Care Home: Mayfair Lodge

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What the care home does well On the day of this inspection the home had a well-ordered and homely atmosphere where staff and residents were seen to be interacting positively together. The home was beautifully decorated for Christmas and residents, relatives and other visitors were seen to be enjoying the external entertainment provided for their Christmas party. Many visitors were seen to be welcomed into the home on the day of this inspection. We observed some good interaction between the staff and residents and also between the various teams of staff of all grades who work closely together thereby delivering a smooth and seamless service. The home is offering good person centred care in a warm and friendly environment. Management systems are stable and well known to the staff and appear to be being consistently followed.The stable staff group are well trained and demonstrate a positive and professional approach to their work for the benefit of the people who use the service. What has improved since the last inspection? Since the last inspection improvements have been made to the homes medication storage and administration systems. This ensures that the people who use the service receive their medication safely. To ensure people are engaged in social activities a wider ranges of activities are now offered by the increased number of activity organisers employed. The menus have been revised, food suppliers changed to achieve a better quality and a system of regular consultation with residents and relatives about the day-to-day menus introduced. The special dietary needs of the residents on the dementia care units are being given much closer attention to ensure that they receive the nutrition they require. To ensure that the home continues to offer a homely safe environment to the people who live there the programme of maintenance and refurbishment has continued with several areas of re decoration the provision of new equipment fittings and furnishings along with the development of two new kitchen-dining areas. To ensure that the service can meet the needs of those that live there more staff have now attended special training concerning the care of dementia. To ensure that care is appropriate to peoples needs care plans have all been reviewed to more closely follow a person centred care planning format and to more fully record medical/nursing care given to the residents; an improvement in the standard of these records was also noted. What the care home could do better: The manager reported that it was her aim that further improvements should be made to the food provided with consideration especially to better meeting the complex nutritional needs of some of the people with dementia. The manager also intends that the activities programme should be further improved so to better meet peoples needs and expectations. An increase in staff numbers on the dementia units would also be beneficial to meet the increasingly complex needs of these residents at specific busy times.To meet specific needs the training for some staff concerning the care needs of residents with visual impairments would be advantageous. Some notices concerning aspects of care were seen displayed in some areas of the home in a somewhat institutional manner. More discrete methods of sharing this information should be found. CARE HOMES FOR OLDER PEOPLE Mayfair Lodge The Walk Watkins Rise Potters Bar Hertfordshire EN6 1QN Lead Inspector Mrs Jan Sheppard Unannounced Inspection 14th December 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Mayfair Lodge DS0000019462.V356612.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. Mayfair Lodge DS0000019462.V356612.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mayfair Lodge Address The Walk Watkins Rise Potters Bar Hertfordshire EN6 1QN 01707 871800 01707 871861 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) www.quantumcare.co.uk Quantum Care Limited Mrs Karen Lorraine Pay Care Home 62 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (61), Old age, not falling within any other of places category (61), Physical disability (1), Physical disability over 65 years of age (61) Mayfair Lodge DS0000019462.V356612.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th February 2007 Brief Description of the Service: Mayfair Lodge is a purpose built care home for older people, which is run by Quantum Care Ltd. and was opened in 1998. It offers 62 single bedrooms, 61 have en-suite facilities and one provides wash facilities only. These are grouped in four separate units; two units provide specialist dementia care. The home is well equipped and is wheelchair accessible. It is located close to the town centre of Potters Bar where all the amenities of a high street can be easily accessed. All major public transport is within a short distance. The home offers a secure and homely environment for its service users. Information about the home is included in the Statement of Purpose and Service User Guide, these and the most recent CSCI Inspection Report and the Complaints Procedure are available in the entrance foyer along with facilities seeking the views and comments of visitors and friends. The fees, which are determined according to the level of care needs, range from £495 to £580 per week. Mayfair Lodge DS0000019462.V356612.