Inspection on 14/03/08 for Mais House

This inspection was carried out on 14th March 2008.

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

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

Other inspections for this house

Mais House 23/11/06

Mais House 07/12/05

Mais House 17/06/05

Mais House 27/01/05

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

CARE HOMES FOR OLDER PEOPLE Mais House 18 Hastings Road Bexhill on Sea East Sussex TN40 2HH Lead Inspector Caroline Johnson Unannounced Inspection 09:20 14 March 2008 th 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 Mais House DS0000039554.V360685.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. Mais House DS0000039554.V360685.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mais House Address 18 Hastings Road Bexhill on Sea East Sussex TN40 2HH 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) 01424 215871 01424 732197 ljackson@britishlegion.org.uk www.britishlegion.org.uk The Royal British Legion vacant post Care Home 54 Category(ies) of Old age, not falling within any other category registration, with number (54) of places Mais House DS0000039554.V360685.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is fiftyfour (54). Service users must be older people aged sixty-five (65) years or over on admission. Service users can be accommodated who in addition to old age may have a physical disability. 23rd November 2006 Date of last inspection Brief Description of the Service: Mais House is a large purpose built care home proving personal and nursing care for up to 54 older people. It is situated in a cul-de-sac in a quiet residential area of Bexhill. The premises are well maintained both internally and externally and the standard of décor is very good. The building is set on two floors and has two shaft lifts either end of the building to facilitate access for the service users. Facilities for service users in the home include a bar, hairdressers, activities room, conservatory, and a very well maintained and attractive garden. Mais House is owned and run by The Royal British Legion and external managers employed by the organisation visit the home to monitor it’s performance. Copies of inspection reports and the homes Statement of Purpose are made available on request. Fees charged as from 1 April 2008 range from £485£685 weekly, which does not include toiletries. Additional charges are made for hairdressing, chiropody, newspapers and outside activities such as visits to the theatre. Intermediate care is not provided. Mais House DS0000039554.V360685.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We have assessed that people who use this service receive a poor quality of care. Over the past year the standard of care at the Mais House has deteriorated. With the appointment of a new manager and support from senior management many of the issues identified in this report are now beginning to be addressed. A warning letter has been sent to the home in relation to an unmet requirement from the last inspection. The Commission will monitor progress over the coming months to ensure that standards improve. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Mais House will be referred to as ‘residents’. This key inspection included an unannounced visit to the home on 14th March 2008 between the hours of 09.20 and 4.10pm and a follow up visit on 18th March 2008, which lasted from 09.30 until 2.30pm. There were 49 people in residence on the day, 27 or which were in receipt of nursing care. Time was spent in one of the lounges speaking with eight residents both male and female. A tour of the premises was undertaken and a range of documentation was viewed including the service users guide, statement of purpose, care plans, medication records and recruitment files. Time was also spent with staff and on the second visit with the manager of the home. Since the last inspection the registered manager has left her position as manager. Following her resignation a temporary manager was recruited. In December 2007 a new manager was appointed to the position. She has yet to submit her application to register as manager of the home. What the service does well: Mais House is well maintained providing a warm and comfortable environment for the residents. Residents are encouraged to personalise their bedrooms and where this has been done bedrooms are very homely. There are several communal areas so that residents can choose where they would like to spend their time. The range of activities on offer is increasing and residents spoken with stated that they choose which activities they wish to participate in. Residents Mais House DS0000039554.V360685.R01.S.doc Version 5.2 Page 6 meetings are held regularly giving residents the opportunity to share their views about the home in particular about activities, food and general house issues. All the residents spoken with praised the food served in the home both in terms of quality and portions sizes. The menus also reflect a wide range of choices on offer. All staff are given regular opportunities to update their knowledge and skills. Over half of the care staff have completed NVQ at level two or above. What has improved since the last inspection? What they could do better: The home is currently going through a very difficult time. The new manager took over mid December and to date she has identified a number of areas where improvements are needed. She along with support from senior management has started the process of trying to improve the quality of care in the home but a number of factors have prevented progress: • • • • • • • A high number of adult protection alerts; Staff disciplinary actions leading to suspensions pending investigations; High use of agency/bank staff; Low staff morale; No head of care or deputy manager; Problems with the administration of medication and not all nursing staff have up to date training in this area; Lack of monitoring to ensure that trained staff have kept up