Inspection on 12/10/06 for WCC Mayfield

This inspection was carried out on 12th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

WCC Mayfield 19/12/08

WCC Mayfield 05/06/08

WCC Mayfield 20/12/07

WCC Mayfield 30/01/06

WCC Mayfield 02/08/05

WCC Mayfield 08/03/05

WCC Mayfield 01/06/04

WCC Mayfield 11/12/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE WCC Mayfield Mayfield Close Bedworth CV12 8ES Lead Inspector Justine Poulton Key Unannounced Inspection 12th October 2006 09:30 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 WCC Mayfield DS0000034958.V314985.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. WCC Mayfield DS0000034958.V314985.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service WCC Mayfield Address Mayfield Close Bedworth CV12 8ES 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) 02476 313600 02476 315376 Warwickshire County Council, Social Services Department Raymond Durkin Care Home 35 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (1), Old age, not falling within any of places other category (35) WCC Mayfield DS0000034958.V314985.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th January 2006 Brief Description of the Service: Mayfield is a Local Authority home for older people, with thirty-five beds. It provides permanent care, phased care (which means that people come in for regular, planned periods) short stay and day care. Four assessment beds are also available for rehabilitation. The home is situated on a housing estate, within easy walking distance of Bedworth town centre. The town is a small but busy community, with a variety of shops, a local market and a civic centre. These are all in a pedestrian zone. The home is close to local bus routes as well as being provided with services from Coventry and Nuneaton. It is also close to the M6 motorway. There is car parking to the front and rear of the home. Mayfield was refurbished in 1995 and provides accommodation on two floors. There are three lounges with kitchenettes as well as the main dining area. There is a day care area with its own lounge with kitchenette. All bedrooms have en-suite toilets and washbasin, and on each floor there are bathrooms and toilets suitable for people with physical disabilities. The main kitchen, laundry and staff offices are on the ground floor. As well as the two staircases, there is a shaft lift to the first floor. The home has a registered manager, three care officers, domestic staff and care staff, which cover the home over twenty-four hours. At the time of this inspection the deputy manager post was vacant. The home does not provide nursing care. Service users who require nursing attention receive this from the community nursing service as they would in their own homes. WCC Mayfield DS0000034958.V314985.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the first key inspection in relation to Inspecting for Better Lives. Identified key standards were looked at, along with a review of the organisations progress towards meeting requirements made at the previous inspection of this service. The pre fieldwork documentation was completed, as well as a site visit to the home, during which time staff, residents and the manager were spoken with. Three residents were identified for close examination by reading their care plans, risk assessments, daily records and other relevant information. This is part of a process known as ‘case tracking’ where evidence is matched to outcomes for service users. Other records, policies and procedures were also examined and the environment was looked at. All of the residents were at home for the inspection. The inspector would like to thank the residents, manager and staff for their hospitality and co-operation during the inspection. On 5th October 2006 the fees charged to stay in the home ranged from £94.45 to £380.24 per week. What the service does well: What has improved since the last inspection? WCC Mayfield DS0000034958.V314985.R01.S.doc Version 5.2 Page 6 Since the last inspection, which took place on 30 January 2006, staff at the home have worked hard to improve the medication procedure to ensure the safety of residents with regards to their medication. The décor has been improved in some areas of the home. In particular one lounge has been recarpeted, and a number of bedrooms and their en suites have been redecorated. 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. WCC Mayfield DS0000034958.V314985.R01.S.doc Version 5.2 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 WCC Mayfield DS0000034958.V314985.R01.S.doc Version 5.2 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): 2, 3, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessments are undertaken to ensure that the home can meet the person’s identified care needs. Prospective residents and/or relatives have the opportunity to visit the home in order to assess the facilities and suitability. Residents admitted to the home for assessment purposes receive support from suitably qualified healthcare professionals. EVIDENCE: The home has had a number of new residents move in since the previous inspection. Two of these residents were chosen for case tracking purposes. Assessments completed by the placing social workers were in place and available in their individual files. Contracts between Warwickshire Social Services, the home and the individual residents were also in place. It was noted that these were signed by the resident, the placing social worker and a representative from the home. WCC Mayfield DS0000034958.V314985.R01.S.doc Version 5.2 Page 9 Visits to the home by prospective residents or their representatives are encouraged before the decision to move in is made. One relative spoken with said that he had visited the home on his fathers behalf before his father moved in. Two residents questionnaires were received prior to this inspection. Both stated that they had received enough information about the home that helped them to decide whether to move in. As well as permanent care the home provides phased or short stay care and also has four beds that are used for assessment purposes. Residents in the home for assessment have been admitted from hospital. Staff at the home work with healthcare professionals such as physiotherapists and occupational therapists to determine whether residents on assessment are able to safely return to their own homes or are in need of residential care. WCC Mayfield DS0000034958.V314985.