Care Home: Mayfields

What the care home does well What has improved since the last inspection? Care records continue to improve and record positive comments about residents and their choices about how they wished to be helped and supported. Staff recruitment had improved and all the necessary information and documents had been obtained so resident were protected from harm. Medicine records were completed at the time medicines were given to residents. Stocks of prescribed medicines were maintained and records of controlled drugs were accurate so residents receive their medicines safely. The management systems within the home had contributed to an overall improvement in records and medicine management. What the care home could do better: Continue to make improvements in record keeping to show how residents` health conditions are managed. CARE HOMES FOR OLDER PEOPLE Mayfields Naylor Crescent, Netherpool Road Overpool Ellesmere Port Cheshire CH66 1TP Lead Inspector Anthony Cliffe Unannounced Inspection 20th May 2008 08:30 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 Mayfields DS0000006684.V363388.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. Mayfields DS0000006684.V363388.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mayfields Address Naylor Crescent, Netherpool Road Overpool Ellesmere Port Cheshire CH66 1TP 0151 356 4913 0151 356 4915 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) home.fxg@mha.org.uk Methodist Homes for the Aged Josephine Bell Care Home 46 Category(ies) of Dementia (46) registration, with number of places Mayfields DS0000006684.V363388.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies 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: Dementia - Code DE The maximum number of service users who can be accommodated is: 46 Date of last inspection 14th August 2007 Brief Description of the Service: Mayfields is a purpose-built single-storey home, which provides care for older people who have dementia. Opened in 1997, it is located in the Overpool area near to a range of local shops and within a mile-and-a-half of Ellesmere Port town centre. The home was extended in August 2002 to provide nine additional bedrooms and three additional lounge areas. Residents’ accommodation is of a high standard, with all individuals having single, en-suite bedrooms. The home consists of three wings off a main central lounge. Each unit has a separate large lounge/dining area (with domestic scale kitchen facilities) and a range of communal bathroom/toilet facilities. A separate ‘services wing’ contains a large kitchen, laundry, staff facilities (staff room and changing/shower-rooms), office accommodation and relatives/visitors accommodation. There are also very pleasant, well maintained and fully accessible garden areas. These are secure to protect the safety of residents. The home charges £517.00 per week. Mayfields DS0000006684.V363388.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 a two star. This means that the people who use the service experience good quality outcomes. This unannounced visit took place on the 20th May 2008 and lasted eight and a half hours. One inspector carried out the visit. This visit was just one part of the inspection. Other information received was also looked at. Before the visit the manager was asked to complete a questionnaire to provide up to date information about services provided. During the visit various records and the premises were looked at. People that live at Mayfileds were spoken with to find out what they think about the services they receive. Seven staff including the manager and a senior carer was also spoken with as well as volunteers and the hairdresser and they gave their views about the service. What the service does well: Mayfields provides a homelike, calm and welcoming atmosphere for both residents and visitors and promotes a communal spirit amongst those involved with it. Residents are seen to move freely around the home and activities have been devised in various parts of the building, such as the shop, café and central lounge, so that residents have a communal space to walk around to aid mobility and a change of environment. Residents receive a very good standard of care and comments from residents, visitors and staff support this. Residents said, “It’s alright here and I like it. The young ladies ask me if I want anything and they are polite. As I’m hard of hearing they have to raise their voice so I can hear them but they don’t shout and seem to understand what I want”. “ I like it here, whoever helped me to get dressed helped me to choose my clothes and I made the right choice as it’s nice and warm in the garden. I’m comfortable and if I ask for someone a face appears. That’s lovely”. Care staff practices were good and staff were very patient, always took time to ask residents questions rather than deciding for them. Staff were seen Mayfields DS0000006684.V363388.R01.S.doc Version 5.2 Page 6 involving residents in decisions about their meals prepare drinks and asking them to help wash and dry dishes. Residents were encouraged to be active, but could also sit quietly if that was their wish. Residents were comfortable and confident in their environment and were experiencing a good quality of life. Signage helps them to recognise where they live. Residents’ were respected and valued as people and their personhood recognised and dignified. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Mayfields DS0000006684.V363388.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mayfields DS0000006684.V363388.