Care Home: Mayfield House

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What the care home does well Mayfield House is well managed so that people living there can expect good standards of care. They will also know that the home’s management team uses effective quality assurance measures to ensure that the home is run in their best interests. Staff are highly regarded by people who live in the home, relatives and health and social care professionals who visit the home. One person living in the home said, “staff very, very good, very obliging,” a relative, “food’s great, no complaints – always been quite happy here, settled” a social care professional, “major improvements in the last six months” and a health professional, “attitudes very good.” People thinking of moving into Mayfield House have their needs fully assessed before admission so they know those needs will be met. The standard of catering at Mayfield House is good offering people living there choice and variety. The home provides a range of activities which people can choose to join in if they wish. Mayfield House DS0000006654.V378266.R01.S.doc Version 5.2 The home has a continuous programme of redecoration and refurbishment so that people live in comfortable and pleasant surroundings. Effective measures are in place to protect people from possible infections. Staff receive support to undertake training so that they are equipped to carry out their role. What has improved since the last inspection? The recruitment process has improved so that the home carries out thorough checks on people before they start work at the home and so people living in the home know that staff are suitable to work there. The management of medication has improved so that people receive the medication they need in a safe manner. Care staff who carry out blood sugar monitoring have received appropriate training so they are safe and competent practitioners. The home has sought advice from the fire officer about fire safety in the home so that people and staff live and work in a safe environment. The owners have appointed a senior manager to act as an advisor and quality assurance representative for the home so that the manager is supported and given feedback about how the home is meeting standards. Staff receive supervision so they are given feedback about how to carry out their role and support to undertake training. What the care home could do better: Effective measures should be put in place to protect people from developing pressure ulcers. All care staff should undertake training in the prevention of pressure sores so that timely action is taken to prevent people developing pressure ulcers. All staff should be given a copy of the revised policy and procedure relating to safeguarding adults so they know how to recognise potential abuse and what to do if they suspect someone is being abused.Mayfield HouseDS0000006654.V378266.R01.S.doc Version 5.2 The manager should submit an application to become registered with us as required by law. Key inspection report CARE HOMES FOR OLDER PEOPLE Mayfield House Mayfield Mews Minshull New Road Crewe Cheshire CW1 3FZ Lead Inspector June Shimmin 21 st Key Unannounced Inspection and 22nd October 2009 09:00 DS0000006654.V378266.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Mayfield House DS0000006654.V378266.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Mayfield House DS0000006654.V378266.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mayfield House Address Mayfield Mews Minshull New Road Crewe Cheshire CW1 3FZ 01270 500414 01270 214946 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) Littleton Homes Limited Manager post vacant Care Home 51 Category(ies) of Dementia (23), Old age, not falling within any registration, with number other category (51) of places Mayfield House DS0000006654.V378266.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia - Code DE (maximum number of places: 23) The maximum number of service users who can be accommodated is: 51 Date of last inspection 24th March 2009 Brief Description of the Service: Mayfield House is a two-storey purpose-built home with 51 places for older people. It is on a modern housing estate, approximately a mile-and-a-half from Crewe town centre, with access to bus links and the railway. The property has been extended and now has two separate units, one for people with personal care needs, and the other for people with dementia. Access to the homes second floor is by a passenger lift and three stairways. There are accessible and well-maintained gardens surrounding the home. Information about the home, including the last inspection report, is available from the home. Current fees range from £376.73 to £624.00 per week depending on the type of care being provided. Further charges apply for toiletries, chiropody, hairdressing, newspapers etc. Mayfield House DS0000006654.V378266.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The overall quality rating for this service is two stars. This means that the people who use the service experience good quality outcomes. This unannounced inspection visit took place over two days and lasted eight and a half hours. One inspector carried out the visit. The report will refer to we and us as it is written on behalf of the Care Quality Commission. This visit was just one part of the inspection. Other information we had received was also looked at. Before the visit the manager was asked to provide information about the home as part of this inspection process. We sent questionnaires to people living in the home and staff members to find out their views about Mayfield House. We also spoke to several people living in the home, a number of relatives, staff members, a social worker and two health professionals during our visit to the home. Their views are incorporated into this report. During our visit we looked at various records and the premises. Records of care plans, medication and staff recruitment and training records were also examined. What the service does well: Mayfield House is well managed so that people living there can expect good standards of care. They will also know that the