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans provide basic information about how best to meet residents assessed needs. The lack of specialised healthcare information leaves those residents with a specific diagnosis at risk of inadequate care and support. Medication is managed safely. Residents generally feel that they are treated with dignity and respect. EVIDENCE: Staff spoken with said that a service plan is completed for each resident shortly after they move into the home. This is based on the information provided in the initial assessment and information gleaned by the staff from supporting and talking to the residents and their families. The care planning information for three residents was looked at. Service plans were in place for two of these and contained information about how best to care for and support the residents in their daily living. One of the residents chosen for case tracking moved into the home in March 2006. It was noted that this resident did not have a service plan available. WCC Mayfield DS0000034958.V314985.R01.S.doc Version 5.2 Page 11 Information was available within the service users files looked at that confirmed that routine healthcare such as chiropody, dental, optical, GP and hospital appointments are offered as appropriate. Little or no information was available within the files looked at regarding more specialist health care needs such as dementia or Parkinson Disease. Staff were not therefore able to meet the specific health needs of residents in relation to specific conditions. Records for falls, pressure areas, weight, bathing and nail checks were in place within the files looked at. A completed Douglas score identifying the risk for pressure areas, nutritional risk screening and a manual handling risk assessment were also in place. The home has a medication policy and procedure in place. Medication is stored in 2 locked cabinets within a locked cupboard. One cabinet holds the medication for the permanent residents whilst the other holds the medication for the residents on phased (short stay) and assessment care. Both cabinets were well ordered and tidy. Medication for the permanent residents was in blister packs which were accompanied by medication administration record charts (MAR). Signatures were in place to confirm that the blister packs had been checked on delivery to the home. Medication brought in by phased care residents is also checked in and signed for upon arrival to the home. A photograph of each resident is available in the medication cabinet for identification purposes. Three service users medication was looked at. The administration information on the blister packs or boxes corresponded with the information on the MAR charts. It was noted that in one instance the code ‘G’ had been recorded on the chart with no explanation on the back to indicate why the resident had not had that particular tablet. A medication round took place during lunch. The member of staff completed this efficiently, discreetly and on an individual basis. With the exception of one incident between staff during the inspection, residents were seen to be treated with dignity and respect. Staff met all requests for help or assistance by residents immediately. Conversations between staff and residents were respectful whilst including a little jovial banter. Residents spoken with said that they were quite happy in the home and that on the whole staff were friendly and helpful. The minutes of the latest residents meeting indicated that on occasion staff were “snappy and bossy”. This was discussed with the manager who said that when issues were raised via this forum they were discussed with staff during handovers, and the information was also taken to the social services management lateral group for monitoring. WCC Mayfield DS0000034958.V314985.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lack of appropriate activities leaves residents open to boredom. Residents have been able to maintain relationships with families and friends. A variety of wholesome nutritious food is served in pleasant surroundings. EVIDENCE: The home did not offer a formal programme of activities for residents to participate in. One care officer said that she had been given the responsibility of devising a new activities programme but that the work that she had done on this was on her home computer. During time spent sitting in the various lounges with the residents very few informal activities were observed. A number of magazines were available for the residents to read but it was noted that these were not necessarily appropriate to the age of the reader. One resident spoken with said that she had had a game of Kerplunk during the morning. Again it is felt that this is not necessarily a game appropriate to the age of the residents in the home. During time spent sat in one lounge after lunch the residents appeared bored. Very little conversation was engaged in and staff were chatting amongst themselves in the kitchenette whilst making tea for everyone. WCC Mayfield DS0000034958.V314985.R01.S.doc Version 5.2 Page 13 Activity records were in place within the residents files looked at but very few activities were recorded. Residents comment forms received prior to the inspection indicated that some activities were “usually” offered and that there were “never” any activities offered that could be taken part in. Residents said in conversation that they were “often bored” and would appreciate more things being made available for them to do. Residents were being supported by staff to retain as much independence over their lives within the home as they were able. In conversation residents said that they were able to bring their own possessions into the home if they wished, a wide and varied choice of meals was available, they were able to choose what times they got up and went to bed and whether to spend time in the lounges or in their own rooms. During time spent in the various lounges residents were given drinks, however there did not appear to be any consultation over what they would like. These drinks were also provided in either mugs, a lidded ‘baby beaker’ or lidded beakers with spouts. Information