hairdresser, cafes, pubs, churches, and a temple. There is a bus route. There is unrestricted parking outside of the home. The home is a large converted and extended house. Accommodation for the service user 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 little used shower room downstairs. At the rear of the house is a patio and a large garden. The Mayfield DS0000017548.V263257.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on a bleak Thursday in November. The inspector talked with the acting manager, the area manager, several staff members, several service users and one relative. The home’s records were inspected and the inspector toured the facility. The inspector would like to thank those who participated in the inspection for their help. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Mayfield DS0000017548.V263257.R01.S.doc Version 5.0 Page 6 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.V263257.R01.S.doc Version 5.0 Page 7 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): 1,3,5,6 Prospective service users are given the information they need to make an informed choice about where they live but not always in a suitable format. No service user moves into the home without having their needs assessed and being assured that these needs will be met. Prospective service users and their relatives have the opportunity to visit the home and assess its quality. EVIDENCE: The inspector viewed the home’s statement of purpose. This covered the required information such as aims, objectives, philosophy of care, service and facilities and terms and conditions of the home. The statement of purpose informs the prospective service user about the physical lay-out of the home. However, the statement of purpose had not been reviewed for several years and needs updating. It is written in plain English format. There are 7 Asian service users; therefore, the statement of purpose needs to be translated into The Mayfield DS0000017548.V263257.R01.S.doc Version 5.0 Page 8 Gujarati for the Asian service users and their relatives to be able to access with ease. The service users’ guide is written in plain English and is available for prospective service users and their relatives. It describes the services provided, the physical layout of the home, the qualifications of the manager and staff, the complaints procedure and the most recent inspection report. Again this had not been reviewed for several years and needs to be updated. Information relating to the manager is not applicable. It needs to be translated into Gujarati for the Asian service users and their relatives. The manager informed the inspector that the service users and their representatives are given information in writing about how to contact the local office of CSCI, local social services and health care authorities. However, this also needs to be translated into Gujarati for the Asian service users and their relatives. The manager informed the inspector that new service users are only admitted on the basis of full assessment that identifies whether or not the home can meet the needs of the service user. When a service user is admitted through the care management process, information is forwarded through social services. The records showed that some of the older service user assessments lacked detail. This is being rectified. More recent assessments cover the range of topics recommended in the regulations. Care plans showed that they were informed by the assessments. The inspector was told that prospective service users and their families are encouraged to visit the home before a decision is made to move in. After a decision is made, there is a trial period of four weeks. Prior to admission the manager visits the prospective service user in their own home or in hospital. All information is offered to the prospective service user to help them make a decision about where they want to live. The Mayfield does not offer intermediate care or a rehabilitation service. The Mayfield DS0000017548.V263257.R01.S.doc Version 5.0 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 the following standard(s): 7,9,10,11 New service users’ health, personal and social care needs are set out in an individual plan of care. The new format needs to be provided to long term residents also. The system of medication administration needs tightening. Service users feel they are treated with respect and their right to privacy is upheld. At the time of illness or death, staff treat them and their family with care, sensitivity and respect. EVIDENCE: The inspector viewed the individual files of 5 service users. The service users’ plans were generated from the assessments. More recent admissions had more comprehensive assessments and the new care plans cover all of the topics recommended in the regulations. The care plans give the detail of the action to be taken to ensure all aspects of physical, mental and social health needs are met. However, service users who had been resident in the home for The Mayfield DS0000017548.V263257.R01.S.doc Version 5.0 Page 10 some time need more information to be gathered and documented in the assessment and new care plans devised to reflect the assessment. The service user files contained documented evidence that service users have regular appointments with a variety of health professionals. However, the ensuing recommendations from the health professionals need to be documented in the care plans. The inspector noted that the care plans are reviewed monthly. This is good practice. However, along with the reviewer, the service user needs to sign the monthly review to show their agreement to the plan. If they are unable to sign this must be done by