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 People who use services experience good care in this outcome area. We have made this judgement using available evidence, including a visit to the service. Detailed information is gathered on the needs of people that use services prior to them moving into Mayfields so their needs can be met. EVIDENCE: Mayfields accommodates mainly people from the Ellesmere Port area and is welcoming to anyone from outside the area or with a disability, different ethnic or cultural needs, religious beliefs, sexual orientation or political affiliation. Information gathered about residents was seen on all files examined. This covered personal information, care needs and support required, medication, carer and family support, interests and other relevant information. The support plans were written from the residents’ view of their care and demonstrated that staff were gathering information to make care records more personal and reflect the personalisation of their care. Examples of this were that staff were recording information about daily routines and making positive statements about people An example of this was that a resident was described as being ‘a Mayfields DS0000006684.V363388.R01.S.doc Version 5.2 Page 9 positive and appreciative person’ and ‘did not like being pressured into doing things’. Additional information was also gathered when prospective residents made introductory visits to Mayfields. Mayfields DS0000006684.V363388.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use services experience good care in this outcome area. We have made this judgement using available evidence, including a visit to the service. Improved records of care, medicine management and liaison with health and social care professionals are consistent so residents’ health and welfare needs are met. EVIDENCE: A total of three residents care records were looked at. These included a “getting to know me” document which was completed by family or friends and assisted in the process of understanding new residents and their past life. Staff spoken with said that care records were always available for them to read and they gave them important information on residents. Care records including support plans to assist staff and help them meet residents needs including daily records were written in the first person. This included positive statements about residents and staff using direct quotes from residents. For example a resident had said she enjoyed “excellent meals”. Staff were also interpreting residents’ moods or behaviour and recording these. Again this was positive practice but it would be difficult for staff to say how a resident was feeling unless they told them or they observed signs that residents were happy or in pain. Mayfields DS0000006684.V363388.R01.S.doc Version 5.2 Page 11 The provider agreed that staff would continue to record positive comments from residents and observations from staff but not use the first person when recording the care staff had provided. Care records contained information on the routines of residents and staff were given guidance on how to support residents to maintain routines in the records. Records also recorded where residents maintained their independence and how staff should support this. For example reminding residents of the location of the toilet. Support plans were written from the residents’ perspective of their care and recorded how residents wished to be cared for and that personal routines were respected. The support plans demonstrated that staff thought about people when writing them and respected and supported residents’ lifestyle choices while promoting their dignity, choice and independence. There were records that healthcare professionals saw residents. The district nurse regularly saw one resident and these visits were recorded. The district nurse had a separate care records to monitor the resident’s healthcare. A support plan was in place regarding tissue viability and referred to the treatment provided by the district nurse. The records said that the resident’s skin had healed but further treatment was needed. Mayfields had provided the resident with a special bed and mattress to help her skin remain intact. A resident approached the senior carer on duty and said his teeth were hurting him and a dental appointment was agreed and made. Care staff sought out the senior carer to share/seek information or if they had concerns about residents’ health. The senior carer spent time liaising with General Practitioners (GP’s). Daily fluid and turning charts were seen in a resident’s bedroom that was being monitored by staff. A resident was described as having seizures but did not instruct staff what to do if the resident had one. Another resident’s support plan for mobility said the resident had falls due to low blood pressure but risk assessment for mobility did not say this. The manager agreed that further work needed to be done on residents’ care records for their health and confirmed that further training on writing care records was to take place. Visiting healthcare professionals returned surveys as part of the site visit and said that staff at Mayfields always sought advice on healthcare and were ‘good at supporting relatives’ and offered a ‘pleasant environment, good activities, well supported relatives and the hairdresser’. The routines around the administration of medicines had improved and were organised. Medicine receipt, storage, administration and disposal were examined on the three units. There were no missing signatures and codes used to indicate a person did not need a medicine were used correctly. There was a Mayfields DS0000006684.V363388.R01.S.doc Version 5.2 Page 12 stock of a controlled drug stored in the controlled drugs cupboard. This was stored appropriately as the medicines cupboard had been fitted with controlled drug storage facilities. Medicines were managed with records of receipts on medicine administration records and disposal of medicines recorded. Medicines were audited by both the manager and deputy managers and identified where errors occurred. Mayfields DS0000006684.V363388.