provided in the pre inspection questionnaire received prior to the home stated that all of the residents have external appointees looking after their finances. This was confirmed by staff on duty in the home. The residents have small amounts of personal spending monies which some look after themselves, and some leave in the safe in the home. Records of the monies checked tallied with the balances of monies in the homes safe. The home has a large pleasant dining room that is called ‘the restaurant’ in which residents eat their meals. Tables were laid nicely with mats, cutlery, condiments and a jug of squash. Comments received in the residents questionnaires regarding the food provided range from “lacks variety” to “ meals very good”, “plenty of choice”, “served efficiently”. Residents spoken with over lunch were very complementary about the food in the home saying that the meals were “an excellent standard”, “very good” and “plentiful and excellent”. A four weekly rolling menu that had been compiled with input by the residents at their residents meetings had recently been introduced. Any assistance required by residents during lunch was provided discreetly by staff. Inspection of the kitchen showed it to be tidy with appropriate cleaning schedules in place. Temperature records for delivered foods, frozen foods, cooked foods and fridges and freezers were in place, as was a hazard analysis. A list of each residents likes and dislikes along with any special diets was also available in the kitchen for the cook to consult. Plentiful stocks of fresh, frozen and tinned foods were available. The cook said that she was qualified to NVQ II. WCC Mayfield DS0000034958.V314985.R01.S.doc Version 5.2 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory system for the management of complaints in place that ensures residents can be confident that their concerns are listened to, taken seriously and acted up on. There is a clear Adult Protection policy in place, to make staff aware of their responsibilities to provide a proper response to any suspicion or allegation of abuse. EVIDENCE: The home adheres to the Warwickshire County Council complaints policy and procedure. The complaints record for the home had one complaint recorded since the previous inspection. Information regarding a complaint made in August was seen however this was not recorded in the complaints log and there was no evidence of any investigation or outcome. This was queried with the manager who was able to explain what the complaint was about and the status of the investigation at the time of the inspection. A ‘complaints, concerns and compliments’ box is available in one of the downstairs hallways next to the notice board, which has a copy of the complaints procedure on it. Anyone that lives in or visits the home is welcome to post any issues of concern to them in this box. A number of residents were asked if they knew how to complain and whether they felt able to, all responded that they did, but were quite happy with the home. WCC Mayfield DS0000034958.V314985.R01.S.doc Version 5.2 Page 15 The home adheres to Warwickshire County Councils policy on adult abuse. One allegation has been made since the previous inspection, which resulted in the Protection of Vulnerable Adults procedures being instigated. WCC Mayfield DS0000034958.V314985.R01.S.doc Version 5.2 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, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally well maintained and residents live in a safe, clean and comfortable environment. A change of décor in identified areas would improve the first impressions of people visiting the home. EVIDENCE: There has been some change to the décor since the last inspection. One of the downstairs lounges has been re-carpeted, a number of the bedrooms and their en-suites have been redecorated and the homes public toilets have been redecorated. The kitchenettes in the lounges have also been replaced or redecorated. Unfortunately the hallways, including the main entrance hallway to the home were still decorated in dark wallpaper with dark wood doorframes and skirting boards. WCC Mayfield DS0000034958.V314985.R01.S.doc Version 5.2 Page 17 This makes these areas appear uninviting and dark if all of the lighting is not working effectively. During a walk around the home it was noted that there was a strong smell of urine in the phased care / assessment corridor. Wall paper and woodwork was damaged in the hallways throughout the home, the ceiling in the walk in shower room upstairs required repairing and the downstairs Parker bathroom was being used as a storage area. Although these do not pose any risk to the residents, staff or visitors to the home, they do not create a good impression when walking around. The main lounges, dining room and residents bedrooms looked in were all nicely decorated, comfortable and homely. WCC Mayfield DS0000034958.V314985.R01.S.doc Version 5.2 Page 18 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, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Sufficient trained and competent staff are not always on duty thus making it difficult to ensure the needs of the residents are met. The lack of training relating specifically to old age, the aging process or health related conditions place residents in a vulnerable position. The lack of specific documentation in staff files means that it is not possible to confirm that safe recruitment practices are undertaken. EVIDENCE: Throughout the inspection one of the main concerns being put across by staff were issues about staffing numbers. Rotas provided prior to the inspection indicated that the home was staffed by one senior staff member in charge of the entire home along with five care staff on the morning shift divided between the two floors, four care staff on the afternoon shift again divided between the two floors and two night staff. Staff spoken with said that day staff are being used to cover night staff sickness on a reasonably regular basis, which then leaves the daytime cover short. This was not apparent on the copy rotas received. WCC Mayfield DS0000034958.V314985.R01.S.doc Version 5.2 Page 19 During the inspection sufficient staff in line with the rota numbers were on duty for the first day. Staffing levels were one short for the morning of the second