their representative. During the inspection staff were observed giving out medication. MARS sheets were checked and the inspector talked with staff. The mars sheets needed tightening, as there were some gaps where signatures or coding needed to be filled in. A person who was trained to give medications was taking the medication from the blister packs; however, they were being passed onto another staff member for distribution. This practice needs to cease. Only the person who takes the medication out of the blister pack must distribute that medication to the service user. The Pharmacy inspector has recently visited the home and made a separate report. The inspector observed that during the inspection the service users were treated with dignity and privacy. Staff were seen to knock on the service user’s door before entering. The manager reported that the health professionals see service users in the privacy of their own rooms. Relatives are also encouraged to visit and to spend time with the service user in their room. According to the manager, service users have access to a portable telephone that can be used in the privacy of their own room. Service users were seen during the inspection to be wearing their own clothes and to be called by the name they have chosen. This is documented in the care plan. The inspector talked with the manager about their palliative care practice. She was assured that the home makes every effort to ensure that the service user is kept free from pain. In the event of illness or death the home endeavours to meet the needs of the service user in accordance with the wishes of the service user and their family. However, these wishes need to be recorded in the service user care plan. The Mayfield DS0000017548.V263257.R01.S.doc Version 5.0 Page 11 Service users are able to spend their final days in their own rooms and the home supports staff and service users who wish to offer support to the dying. The inspector was given an example of how this had occurred recently. Family are encouraged to stay as long as they wish with the service users in their own room. The manager of the home, the GP and the social worker review the needs of service users when those needs are changing. If the home can no longer meet the needs of the service user, alternative accommodation is sought. The manager was able to give the inspector a recent example of this practice. The Mayfield DS0000017548.V263257.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): 13,14 Service users maintain contact with family, friends and representatives. They are encouraged to exercise choice and control over their lives. EVIDENCE: Service users are encouraged to have visitors at any time. Records are kept of visitors to the home. Service users are encouraged to see their visitors in the privacy of their own rooms. If they do not wish to see a visitor the manager of the home agreed that they would support them. Relatives and friends are given written information about the home’s policy on maintaining relatives’ and friends’ involvement with service users when they move into the home. However, this also needs to be translated into Gujarati. Local community groups are involved with the home. Harrow School send young people to talk with the service users. A priest visits regularly and there are weekly music sessions with two different entertainers. Service users are taken on outings. They go for walks, drives and recently went on a riverboat cruise. Asian service users celebrate Diwali and there is a dedicated area for Hindu religious items. Bajan CDs are played. The Mayfield DS0000017548.V263257.R01.S.doc Version 5.0 Page 13 The manager explained how choices are offered to the service users to help maximise their capacity to exercise personal autonomy. Service users are given to opportunity to handle their own finances. Two service users in the home take this opportunity. Other options available to service users are that their family organise their finances, a solicitor or a power of attorney. The service user’s chosen method is recorded. The inspector noted that service users’ bedrooms were decorated with their personal belongings. The rooms were homely. During the inspection the manager showed the inspector that she was familiar with and facilitated the Data Protection Act 1998. The Mayfield DS0000017548.V263257.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): 16,18 The complaints procedure needs to be tightened up to ensure the service user and their relatives and friends feel confident that they are listened to and taken seriously. Service users are protected from abuse and their legal rights are protected. EVIDENCE: The home has a complaints procedure that is documented in the policy and procedure manual. However, until recently copies were not given to the service user or the relatives. This has been rectified and copies placed into the new service user pack. However, copies still need to be given to the service users that are already resident in the home and their relatives. The manager assured the inspector that all complaints are dealt with in 28 days and recorded in the complaints file. There was one complaint in the file and this had been dealt with according to the correct procedure. However, the inspector spoke with the relative of a service user who had made four complaints since the last inspection. None of these complaints had been recorded although the relative felt that the issues had probably been dealt with. All complaints must be recorded and dealt with in accordance with regulations. The Mayfield DS0000017548.V263257.R01.S.doc Version 5.0 Page 15 The manager needs to give written information in a format that is