home’s management team uses effective quality assurance measures to ensure that the home is run in their best interests. Staff are highly regarded by people who live in the home, relatives and health and social care professionals who visit the home. One person living in the home said, “staff very, very good, very obliging,” a relative, “food’s great, no complaints – always been quite happy here, settled” a social care professional, “major improvements in the last six months” and a health professional, “attitudes very good.” People thinking of moving into Mayfield House have their needs fully assessed before admission so they know those needs will be met. The standard of catering at Mayfield House is good offering people living there choice and variety. The home provides a range of activities which people can choose to join in if they wish. Mayfield House DS0000006654.V378266.R01.S.doc Version 5.2 Page 6 The home has a continuous programme of redecoration and refurbishment so that people live in comfortable and pleasant surroundings. Effective measures are in place to protect people from possible infections. Staff receive support to undertake training so that they are equipped to carry out their role. What has improved since the last inspection? What they could do better: Effective measures should be put in place to protect people from developing pressure ulcers. All care staff should undertake training in the prevention of pressure sores so that timely action is taken to prevent people developing pressure ulcers. All staff should be given a copy of the revised policy and procedure relating to safeguarding adults so they know how to recognise potential abuse and what to do if they suspect someone is being abused. Mayfield House DS0000006654.V378266.R01.S.doc Version 5.2 Page 7 The manager should submit an application to become registered with us as required by law. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Mayfield House DS0000006654.V378266.R01.S.doc Version 5.3 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 Mayfield House DS0000006654.V378266.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have their needs assessed before admission to Mayfield House so they know their needs can be met at the home. EVIDENCE: Mayfield House has updated its information booklet or Service User Guide so that people thinking about moving into the home know about its services and facilities, which will help them make a choice about whether Mayfield House will meet their needs. Mayfield House DS0000006654.V378266.R01.S.doc Version 5.3 Page 10 We looked at the assessments of three people who had come to live at Mayfield House on a permanent basis. The manager told us that she does these assessments and that she is training other senior staff members at the home to carry out the assessments. In one case the home had also received information from a social worker about the person’s needs. The content of each assessment was of a good standard overall and included relevant information about any risks relating to the person’s care needs. Other information about the person’s family, social, work and preferences was also included. This means that the home could demonstrate that it was moving towards person centred care whereby the person’s life history and individual needs are taken into account when drawing up a care plan. This information was then looked at again on the day of admission, recorded and used to draw up a care plan. In some cases some of this information was not included on the care plan so was not always person centred. Wherever possible the manager encourages people to visit the home before they make the decision to move in and to spend time at the home, have a meal and take part in an activity to see if the home will meet their needs. We spoke to several people who had just moved into the home during our visit. One person was finding it difficult to adapt to the new environment but had no complaints about the home and its staff. The other person seemed to be settling in well. Mayfield House does not currently provide intermediate care. Mayfield House DS0000006654.V378266.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care needs of people living in the home are mainly met and in a manner that respects their privacy and dignity. However, actions need to be taken to minimise the risk of people developing pressure ulcers so they are protected. EVIDENCE: We looked at the care plans of four people in detail to find out if they were receiving the care outlined in their assessment. These included three people who had recently moved into the home. The care plans were written on a computer by one senior staff member and included relevant risk assessments. Mayfield House DS0000006654.V378266.R01.S.doc Version 5.3 Page 12 The content of the care plans and risk assessments was very detailed and gave staff in-depth guidance about how to meet the needs of the people receiving care. We expressed concerns that because the care plans and risk assessments were so detailed that care staff might not have time to read them in full. The other concern was that some information was incorrect. This related specifically to the prevention of pressure ulcers. We were told during our visit about one person who has developed a pressure ulcer but it was unclear whether the person had a pressure ulcer on admission to the home. No pressure relieving aids were in use although the district nurse was visiting the home to manage the pressure ulcers. Since our visit we have been told about another person who has developed a pressure ulcer. Although an appropriate risk assessment tool was being used by the home the tool did not appear to have either been completed correctly or updated to reflect changing needs. We found the care planning system to be difficult to use and this was also mentioned by a visiting social worker. Senior staff use the computer to make comments but carers also keep written daily records so there are two sets of records, which can be confusing. Care plans and risk assessments were being reviewed monthly but the reviews were not easy to find on the computer and appeared to be