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over seven hours during a weekday. This was a key inspection that focused on the key standards relating to older people. During this inspection the inspector made a tour of the building, had in depth discussions with the homes manager, met the residents and spoke individually with many of them, spoke with many of the staff on duty and carried out spot checks on a number of the homes records. The inspector also spent two hours observing the care of the most vulnerable service users in the Bryon Dementia Care Unit – this observation is called a Short Observational Framework for Inspectors (SOFI). The inspection although completed by just one inspector will refer to ‘we’ throughout the report as the inspection report is written on behalf of the Commission. The detail in this report reflects the findings on that day and also takes account of information sent periodically to us (the Commission) by the homes Manager as well as information received from residents, relatives, home staff and other associated professionals in the fifty five pre inspection survey questionnaires received prior to this inspection. This was a positive inspection where it was found that the requirements/recommendations made at the last inspection had all been met. Two recommendations are made following this inspection. What the service does well: On the day of this inspection the home had a well-ordered and homely atmosphere where staff and residents were seen to be interacting positively together. The home was beautifully decorated for Christmas and residents, relatives and other visitors were seen to be enjoying the external entertainment provided for their Christmas party. Many visitors were seen to be welcomed into the home on the day of this inspection. We observed some good interaction between the staff and residents and also between the various teams of staff of all grades who work closely together thereby delivering a smooth and seamless service. The home is offering good person centred care in a warm and friendly environment. Management systems are stable and well known to the staff and appear to be being consistently followed. Mayfair Lodge DS0000019462.V356612.R01.S.doc Version 5.2 Page 6 The stable staff group are well trained and demonstrate a positive and professional approach to their work for the benefit of the people who use the service. What has improved since the last inspection? What they could do better: The manager reported that it was her aim that further improvements should be made to the food provided with consideration especially to better meeting the complex nutritional needs of some of the people with dementia. The manager also intends that the activities programme should be further improved so to better meet peoples needs and expectations. An increase in staff numbers on the dementia units would also be beneficial to meet the increasingly complex needs of these residents at specific busy times. Mayfair Lodge DS0000019462.V356612.R01.S.doc Version 5.2 Page 7 To meet specific needs the training for some staff concerning the care needs of residents with visual impairments would be advantageous. Some notices concerning aspects of care were seen displayed in some areas of the home in a somewhat institutional manner. More discrete methods of sharing this information should be found. 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 summary of this inspection report can be made available in other formats on request. Mayfair Lodge DS0000019462.V356612.R01.S.doc Version 5.2 Page 8 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 Mayfair Lodge DS0000019462.V356612.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 is not applicable, as this home does not offer intermediate care. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to the service. People who use the service can be confident that they will receive sufficient information to enable them to make an informed choice about using this service and that admissions to the home are not agreed until a full needs assessment has been carried out and the home is satisfied that it can meet these needs. EVIDENCE: The manager said that there had been no changes to the pre admission assessment procedure carried out by the home since the last inspection and the information provided on the Annual Quality Assurance Assessment (AQAA) return confirmed this. The AQAA is a self-assessment document that the provider and or the manager of the service completes. Mayfair Lodge DS0000019462.V356612.R01.S.doc Version 5.2 Page 10 One or more of the homes managers and a senior carer who will if possible work on the unit with the vacancy individually assesses each new resident referred to the home. Arrangements for the prospective resident and their relatives to visit the home are always offered. There is a comprehensive information pack containing good details of the accommodation and services offered and of the financial contractual details. This information is presented in a format, which is accessible for the prospective resident. Care plans contained assessments of service users needs on admission and further evidence could be seen that this initial assessment was regularly reviewed during the initial days of residency in the home and that these reviews involved where possible both the resident and their relatives. Mayfair Lodge DS0000019462.V356612.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that they will have a person centred care plan which identifies their individual requirements in order to enable staff to meet any needs or preferences expressed in a manner that promotes privacy, dignity and respect. EVIDENCE: We looked at the care plans that have been reviewed and updated since the last inspection. Each contained a photo and recently reviewed risk assessments. Good information on how to care for the resident was seen on each plan along with guidance details as to how best such care should be delivered. Comments such as ‘Staff to sit with and reassure’ were noted, as was a record of one resident’s varying moods with comments as to how these should best be treated. Frequent reference was made as to how to meet care Mayfair Lodge DS0000019462.V356612.R01.S.doc Version 5.2 Page 12 needs in a manner, which suited the resident and promoted their privacy and dignity. Some notices concerning aspects of care were seen displayed in some areas of the home in a somewhat institutional manner. More discrete methods of sharing this information should be found. Since the last inspection good progress has been made with collecting and recording details of the residents life histories with evidence seen of the involvement of some relatives with this process. Staff explained that knowledge of this