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use services experience excellent care in this outcome area. We have made this judgement using available evidence, including a visit to the service. Residents are supported in making choices about their lifestyle so they have more control over their lives. EVIDENCE: There was a programme of activities displayed in each of the three units. These generally took place between 14.30 and 18.30. Activities were arranged for example Mondays were a day out using the minibus. Tuesdays was aromatherapy and a film. Wednesdays was community singing. Thursday a hymn service or parachute games and Fridays nit and natter. Saturdays was for families to visit relatives visit and on Sunday a church service took place. Other activities were arranged as well with residents involved in baking. The activities organiser said the budget for activities was never questioned. She arranged for regular entertainers that visited Mayfields. In addition there were indoor board games and DVD’s and outdoor games like snakes and ladders, drafts and a soft football. There was a residents shop manned by volunteers on weekdays and the residents café open twice a week. At the time of the site visit the hairdresser was doing a resident’s hair. The hairdresser asked if she wanted this done as she knew she enjoyed looking smart in her appearance. Mayfields DS0000006684.V363388.R01.S.doc Version 5.2 Page 14 The resident said, “I like this lady she always does my hair just as I like it. Not to long, just nice so I feel special”. Volunteers talked warmly about their involvement and a lady said she had been a volunteer for two years and became involved through a friend. She said “it’s a lovely place with a nice atmosphere. The staff are ever so friendly. I have got to know the residents and they are treated very well. We have a great system for our shop and café. We use real money so the residents purchase sweets and other things. I give them a receipt and we then tally up with the manager later. Staff helps residents pay for their items so it’s a real shop. It gives residents the opportunity to buy things and use money. For the café I have bought a record player so we can play records and have a sing along”. The activities coordinator was seen organising the care staff on the units to lead some activities. A male carer was doing an exercise group in the communal lounge with a group of residents encouraging them to throw a ball to one another. The activities coordinator explained how she and a carer had helped a resident with an interest in aircraft make a model. They had found out the resident liked making models and aircraft so they bought a model Spitfire. The carer and resident had made this and painted it. They had bought some more as the resident had been so pleased. The activities organiser was delegating activities to staff on Rose unit. She advised staff that a film was being shown in the main lounge and individual residents could have hand massages and aromatherapy. She said each day activities were organised and she did some 1 to 1 activities on a regular basis with individual resident that were not able top join in the larger groups. Examples where that a resident enjoyed her talking book and the activities organiser would go and listen to this with her. Another resident liked to talk about her family and liked to sing with the activities organiser. The activities organiser said a male resident who liked to walk and be active was encouraged to help her when she was organising things as he liked to walk around and likes to be involved. Relatives returned surveys as part of the site visit and said ‘dementia needs are well met within the home. Daily activities are provided for. Relatives are made welcome’. ‘My sister and I chose Mayfields for mum as we knew it to be the best home for her needs’. Mayfields DS0000006684.V363388.R01.S.doc Version 5.2 Page 15 Residents were seen asking for drinks, being helped to make them and being served drinks. Residents were seen tidying up after meals and drying dishes and putting them away. Staff anticipated residents needs and were seen to spend time with them talking and explaining what activities were taking place or asking residents what they wanted to do. Staff talked positively about activities and said they were happy to carry out the activities the organiser had arranged on the units. Menus were displayed on the dining tables for residents to read. Meals were ordered in advance with residents and their meal preferences were known. For example a resident was vegetarian and her care records recorded her meal preferences. The menu for the day covered breakfast through to supper and had a number of alternatives residents could choose from other than the two main meal choices. For example the lunch at the time of the site visit was fish pie in tomato sauce or turkey stroganoff. The chef monitors meals to see if there are any menu choices that residents dislike. Menus are revised and discussed at residents and relatives meetings. At meal times tables were set with fresh flowers and condiments and crockery. Residents were shown the menu choice in case they decided or could not recall what they had ordered. Sufficient portions were made should residents decide to change their decision on what meal they had ordered. Staff were available to assist residents at meal times. When they assisted someone they sat with them and maintained a conversation or talked to them at all times. Residents were aware of the meal times. A resident was heard to say “It’s half past four which is nearly teatime, I look forward tea it’s lovely”. Mayfields DS0000006684.V363388.