day of the inspection, and the working rota in the home indicated that there were often periods of time during each shift when staffing number were below those specified. The impact of this on the residents did not appear to be great during the inspection however, as the senior staff member on duty left the office work and undertook some of the care tasks. Staffing levels were discussed with the manager who said that they are generally able to cover staff sickness and absence by offering overtime to existing employees. A small pool of bank staff are also available to cover shifts as necessary. Issues of conflict that arose between some staff on duty in an inappropriate manner and setting were discussed in detail with the manager who undertook to assist staff resolve whatever concerns or grievances they may have. A new staff training plan has been produced by the senior member of staff that has recently taken on the role of co-ordinating staff training. This staff member said that the first major task in relation to staff training was to sort out exactly what training had been completed by which staff and when, as the information in the home was limited, outdated and sparse. Each member of staff has a training file in place which has been put together by the training co-ordinator who said that she is now working on ensuring that all staff are up to date with their mandatory training. It was apparent by looking through the staff files that very limited training relating to old age, the aging process or specific health related conditions such as Parkinsons Disease is provided. Staff spoken with said that they are provided with dementia training, however the limited records that were available indicated that this was at least two years ago and was attended by a very small number of staff. Information provided in the pre inspection questionnaire received prior to the inspection indicates that fourteen staff have successfully obtained their NVQ II in care. The staff files of five staff were looked at. All five contained an application form, two were missing either one or both references, one did not have confirmation of a satisfactory Criminal Records Bureau (CRB) check being received and four did not have confirmation of the POVA First checks being received. The original CRB and POVA 1st documentation is held by the social services human resources department who are responsible for ensuring that this information is available in the home. WCC Mayfield DS0000034958.V314985.R01.S.doc Version 5.2 Page 20 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, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An experienced manager runs the home. Systems are in place to monitor the quality of the service provided and identify areas in need of improvement. The health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: The home continues to be run by a registered manager with appropriate qualifications, who has considerable experience in managing a care home for older people. WCC Mayfield DS0000034958.V314985.R01.S.doc Version 5.2 Page 21 The quality of the service provided is monitored through regular regulation 26 reports, and by seeking the views of residents, their relatives and friends. Quality assurance questionnaires are sent out on an annual basis to residents and other key stakeholders. Staff spoken with said that these were due to go out shortly. All of the residents have appointees that are independent of the home. Residents spending money is located in the homes safe and looked after by named senior staff where requested. Two residents personal spending monies were checked and were in order with receipts and spending records matching the balance available. Information provided in the pre inspection questionnaire indicated that all of the necessary health and safety checks are carried out. This was confirmed by a sample of health and safety records, which included fire safety maintenance, fire drills, fire alarm testing and legionella prevention. No health and safety hazards were identified during the inspection. WCC Mayfield DS0000034958.V314985.R01.S.doc Version 5.2 Page 22 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 x 3 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x 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 3 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 WCC Mayfield DS0000034958.V314985.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 15 Requirement The registered manager must ensure that residents have a written plan of care that sets out how their assessed health and social care needs are to be met. The registered manager must ensure that MAR charts are completed correctly when administration codes are used. The registered manager must ensure that residents are consulted about their social interests and make arrangements for them to participate in local, social and community based activities. The registered manager must ensure that residents are consulted about the programme of activities arranged by the care home and provide facilities for recreation in line with residents needs. The registered provider must ensure that the home is kept in good decorative repair. (Previous timescale of 31/05/06 not met.) Timescale for action 30/11/06 2 OP9 13(2) 30/11/06 3 OP12 16(m) 21/12/06 4 OP12 16(n) 21/12/06 5 OP19 23 09/02/07 WCC Mayfield DS0000034958.V314985.R01.S.doc Version 5.2 Page 24 6 OP28 12(5)(a) 7 OP29 17(2) schedule 4(6) 18(1)(c)(i ) 8 OP30 The registered manager must ensure that staff maintain good personal and professional relationships with each other. The responsible person must ensure that information to confirm that safe recruitment practices are undertaken. The registered manager must ensure that staff receive training appropriate to the work they perform. 30/11/06 21/12/06 09/02/07 WCC Mayfield DS0000034958.V314985.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP14 Good Practice Recommendations It is recommended that residents be offered a choice of drinks throughout the day, along with the choice of whether they are served in cups and saucers or mugs. WCC Mayfield DS0000034958.V314985.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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 WCC Mayfield DS0000034958.V314985.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!