understood by the service user and their relatives, to the service user and the relatives concerning the referring of a complaint to CSCI at any stage, should the complainant wish to do so. This needs to be done immediately. The service users have their legal rights protected. The manager informed the inspector that two service users have a solicitor to administer their affairs, while many have power of attorneys. The home also encourages families to support the service user. Where a service user lacks capacity, the manager of the home contacts Age Concern regarding access to advocacy. The manager reported that all service users are registered to vote and the home supports postal voting. All staff receive Protection of Vulnerable Adult training. The Mayfield DS0000017548.V263257.R01.S.doc Version 5.0 Page 16 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): 19,20,21,22,23,24,26 The internal surroundings of the home need to be continually maintained. Service users have access to safe and comfortable indoor and outdoor communal facilities. They have sufficient and suitable lavatories and bathrooms and have specialist equipment to maximise their independence. Service users’ own rooms suit their needs and are comfortable and safe with their own possessions around them. The home is clean and hygienic. EVIDENCE: During the inspection it was noted that wallpaper had been pulled from the wall in various places. It is understood that this was beyond the control of the home at the time it was occurring, however, a continuous programme of The Mayfield DS0000017548.V263257.R01.S.doc Version 5.0 Page 17 maintenance needs to be in place so that these sorts of problems are rectified quickly for the sake of the other service users. One of the service users complained to the inspector that doors were left to bang during the night that disturbed their sleep. The inspector checked the doors of several bedrooms and found that they did in fact bang shut when released. All doors need to be checked and the problem rectified. During the inspection it was noted that one of the fire alarm censors was being triggered without a fire being detected. The home had asked a private company to rectify this problem. However, at the end of the inspection the problem had still not been identified. This needs to be rectified immediately. The inspector toured the facility and several service users invited the inspector to view their bedrooms. Apart from the service users’ private space, the home provides recreational and dining space inside the home and a seating area outside of the home. The garden furniture has recently been replaced. The communal space that is made available inside of the home includes an area for religious activities and a large dining area. Lighting in communal rooms is domestic in nature and the inspector saw service users using communal areas to read. Furniture is domestic and of good quality. All but five of the bedrooms have en-suite bathrooms. Service users who use communal bathroom facilities are transported via a stair lift. The home is seeking quotations for the installation of a flush shower for wheelchair use. The inspector viewed a sample of the en-suite bathrooms. They were of an adequate size and utilised appropriate equipment for the safety of the resident. The home utilizes one hoist, and has three wheelchair users. During the inspection grab rails were seen to be installed and bath boards in use. Toilets were fitted with raiser seats and when necessary slide sheets were available for use. The home has wheelchair access at the front and ramps available for use at the side door for entry to the garden. The hoist and wheelchairs are stored in the service user’s rooms. A separate area needs to be found for the storage of equipment. When equipment is stored in the service user’s room, it also minimises the usable floor space available. The home does not currently require the use of a communication aid, but the manager pointed out to the inspector that if this became necessary they would utilise a loop system. The Mayfield DS0000017548.V263257.R01.S.doc Version 5.0 Page 18 The call system is checked weekly and documented. The manager informed the inspector that where a room is shared, the service user has a choice about whom they share with. When a place becomes vacant, the service user and the relatives are given the opportunity to make a decision about whether the service user wishes to continue sharing. The service user’s bedrooms were carpeted and provided a comfortable bed, curtains, a mirror, overhead and bedside lighting, comfortable seating for one person, draws and hanging space. They were decorated with the service user’s own belongings. Some of the service users had locks on their doors. The manager informed the inspector that locks are provided only on request and as required. Service users are provided with keys when they request them. However, all bedroom doors should be made lockable so that the service user is able to make a choice at any time, about the security of their belongings, particularly if they are to go out of the facility. All service users are provided with a cash box for lockable storage. During the inspection the home was free from any offensive odours. The laundry facilities were inspected. The home has bought two new gas tumble driers and a new sluice washing machine. The laundry was clean and tidy. Shelves held baskets individually marked with the name of each service user to assist with the sorting of clothes. The floor had been damaged when the new tumble driers were installed. The home has made a request to the company who caused the damage to rectify this situation and is awaiting a reply. The home has an infection control policy that is kept in the policy and procedure manual. They have a contract with Cliniserve for the removal of yellow bags containing clinical waste. The home has rubber gloves and disposable plastic aprons for the protection of staff in the event of chemical spillage. The Mayfield DS0000017548.V263257.