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 services experience Good care in this outcome area. We have made this judgement using available evidence, including a visit to the service. Complaints were dealt with appropriately so residents and relatives would be confident they are taken seriously and acted upon. EVIDENCE: The Commission had not received any complaints since the previous visit. The home had received four and three of these had been dealt with. The complaints procedure was displayed in the entrance foyer to Mayfields. Surveys returned by residents and relatives said they were aware who to raise concerns and complaints to and that they were acted upon. The registered manager was responsible for training staff on the protection of vulnerable adults. She was aware that two new staff had not yet had this training. Training provided used the Methodist Homes Association abuse awareness policies and procedures. This was supplemented by a DVD ‘Abuse in Care Homes’ and a set of reflective questionnaires for staff based on this to allow staff to think about how they would recognise and respond to abuse. The reflective questionnaires used ask questions about reference documents. The abuse awareness training and policy referred to the whistle blowing policy. Senior staff on duty had access to contact numbers for social services. Copies of the Cheshire County Council adult protection policy and procedure ‘There Mayfields DS0000006684.V363388.R01.S.doc Version 5.2 Page 17 are No Secrets’ were available in the home and information on this displayed in the assistant managers office. Methodist Homes Association provide information leaflets to staff called ‘No Secrets Here’. This has a free telephone number and the information explains to staff what they can do if they see or suspect something they are not happy with. On the training records provided at the time of the site visit fifteen staff needed to have adult abuse awareness training and one staff last had this in 2005. All non-care staff had standard Criminal Records Bureau (CRB) disclosures. Domestic staff that was left unsupervised in areas of the home where they interacted with residents such as bedrooms had standard disclosures. The manager confirmed this is company policy. As the CRB did not issue specific guidance on this the manager agreed to discuss this with her organisation to see if a higher standard of CRB disclosure was needed. Staff was issued with the Methodist Homes Association code of practice for staff. The manager was unaware of the General Social Care Council Code of practice for care staff and advised on how to obtain this Mayfields DS0000006684.V363388.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 services experience Good care in this outcome area. We have made this judgement using available evidence, including a visit to the service. Residents live in a safe, comfortable and well-maintained environment, which is equipped to meet their needs. EVIDENCE: The building was well maintained both internally and externally. The gardens were due to be attended to in preparation for a garden fate. The residents’ café had been fitted with a base unit and sink to provide a water supply to make drinks and wash dishes. The manager said that a resident that could not make it to the en suite toilet needed the bedroom carpet replacing and would consider an alternative to a carpet, which had to continually shampooed. It was company policy that if flooring was replaced it would be safe, comfortable and suit the needs of residents. Mayfields DS0000006684.V363388.R01.S.doc Version 5.2 Page 19 Signage in the building was helpful to resident with memory boxes used to indicate bedrooms and symbols to indicate toilets and bathrooms. Mayfields DS0000006684.V363388.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 services experience Good care in this outcome area. We have made this judgement using available evidence, including a visit to the service. The recruitment, deployment of staff and training programme provides a skilled workforce so residents are protected and in safe hands at all times. EVIDENCE: The senior carer on duty was supported by a large staff team and gave a handover to the manager when she arrived. The number of staff appeared to meet the needs of residents. Three care staff was on duty in each of the three units. Three staff files were examined and they all contained job descriptions, person specifications, application forms, terms and conditions of employment and CRB checks. Files contained photographs and POVA first checks. A range of mandatory training had been undertaken by most of the staff team. This included health and safety, moving and handling, first aid, fire awareness, COSHH, food hygiene, medication and three-day dementia course. Specialist training included adult abuse, challenging