Inspection on 30/01/06 for WCC Mayfield

This inspection was carried out on 30th January 2006.

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

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

Other inspections for this house

WCC Mayfield 19/12/08

WCC Mayfield 05/06/08

WCC Mayfield 20/12/07

WCC Mayfield 12/10/06

WCC Mayfield 02/08/05

WCC Mayfield 08/03/05

WCC Mayfield 01/06/04

WCC Mayfield 11/12/03

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Maple Lodge

Heathlands

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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 Mayfield Mayfield Close Bedworth CV12 8ES Lead Inspector Patricia Flanaghan Unannounced Inspection 30th January 2006 11:30 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 Mayfield DS0000034958.V282539.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Mayfield DS0000034958.V282539.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 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) Mayfield DS0000034958.V282539.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd August 2005 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 lavatory and washbasin, and on each floor there are bathrooms and lavatories 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, an assistant manager, and three care officers, domestic staff and care staff, which covers the home over twenty-four hours. 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. Mayfield DS0000034958.V282539.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced inspection took place between 11.30pm and 6.00pm. This was the second visit of this inspection year. Discussions took place with residents and staff. The inspection focused on the standards relating to medication, health and safety and staffing. A service questionnaire was completed by the home and returned to the Commission for Social Care Inspection (CSCI). The manager was asked to distribute other questionnaires regarding the service to residents, relatives and health care professionals. The completion of these is voluntary but proves useful in assessing the various views that are held. No responses from relatives or residents had been received by the CSCI at the time of writing this report. What the service does well: What has improved since the last inspection? A quality officer has also been appointed and is undertaking monthly quality reviews of the services provided by the home. Funding has been allocated to refurbish bathrooms within the home. Mayfield DS0000034958.V282539.R01.S.doc Version 5.1 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. Mayfield DS0000034958.V282539.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mayfield DS0000034958.V282539.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed at this inspection. Standards 3 and 5 were assessed as met at the inspection visit on 02/08/05. EVIDENCE: Mayfield DS0000034958.V282539.R01.S.doc Version 5.1 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): 9 Improvements must be made to the medicine management within the home to demonstrate that the resident’s needs are fully met. EVIDENCE: Audits demonstrated that the medicines administered from the Monitored Dosage System (MDS) supplied by the community pharmacist are recorded correctly. There was evidence of good stock control. All unused or unwanted medication is returned promptly to the supplying pharmacist and the returns books had been completed and receipted appropriately. The following issues were identified and discussed with the care officer. The home did not routinely record the quantities of medicines dispensed in boxes and carried over from previous cycles so it could not be demonstrated that these medicines had been administered as prescribed. Medications transcribed by hand had not been initialled by staff. PRN medications did not consistently record the number of tablets given, for example, when the amount of medications can be one or two it should be recorded how many tablets were administered to the resident. Mayfield DS0000034958.V282539.R01.S.doc Version 5.1 Page 10 Some gaps were found on the Medicines Administration Record (MAR) chart and it could not always be demonstrated whether a resident had received the medicine and the MAR chart had not been signed. MARs had been signed to demonstrate medication had been administered, however, the medication was evident in the MDS. Controlled drugs were checked and records were found to be accurate. Appropriate procedures and facilities were in place to facilitate those residents who wish to continue to administer their own medication. Mayfield DS0000034958.V282539.R01.S.doc Version 5.1 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 the following standard(s): 15 Residents receive suitable meals in pleasant surroundings, which promotes social interaction and wellbeing. EVIDENCE: Meals are served by care staff in the pleasant, large dining room. Meals can also be served in resident’s own rooms if preferred. Choices are available at mealtimes. The lunch menu is displayed at the entrance to the dining room, however, residents can choose an alternative meal if they wish. Meals were served by care staff and looked well presented. A number of residents spoken with on the day of the inspection commented positively on the quality of the food served in the home. A brief inspection of the kitchen found it to be clean and in good order Mayfield DS0000034958.V282539.R01.S.doc Version 5.1 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 the following standard(s): 16 and 18 Systems for the management of complaints are satisfactory. 