aspect was particularly important for them when caring for residents with dementia or those who are not able to speak for themselves. Such knowledge enables staff to offer and more appropriately target services so as to help the resident maintain previous life skills and interests. Staff on Bryon Unit discussed with us the various ways in which as they get to know residents with dementia and those without speech better and how they are able to learn to interpret people’s non-verbal requests and preferences. Their achievement with this was noticeable during the lunch and early afternoon period when we observed how care was being delivered to these very vulnerable residents. The staff worked very well together as a team whilst individually targeting their services towards two or three residents, each offering them specific help (with feeding) in a manner which promoted their abilities to feed themselves in what ever manner they preferred. Alternative dishes were offered at various points during the meal to further assist one person and to ensure that they actually consumed sufficient quantities. All the residents were asked if they had enjoyed their meal and if they had had sufficient and one person who wanted to leave the dining room to sit in the lobby before they had finished their sweet took this dish with them to complete there where they were assisted to do this by one member of staff. Because of the constantly changing care needs and the frequent walk a-bouts (where people needed to be coaxed back to their seats) taken by many of the fifteen residents being observed the four staff members had to be constantly vigilant and despite their very best efforts to cope with everything as quickly as possible it was clear to us that more staff at this time would have enabled a better service delivery. The care plans are clearly set out in well defined sections and it was noted that since the last inspection better detail of any doctor and nurses visits to the residents are now recorded including details of what further actions if any are recommended. We examined the controlled medication storage and administration arrangements for the whole home and found these to be well kept with accurate recording and secure storage with good management oversight of this. Other medication storage and administration arrangements were examined on two units where it was found that medication was securely held Mayfair Lodge DS0000019462.V356612.R01.S.doc Version 5.2 Page 13 and the administration records checked were accurately maintained with evidence of three daily management checks to ensure the on going accuracy of these. The staff training records seen showed that staff who administer medication have been appropriately trained to do so and that refresher training is arranged. The manager discussed with us a recent incident where a query concerning medication prescribed for a new residents GP had led to an independent pharmacy assessment carried out by the company pharmacist and the manager discussed how the advice in this report had been followed up. Staff who spoke with us confirmed that they undertook sufficient training to enable them to undertake the role of medication administration and also said that they felt themselves to be well supported by the managers concerning this so that if the had any query they could consult with them at any time. The manager told us that since the last inspection, following her request to them, the residents GP’s had reviewed the medication levels for all the residents in the home, following which some very minor adjustment was made to the prescription for one resident. Mayfair Lodge DS0000019462.V356612.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that they will be provided with a range of activities that meets their needs and expectations; and that they will be provided with a wholesome balanced diet in a manner which meets the their needs and preferences. EVIDENCE: Since the last inspection the home has increased the range of activities that are available for the residents and also now has one specially trained activity organiser working specifically with residents on the dementia care units. All residents receive an assessment as to their activity needs likes and dislikes and where necessary this assessment will also include input from their relatives. Details of these activity assessments and any review of them are recorded in their care plans. The manager explained that she is currently advertising for a third activity worker which should enable better quality time to be spent with the residents. Many of the pre inspection survey questionnaires mentioned the recent improvement in the activities programme Mayfair Lodge DS0000019462.V356612.R01.S.doc Version 5.2 Page 15 and the several suggestions made for further improvements were discussed with the manager. There is an established large and very supportive group of friends and relatives or relatives of former residents who still regularly visit the home and participate in and also promote various fund raising and other social events. On the day of this inspection a large number of visitors were seen supporting the Christmas Party being held on one of the units. There are also regular external outings and parties to which relatives are invited so that they can enjoy themselves alongside their family member. A nutritious and varied diet is available for all of the residents. Many of those consulted commented on the recent improvement in the variety of dishes offered and several expressed their appreciation of the tasty sweets and beautiful cakes provided especially for birthdays and other celebrations. However comments from some relatives indicated that they felt that this was an area where further improvements could be made. Each resident has a food preference sheet in their care plan with details given as to likes and dislikes in relation to both food and drink. Where required this information is completed with the resident and with family members. The chef manager consults on a daily basis with the residents to seek