incorrect in some instances. We found that the staff at Mayfield House are prompt in contacting health professionals when there is a need. These include dieticians, GP’s, chiropodists, district nurses and opticians. We spoke to two health professionals during our visit, both of whom were complimentary about Mayfield House. One said, “this is one of the better homes. If I say something here it gets done” and the other, “respectful to residents, observe privacy – always see them in their own room or the treatment room.” Our observations of staff interactions with people living in the home indicated that staff approach people in a sensitive and kind manner and are mindful of the need to protect the person’s privacy and dignity. Overall, medication is well managed. The home is now using a medication change form with GP’s to discuss any changes to the prescription, which is documented and is good practice. We noted that several people had not received their medication when the medication was not available from the pharmacist. The manager told us that this would be put right so that people receive their medication in a timely fashion. Mayfield House DS0000006654.V378266.R01.S.doc Version 5.3 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Mayfield House provides a variety of suitable activities, which people can choose to take part in so they are not socially isolated. The standard of catering is good so people are well nourished. EVIDENCE: Mayfield House employs two activity coordinators, one part time and the other full time. They arrange a variety of group and one to one activities, as well as outside entertainers for the enjoyment of people living in the home. Although these activities mainly take place during the working week they also happen at weekends and the activity coordinators put together special events such as birthdays and Easter/Christmas celebrations. People we spoke to said they appreciated the activities provided by the home but were not made to Mayfield House DS0000006654.V378266.R01.S.doc Version 5.3 Page 14 participate if they did not wish to do so. The weekly activities were not displayed on notice boards throughout the home but the manager told us that they are planning to do this so people know what activities are available. The manager told us that the home arranges trips to local shops, garden centres and pubs so that people are able to go into the wider community. The home also organises visits from local clergy and there is a weekly church service held at Mayfield House so the spiritual needs of people are met. Visitors said they were made to feel welcome when they came to the home and were able to join in meals and activities if they wished so they felt part of the home. We looked at the way in which food and drink is provided at Mayfield House and found this to be of a good standard. Most of the food is home made and people told us that they liked the food provided and that there was enough to eat. The home ensures that people have a choice at all meals so that if people do not like the first choice there is always an alternative. The manager told us that they provide special diets and meals in a soft or pureed form so people are well nourished. People can eat their meal in one of the two dining rooms or their own room if they prefer. The manager told us that the home has four weekly menus, which are changed every three months according to the season. Mayfield House are devising a pictorial menu which will be laminated and presented in a book format so that people will be able to point to their preferences if they cannot communicate verbally. The home makes sure that all menus and choices are saved so that the home has a record of what people have eaten. Mayfield House DS0000006654.V378266.R01.S.doc Version 5.3 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home are protected by policies, procedures and training on complaints and safeguarding adults. EVIDENCE: Mayfield House has a complaints procedure, which is displayed at the main entrance of the home so people can see it. The procedure contains our details so people can contact us if they wish. We looked at the complaints received by the home in the last twelve months and the manager had investigated the complaints so people would be reassured that their concerns were being taken seriously. The manager told us that she likes to sit down with relatives and discuss any concerns they may have about the home. Relatives confirmed that they would know who to speak to if they had any concerns about Mayfield House. The home’s safeguarding adults procedure has just been updated so that it gives staff clearer guidance about the different types of abuse, recognition of abuse and what to do if they suspect someone has been abused. The manager Mayfield House DS0000006654.V378266.R01.S.doc Version 5.3 Page 16 told us that staff have not yet seen this policy but will ensure that they are familiar with its contents. The manager also told us that the majority of staff have completed training in safeguarding adults so should know what to do if they suspect someone is being abused. The staff we spoke to said that they had done this training. The manager has recently attended training on safeguarding organised by East Cheshire County Council and was up to date with procedures. Mayfield House DS0000006654.V378266.R01.S.doc Version 5.3 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Mayfield House is well maintained so that people live in a safe, clean and comfortable environment. EVIDENCE: We looked around Mayfield House and found it clean, tidy and with no unpleasant odours. Appropriate measures were in place to prevent the spread of infection in the home so people who live there are protected. We looked at several bedrooms and noticed that people were able to personalise them with Mayfield House DS0000006654.V378266.R01.S.doc Version 5.3 Page 18 mementos such as photographs and ornaments so that they could make their rooms more homely. The manager provided us with information before the inspection, which indicated that services and facilities at the home are maintained and serviced on a regular basis so