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29,30 The numbers and skill mix of staff meets service users’ needs. Service users are supported and protected by the home’s recruitment policy and practices. Staff training needs to be updated. EVIDENCE: The inspector viewed the staff rota for two weeks. Staff numbers were consistent with the necessary ratio of staff to service users. The home is registered to provide care for 23 service users. There are four staff rostered during the day with one cook and two cleaners plus the manager. There are three staff in the afternoon and two overnight. The rota suggested that staffing levels were adequate and consistent. The manager assured the inspector that staff providing personal care to service users were at least age 18. Records show that for staff to be employed they are required to supply two written references and obtain a CRB check. All new staff are given a statement of terms and conditions. The Mayfield DS0000017548.V263257.R01.S.doc Version 5.0 Page 20 The inspector asked to see the programme of training for staff. This was out of date and needs to be brought up to date. Training needs are being met in part, but there needs to be more consistent and rigorous attention paid to the training needs of all of the care staff, particularly the core subjects. The Mayfield DS0000017548.V263257.R01.S.doc Version 5.0 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34,35,36,37 Service users finances are not organised by the home. Staff should be supervised on a two monthly basis. Service users have the right to access their personal records. EVIDENCE: Handover of information continues to be addressed and appears to be improving. Staff are being encouraged to write more detailed information in the daily service user records. The relative of the service user who spoke with the inspector reported that she believed that since the new manager has taken charge the staff have been happier and more communicative. Staff who spoke to the inspector reported the manager as being approachable and understanding. They felt that the The Mayfield DS0000017548.V263257.R01.S.doc Version 5.0 Page 22 ambiance of the home was more comfortable since she took on the management role. The manager has recently completed two years of nurse training and a year working in health care. She is undertaking the registered managers’ course. The new manager must apply for registration with CSCI as soon as possible. The home has a policy of equal opportunity and the manager showed a commitment to multi culturalism. The manager reported to the inspector that the home is financially viable and that money is available for improvements. Head office deals with all finances. The liability insurance was on display in the hallway and will be due for renewal on 28th April, 2006. The manager reported that all insurance cover is with Norwich Union. The manager reported to the inspector that the home does not manage any of the service users’ finances. Several service users have a solicitor, power of attorney or their family manages their finances. However, she was aware that if the need arose, and they were asked to manage the finances of a service user, she would keep a record of incoming and outgoing money along with the receipts in a locked cupboard or box. She and the service user would then sign each transaction. Each service user has a cash box in their room for valuables. The office has a lockable drawer. The manager informed the inspector that although she has been in her role for the last five months, she has not as yet commenced a programme of formal supervision for the staff, nor has she received any formal supervision. The manager is aware that all staff need to have formal supervision that covers all aspects of practice, philosophy of care in the home and career development needs every two months. This must be rectified immediately. The manager told the inspector that service users have access to their records if they wish and that the records are stored in a lockable office. The Mayfield DS0000017548.V263257.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 2 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 3 3 2 2 2 x 2 STAFFING Standard No Score 27 3 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X 3 3 1 3 x The Mayfield DS0000017548.V263257.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 6(a) (b) Requirement The statement of purpose needs to be reviewed and up-dated with current changes in information. 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. The service users guide needs to be updated and include the service user’s view of the home. 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. 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. DS0000017548.V263257.R01.S.doc Timescale for action 15/12/05 2. OP1 12 (4) (b) 15/01/06 3. 