behaviour, yesterday, today and tomorrow and care planning. Good progress continued to be made toward the staff team having NVQ level 2 qualifications in care. Recently employed staff had completed induction training and a detailed record of training that had been arranged and completed by staff was kept. Mayfields DS0000006684.V363388.R01.S.doc Version 5.2 Page 21 Staff were spoken with throughout the site visit and said, “I’ve only been here five weeks but from coming in for my application form I’ve been welcomed. I was shown around and staff explained about the home. Induction gave me confidence as well as the staff support. They are all good, really supportive, you can ask anything. I’m impressed with the management and the deputies, they have been supportive and helpful and helped me build my confidence”. “Induction was good this is totally different from my last job and it prepared me for this job. Working here is great. Residents please themselves what they do with their life. Care is over twenty-four hours and there are no routines you have to stick to. It’s not institutional or restrictive. Residents have plenty of time to spend with one another or in their room. There is time to provide stimulation and we encourage them to help themselves. The manager is very encouraging and there is always something going on”. Mayfields DS0000006684.V363388.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 services experience Good care in this outcome area. We have made this judgement using available evidence, including a visit to the service. Proactive management, consistent quality assurance, safe financial procedures and regular maintenance are done so the welfare of people that use service is maintained. EVIDENCE: At the start of the site visit a senior carer was in charge of the home. The senior carer very competently delegated her time and said when she would be busy. She made herself available to residents and visitors. She made telephone calls and received these. She was organised and went about her duties confidently. She made herself available to staff and answered any queries about their care and to take information to contact health professionals such as dentists and General Practitioners. When she needed to be available to administer medicines she indicated this. When the manager came on duty she gave her a detailed handover. Mayfields DS0000006684.V363388.R01.S.doc Version 5.2 Page 23 Staff surveys returned as part of the site visit said the manager was supportive. A visiting relative said of the staff team, “I’m here everyday and staff don’t know when I’m sitting in mum’s room with her. I hear them talking to other residents and can unfailingly say that staff treat people with dignity and respect. Staff are always with residents in their bedrooms or sitting talking to them. There’s always something going on. Mum’s happy and in the right place and you always receive a warm welcome. If you ask for something it’s done”. As part of the quality assurance system the management team has responsibility for monitoring the weights of residents, the skin condition of residents and risk of them developing pressure ulcers. The pressure ulcer audit recorded the pressure ulcer of a resident that was being treated by the district nursing service. The monitoring of sickness and absence has increased leading to actions being taken by the manager. The business plan for 2008 took account of the last CSCI inspection and had addressed the requirements identified. The Methodists Homes Association has an ongoing quality assurance process with monthly audits by the management team of the home and more comprehensive six monthly audits against set organisational standards. This was also supported by external audits from Methodist Homes quality assurance team. The regional manager also does three monthly quality assurance checks of Mayfields. In addition satisfaction surveys were sent out to relatives of residents. The manager does not see these but received the results of them. The manager had to respond to the findings of the surveys to demonstrate improvements in the areas of the cleanliness of the building, security, customer care, responding to residents calling staff at night time and staff being moved around the units. The manager had completed a response to these. The home held residents and relatives meetings every three months and senior staff and staff meetings monthly. The residents have limited amounts of personal monies kept at Mayfields. The home does not manage any finances on behalf of residents. The monies for some residents were checked against the balances and records of debits and credits. These were securely and safely managed. The Annual Quality Assurance Assessment recorded that all the necessary maintenance checks had been completed. Mayfields DS0000006684.V363388.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 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 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 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 3 Mayfields DS0000006684.V363388.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. Refer to Standard Good Practice Recommendations Mayfields DS0000006684.V363388.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Merseyside Area Office 2nd Floor South Wing Burlington House Crosby Road North Waterloo, Liverpool L22 OLG 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 Mayfields DS0000006684.V363388.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. 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