that it is safe. The manager also told us that an environmental audit had been carried out and this was being used to implement a repair and renewal plan so that many changes were being made at the home. These included new mattresses and bedding, new armchairs, new hoists, two new flatscreen televisions and a new bath, amongst others. Additionally various parts of the home are being redecorated so that the home’s environment is being continuously upgraded. We spoke to several people who were visiting the home and they commented that Mayfield House is kept clean and tidy, “always clean” and “home is clean – no smells.” Mayfield House DS0000006654.V378266.R01.S.doc Version 5.3 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff undertake training to do their job so that people know their needs will be met by appropriately qualified staff. Recruitment practices are thorough so that people are protected. EVIDENCE: We looked at the recruitment records of three new staff to make sure that the home was using thorough methods to check that staff were suitable to work in the home. The records were of a good standard and where there was a query about one person’s reference this had been discussed during the interview process so that the manager was satisfied that the person could be safely employed. The necessary security checks had also been carried out and the manager told us that staff work under supervision until an enhanced security check has been received from the Criminal Records Bureau [CRB]. We also noted that staff go through an induction period and are allocated someone to whom they can go for support. Records indicated that staff receive supervision on a regular basis so that they have feedback about care practices and are Mayfield House DS0000006654.V378266.R01.S.doc Version 5.3 Page 20 given guidance about training needs. The manager told us that nearly 50 of care staff have achieved the NVQ2 in care qualification so they have the knowledge and skills to carry out their role. We received an anonymous concern about staffing levels at Mayfield House. During our visit we considered that staffing levels were satisfactory although one senior staff member felt that more staff were needed at times on the unit for people who are elderly and frail. Other staff considered that there were sufficient numbers of staff on duty. The manager told us that a number of staff had left Mayfield House in the last year but that the home was actively recruiting new staff so that staffing levels would improve during the coming months. Mayfield House DS0000006654.V378266.R01.S.doc Version 5.3 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Mayfield House is well managed so it is run in the best interests of the people living there. EVIDENCE: The manager has been in post for nearly nine months and has been a manager of other care homes for over ten years prior to taking up this post. The Mayfield House DS0000006654.V378266.R01.S.doc Version 5.3 Page 22 manager has a background in caring for the elderly and people with learning disability and completed her Registered Manager’s Award in 2003 so has the experience and qualifications necessary to carry out her role. We received favourable feedback about the manager during our visit and we were told that she is accessible and friendly. The manager is supported by a deputy manager who works full time. The manager is also supported in her role by a senior representative of the owners who visits Mayfield House on at least a monthly basis to check on the quality of care provided and to give the manager feedback about this. The senior manager was at Mayfield House during our inspection and told us that she has recently carried out a major audit of the home based on our standards to find out what areas need to improve and to implement an action plan with the manager following the audit. The manager gave us information before the inspection about the finances of people living in the home. All residents are given the opportunity to manage their own finances. If they are unable to do so support is sought from family members, an advocate or social worker. The manager told us that accurate records are kept in relation to the finances of residents. We asked about fire safety in the home and the manager told us that a fire officer had visited Mayfield House in June 2009 and was satisfied with fire safety in the home. The manager said that all staff had recently taken part in a fire drill so they would know what to do in the event of fire. We also looked at training records and found that about a third of staff needed to do safe moving and handling training so that they were safe practitioners. The manager told us that they were mainly ancillary staff but that training would be completed within the next few weeks. Mayfield House DS0000006654.V378266.R01.S.doc Version 5.3 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X n/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 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 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Mayfield House DS0000006654.V378266.R01.S.doc Version 5.3 Page 24 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. Refer to Standard OP8 Good Practice Recommendations The registered person should ensure that appropriate action is taken to prevent people developing pressure ulcers so they are protected. The registered person should ensure that all staff undertake training or refresher training in the prevention of pressure sores so that people living in the home are protected. The home’s policy about safeguarding adults should be given to staff to read and understand so they are given appropriate guidance about safeguarding adults. The manager should submit a valid application to become registered with us as required by law. 2. OP8 3. OP18 4. OP31 Mayfield House DS0000006654.V378266.R01.S.doc Version 5.3 Page 25 Mayfield House DS0000006654.V378266.R01.S.doc Version 5.3 Page 26 Care Quality Commission North West Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Mayfield House DS0000006654.V378266.R01.S.doc Version 5.3 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!