4. OP1 OP1 6 (a) (b) 12 (4) (b) 15/12/05 15/01/06 5. OP1 12 (4) (b) 15/01/06 The Mayfield Version 5.0 Page 25 6. OP3 14 (1) (b) 7. OP7 15 (2) (b) 8. OP7 15 (1) 9. OP7 15 10. OP9 13(2) 11. OP9 13(2) 12. OP11 17(1)(a) sch 3 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. This needs to be attended to for those already resident at the home as well as new admissions. All care plans must be kept under review and brought up to date in the new format. This includes those who have been resident for some time. The care plan needs to meet clinical guidelines by including recommendations from relevant health professionals. Care plans need to be drawn up with the involvement of the service user, agreed by the service user and signed by the service user or where not possible, their representative. This must be completed for all service users currently resident as well as for new service users. (Previous time scales not met – 1/4/05, 1/8/05) The person who takes the medication from the blister pack must be the same person who then gives the medications to the service user. This must be made a standard policy. Someone who is trained to give medication must be the only person who gives medication to the service user. Runners must not be used – especially untrained runners. The service user and their family’s wishes in relation to illness and death must be recorded in their care plan. 15/01/06 15/01/06 15/01/06 15/01/06 15/12/05 15/12/05 15/01/06 The Mayfield DS0000017548.V263257.R01.S.doc Version 5.0 Page 26 13. OP16 22 (5) 14. OP16 22 (1)(3)(4) 15. OP16 22 (7) (a)(b)(8) 16. 17. OP19 OP19 23 (2) (b) (d) 23 (2) (b) (d) 23 (1) (a) 18. OP19 19. 20. OP19 OP22 23 (4) (a) 23(2)(l, m) 21. 22. OP24 OP24 23(2)(e) 12(4), 23(2)(e) 23. OP26 23 (2) (b) All service users including those who are already resident in the home must be given a copy of the complaints procedure that includes the stages and timescales for the process. All complaints made to the home must be recorded, investigated and outcome reported within the timescales and procedures documented in the complaints procedure. The registered person must ensure that written information is provided to all service users for referring a complaint to the CSCI at any stage should the complainant wish to do so. The hallway carpets on the first floor need replacing. The wallpaper on the first floor requires attention as it has been peeled away from the wall in some areas. All bedroom doors must be checked to make sure that they close quietly. Doors must not be left to bang during the night. The problem with the smoke detectors alarming unnecessarily, must be rectified. A storage area must be found for wheelchairs and hoists. These must not be stored in bedrooms where they impinge on minimum floor space. Comfortable seating for two people must be provided in each service user’s bedroom Doors to service users private accommodation must be fitted with appropriate locks and they must be provided with keys unless their risk assessment suggests otherwise. This allows for choice at any time to secure their personal space. Clothes dryer installers have DS0000017548.V263257.R01.S.doc 15/01/06 15/12/05 15/12/05 15/02/06 15/01/06 15/01/06 15/12/05 15/01/06 15/01/06 15/01/06 15/01/06 Page 27 The Mayfield Version 5.0 damaged the laundry floor. This needs to be repaired. 24. 25. OP31 OP30 8 (2) (a) (b) 18(1)(c) The new manager of the home must apply for registration with CSCI as soon as possible. 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. Care staff must receive formal supervision every two months. This must be documented and include all aspects of practice, philosophy of care in the home and career development needs. A general assessment of risks and how these will be addressed must be in place on each service users file. Assessments must include what the home will do to reduce the risks and noting when each aspect of this has been achieved. This needs to be completed for all service users. (Previous time scales not met – 15/2/05, 1/9/05) A pressure relief policy, that addresses how staff will support service users in this respect before district nurses become involved, must be written and used. A copy must be sent to CSCI. (Previous time scales not met – 1/9/04, 1/2/05, 1/9/05) The registered people must provide training to all staff not just seniors for Adult protection. (Previous time scales not met – 31/1/04, 1/4/05, 1/9/05) 15/01/06 15/01/06 26. OP36 12 (1)(b) 15/12/05 27. OP7 13(4)14(2 15(2) 15/01/06 28. OP8 13(1)18(1 C) 15/12/05 29. OP18 12 (1) 15/01/06 30. OP25 13(4) The manager must ensure that DS0000017548.V263257.R01.S.doc 15/01/06 Page 28 The Mayfield Version 5.0 radiators either have a guaranteed low surface temperature or are fitted with guards. Work has commenced but still not completed. Risk assessments dated 6/10/03 must also be updated. (Previous time scales not met – 31/1/04, 15/2/05, 1/10/05). 31. OP28 18 (1c) The registered people must ensure that at least 50 of care staff have qualified at NVQ level 2 in care. (Previous time scales not met – 1/1/05, 1/12/05, 1/12/05) The manager must ensure that all staff have attended the planned first aid and food hygiene training. (Previous time scales not met – 1/10/04, 1/3/05, 1/9/05) 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 time scales not met – 1/7/04, 15/1/05, 1/8/05) The general risk assessments on file for the home remain dated from June 2003. They require reviewing and updating. (Previous time scales not met – 1/2/05, 1/9/05) 15/03/06 32. OP30 13(4) 18(1)c 15/02/06 33. OP38 13(4) 14 (2)15(2) 15/02/06 34. OP38 12(1) 13(4) 15/02/06 The Mayfield DS0000017548.V263257.R01.S.doc Version 5.0 Page 29 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 OP13 Good Practice Recommendations Relatives, friends and representatives of service users should be given written information about the home’s policy on maintaining involvement with the service user. It would be good practice to have this translated into the language of the service user or their relatives. The Mayfield DS0000017548.V263257.R01.S.doc Version 5.0 Page 30 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. 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