their opinions as to the dishes served that day and to seek suggestions as to other new dishes. It was noted that attention is also given as to the temperature of the food when it arrives on the units and the consistency of the custard was heard being discussed. Since the last inspection a number of themed food weeks have been held including strawberries and cream for Wimbledon week and these special events seemed to have been much appreciated by the residents. The nutritional needs of the residents on the dementia care units were being given increased attention. Finger food is now constantly available for some residents who were seen to be being encouraged and assisted to eat this at times other than set meal times. Their weights, BMI (body mass index) along with records of food actually consumed was seen recorded on the care plans for all residents on the dementia care units. Where needed the dietician makes an assessment and suggests an action plan for individual residents who are felt to be potentially at nutritional risk. The need for adequate nutrition during the night hours was discussed with the manager along with possible alternatives for providing more substantial dishes. Mayfair Lodge DS0000019462.V356612.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service can be confident the policies and procedures in place regarding complaints, or whistle blowing will ensure that any issues or complaints will be listened to, appropriately investigated and acted on and people will be appropriately protected. EVIDENCE: There is a comprehensive complaints policy in place that is well advertised and comments on the pre inspection surveys evidenced that these are known and understood by relatives. Several comments from relatives such as “I would always speak to the manager first if I had any concerns” were also noted. The manager said that she operates an open door office policy and encourages visiting relatives to pop in to speak with her. “I hope that they feel able to approach myself and the team with any concerns or issues that they may have,” she said. Staff are also encouraged to check with visiting relatives and to regularly ask residents if they are happy with the services that they are receiving. The limited written complaints received since the last inspection were seen to have been properly addressed within the prescribed time scales. Since the last Mayfair Lodge DS0000019462.V356612.R01.S.doc Version 5.2 Page 17 inspection more than eight written notes of compliment and appreciation have also been received by the home. All the staff attend Safeguarding training, which is regularly updated. Staff replies evidenced that they have a sound understanding of this area and a heightened awareness of their additional responsibilities was shown by staff working on the dementia care units with the most vulnerable residents. “ We have to constantly watch their moods and interpret their moods as an indication if any thing is wrong,” one said. Mayfair Lodge DS0000019462.V356612.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use this service can be confident that the home is well appointed and subject to regular maintenance so that it meets the needs of the residents. EVIDENCE: The home, which was purpose built ten years ago, provides single bed sitting rooms all with en-suite facilities for its residents. The accommodation is divided into small units each with their own lounge, dining room small kitchen and assisted bathrooms. All these bedrooms were maintained in good decorative order and to be furnished in a homely and comfortable manner with a style chosen by residents that reflected their own tastes and interests. Staff said Mayfair Lodge DS0000019462.V356612.R01.S.doc Version 5.2 Page 19 that relatives often assist new residents decorate and arrange personal items in their rooms when they newly arrive in the home. Since the last inspection a number of areas of the home had been redecorated and where needed have also been re carpeted. A larger dining room with new kitchen has been created on one unit and another unit has had its kitchen refurbished. All the assisted bathrooms have been redecorated and new fittings added so that these now look warm inviting places in which to take a bath. The manager explained what is planned in the refurbishment programme for the next year, works which include the remodelling of the patio and raised garden areas accessible form the ground floor unit lounges with the creation of a sensory garden area and more outdoor sitting furniture including sun umbrellas. Plans have also been agreed to re develop the existing sun lounge area so as to make it more resident friendly. On the day of this unannounced inspection the home was found to be very clean and tidy. Good attention was seen given to infection control measures and a routine cleaning programme for the whole home was being followed. The laundry area is now following revised safety rules; no complaints or criticisms have been received concerning the laundry services rather the opposite with several residents commenting favourably on the speed and quality of the return of their washed and well ironed clothes. The manager explained that if, as is inevitable with such a large volume of laundry some items are spoilt or lost she always takes a sympathetic view concerning replacement and the staff said that they always try to follow the specific hand washing instructions for individual delicate items. The residents all appeared to be well dressed with appropriate clothing that had a fresh and clean appearance and which was seen to be being replaced during the day where needed. Staff offered several residents the opportunity to be redressed in special clothes for the party held on one of the units during the time of this inspection. Risk assessments for all aspects of the home and its environment were well maintained with regular updates and reviews. Mayfair Lodge DS0000019462.V356612.