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: Residents and a relative spoken with were aware of the complaints procedure and how to make a complaint if they needed to. They were satisfied that any issues taken to the manager or a member of staff would be dealt with promptly. The home has a clear complaints procedure, which is explained in the homes statement of purpose and given to all prospective service users or their family/representative before moving into the home. The complaints procedure is also located on a notice board in the reception area. The Commission for Social Care Inspection (CSCI) has not received any complaints since the last inspection visit. The home have in place an Adult Protection Policy, which is in line with the Social Services Policy and the Department of Health document, “No Secrets”. Staff sign a declaration to state that they have read and understand the policy. All staff have taken part in Adult Protection Training. Staff spoken to during the inspection were aware of their responsibilities under the Protection of Vulnerable Adults Scheme. Mayfield DS0000034958.V282539.R01.S.doc Version 5.1 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 the following standard(s): 19 The home is clean and comfortable. Generally the premises are maintained to a satisfactory standard resulting in a suitable living environment for residents. EVIDENCE: There has been no change to the decor since the last inspection and although this does not pose a risk to residents the home is let down by shabby and dark wall coverings/paintwork, scuffed door frames and skirting boards in some communal areas. The care officer said that funding had been made available to refurbish bathrooms in the next financial year. A visitor commented that the anti-glare treatment to the windows in the top lounge made it appear dark. The registered provider should monitor the light levels in this room to ensure they are appropriate. Mayfield DS0000034958.V282539.R01.S.doc Version 5.1 Page 14 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): 28 and 29 The recruitment procedure ensures that suitable people are employed to safely provide care for the residents. A strong commitment to training ensures staff have the knowledge and skills to undertake their duties. EVIDENCE: There is a staff training plan in place and all new staff receive induction training. Training records examined show that staff have attended regular training on the conditions associated with old age. Fourteen care staff have an NVQ Level 2 in Care, with two staff members currently undertaking this award. Recent training undertaken by staff include Dementia Care, Adult Protection, Recording Skills and Infection Control. The staff files of two recently appointed staff were reviewed and indicated that the registered manager has completed all necessary recruitment checks to ensure the protection of service users. Criminal Records Bureau checks and POVA checks are maintained at head office. The home receives written verification from their Human Resources department that satisfactory checks have been obtained and this documentation is retained on individual staff files. Mayfield DS0000034958.V282539.R01.S.doc Version 5.1 Page 15 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 and 38 The home has an experienced manager and is effectively and well managed. 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 registered manager has many years experience in managing a care home for older people. There are clear lines of accountability within the home. Observations made and discussions with both residents and staff indicated that the manager is available and approachable should they wish to discuss any issues. The manager continues to update his knowledge and skills and is familiar with the diseases and conditions associated with old age. Mayfield DS0000034958.V282539.R01.S.doc Version 5.1 Page 16 The quality of the service is continuously monitored through feedback received from the residents and their relatives. A formal quality system is in place. The annual quality assurance survey has recently been completed and the home are awaiting the results. The Local Authority have addressed the need for the registered provider or delegated person to visit the home monthly and write a report on the conduct of the care home. No health and safety hazards were observed. Evidence was seen to confirm that staff receive regular training in moving and handling, fire safety, first aid, food hygiene and infection control. Fire alarm tests, emergency lighting tests and fire drills have been carried out at the required intervals. Certificates were seen during the inspection for the maintenance and service of major systems. Mayfield DS0000034958.V282539.R01.S.doc Version 5.1 Page 17 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 X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X X STAFFING Standard No Score 27 X 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 3 Mayfield DS0000034958.V282539.R01.S.doc Version 5.1 Page 18 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 OP9 Regulation 13(2) Requirement The quantities of all medicines carried over from previous MAR charts must be recorded to enable audits to take place to demonstrate medicines are administered as prescribed. All hand written MAR charts must accurately record all the medication the service user has been prescribed, the strength of the medicines and the correct dose. A competent person should countersign all entries. Staff must refer to the Medicines Administration Record (MAR) chart before the administration of medicines and directly sign following the transaction or record the reasons for nonadministration. The MAR chart must accurately reflect what has been administered within the home. Timescale for action 31/03/06 Mayfield DS0000034958.V282539.R01.S.doc Version 5.1 Page 19 2. OP19 23 The registered provider must ensure that the home is kept in good decorative repair. (Previous timescale of 31/10/05 not met.) 31/05/06 Mayfield DS0000034958.V282539.R01.S.doc Version 5.1 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Mayfield DS0000034958.V282539.R01.S.doc Version 5.1 Page 21 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 Mayfield DS0000034958.V282539.R01.S.doc Version 5.1 Page 22 - 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!