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that they will be assisted by staff who have been appropriately recruited and that are well trained and skilled so to meet their needs. EVIDENCE: Since the last inspection the stability of the staff group has considerably improved with far fewer leavers and new staff commencing. There is currently a virtually full staff team and the manager commented that recent advertisements had bought some applicants from the close vicinity to the home and that now the home does not often have to call upon the services of agency staff. The existing staffing group is very diverse and although this composition does not closely reflect the culture or gender of the residents they consistently report that they are having their needs met by a staff team who support them in a kind and friendly manner. This was seen us during this inspection when Mayfair Lodge DS0000019462.V356612.R01.S.doc Version 5.2 Page 21 several residents also confirmed this and comments such as “The staff are lovely girls always willing to help me” were common. A number of incidents concerning the immigration and permission to work status of new staff applicants were discussed with us and it was noted that other authorities had been appropriately involved with these queries. The recruitment records examined for staff recently appointed evidenced that the correct procedures had been followed and checks made to ensure the protection and safety of the residents. The management staff team has now remained stable for more than twelve months and appeared to be working very well together and to be leading a positive and professional staff team. All of these staff consulted said that they were very well supported, were fully consulted about all aspects of the running of the home and that the manager was always very approachable. On the survey questionnaires several comments were made to the effect that the management of the home was now much improved and that everybody was working together to offer the very best care for the residents. The records evidenced that good training opportunities continue to be available, and are taken up, by staff of all grades. Since the last inspection the percentage of care staff holding the qualification NVQ at level 2 has increased this achievement being assisted by the two in house NVQ assessors who are actively working with the staff who are working towards this award. Training concerning Dementia Care continues to be given high priority in the home; many of the pre inspection survey replies from the staff commented on how helpful they had found this training of which they would like more so as to enable them to better meet the challenging needs of this vulnerable group of residents. The observation made during this inspection of the quality of care being given on one of the dementia care units evidenced close team working by sensitive staff who frequently adapted their patterns of care delivery to meet the wishes and changing needs of the residents in a manner that ensured their safely whilst still giving them choices and as much autonomy as possible to their life style. Further training concerning the special needs of residents with visual impairment would be advantageous to meet the specific needs of some people. Mayfair Lodge DS0000019462.V356612.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that the home is run in the best interests of the residents and that their health and welfare is promoted at all times. EVIDENCE: Since the last inspection we have registered the new manager who has now been in post for just over one year. She discussed with us the changes that had been made during this period and her plans for the further development of the home over the next year. She commented very positively about the cooperation and good team spirit shown by all the staff which is undoubtedly Mayfair Lodge DS0000019462.V356612.R01.S.doc Version 5.2 Page 23 contributing to the positive and professional atmosphere found within the home. The manager is fully qualified and bought with her to this post several years’ management experience in other similar settings. The management team are also fully qualified and experienced and have as their prime objective the delivering of the very best care for their residents. The policies and procedures to promote this were evidenced by the records spot-checked (fire, financial, health and safety, water temperatures, accident reporting) and these were being correctly maintained with good detail and consistency, this safeguarding the residents’ rights and interests. We regularly receive detailed written information and have on several occasions since the last inspection spoken directly with us about particular areas of concern. The quality control monitoring system operated by the company Quantum Care is followed from which regular composite reports are made, copies of which are available to the home and to us. The very high number of returned pre inspection survey questionnaires (55) evidenced by the openness and detail of these replies, an overall satisfaction with the service that the home offers. Many respondents stated that they felt well able to approach the managers to discuss any concerns or suggestions that they had and that their comments were always listened to. Mayfair Lodge DS0000019462.V356612.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Mayfair Lodge DS0000019462.V356612.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? no 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP30 OP10 Good Practice Recommendations It is recommended that more training concerning the special care needs of the Visually Impaired would benefit the service users and staff. It is recommended that the wall display of instruction notices in some areas of the home (which is an institutional practice) should be replaced by another more discrete system of information sharing. Mayfair Lodge DS0000019462.V356612.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Inspection Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Mayfair Lodge DS0000019462.V356612.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. 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