to date with skills and knowledge; DS0000039554.V360685.R01.S.doc Version 5.2 Page 7 Mais House • • Inadequate care planning; Inadequate supervision of staff. The senior management need to continue to support the manager to prevent a further fall in standards. Additional senior staff need to be appointed as soon as possible to assist the manager in her role. Suitably qualified and competent staff need to be appointed in numbers appropriate to the needs of the residents. All trained staff must be competent in the area of medication management and the home must be able to demonstrate how they can meet the specialist needs of the residents accommodated. Emphasis needs to be placed on ensuring that care planning is more holistic and that daily records demonstrate progress made with meeting needs. Job descriptions must be clarified and staff must be clear about the extent of their individual role and responsibilities. All staff must receive regular supervision and appraisal. The planned quality assurance system must be introduced to ensure that there is a continuous cycle of review and improvement that will prevent a fall in standards in the future. 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. Mais House DS0000039554.V360685.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 Mais House DS0000039554.V360685.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): 1,2,3 People who use 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. Prospective residents and their representatives are provided with detailed information about the home in order to make an informed choice about accommodation. EVIDENCE: There is a very detailed statement of purpose and service user guide in place. The statement needs to be updated to reflect the changes in the management of the home and the changes to the address of the Commission. A copy of the terms and conditions of residence provided to a new resident was also seen. Mais House DS0000039554.V360685.R01.S.doc Version 5.2 Page 10 Pre admission assessments were seen in relation to two residents. In both cases the home had carried out an assessment of needs prior to admission and a further assessment was carried out at the time of admission. Little emphasis is placed on assessing the emotional needs of residents on admission. Daily records showed some reference to this on the first couple of days after admission but it is not referred to after this. The home does not cater for intermediate care. Mais House DS0000039554.V360685.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): 7,8,9,10 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improved care planning and risk assessment would better promote residents’ health and welfare. Lack of staff training and inadequate medication administration systems do not consistently follow good practice guidance and place residents at risk. EVIDENCE: It was reported that the organisation would be introducing a new format for care planning in the coming months. The manager advised that she has run training sessions for staff on care planning and that further training has also been planned. Mais House DS0000039554.V360685.R01.S.doc Version 5.2 Page 12 Five care plans were examined on this occasion. Some aspects of the care plans were good and there was clear information provided on the action to be taken to meet needs. Dependency profiles were up to date and risk assessments had been carried out on the use of cot sides. Relatives had been asked to sign giving consent for use. Despite the training provided to staff, overall care plans are mainly task orientated and do not reflect holistic needs. There are some exceptions to this. In one care plan it was noted that there was reference to how the resident liked their light on in their room at night. In one file there was a care plan on communication, but the information provided related to use of glasses and vision rather than relating to how the resident communicated. In another file there was good information about feeding but it was not possible to determine if the advice given was followed. Records showing that weights have been monitored were up to date in some files and were not in others. Daily records don’t link with the care plans so it is difficult to see how progress is measured. In relation to one resident it was noted that there were four care plans in place. However, the daily reports all stated ‘remains independent’ and no other information was provided. In relation to another resident there was very detailed advice about the how to promote independence but again no reference in the daily records to whether the advice was being followed or if any progress was being made. There was no evidence that residents are aware of their care plans or that they have been asked to sign them. A staff member spoken with stated that shifts are busy and there is not enough time allocated to completing care plans to enable them to be kept fully up to date. Staff observed in the course of their duties were courteous and were seen to treat residents with respect. Residents spoken with stated that the staff ‘couldn’t be more helpful. There was evidence in the care plans seen that when residents needed to see specialist for example a physiotherapist, then arrangements were made for this to happen. Records of medication administered were examined during the inspection and were in order. Controlled drugs were stored appropriately and double signatures were recorded in the register. Each resident’s medication is stored in individual cabinets in their bedrooms. Staff reported that this works well in the mornings and at night when residents are in their bedrooms but it is more problematic at lunch and evening mealtimes as the nurse has to go to individual rooms to collect the meds and then take it to the dining room to administer. It was noted that several medication errors/problems had been identified by the home in recent weeks. The majority of the problems related to one particular member of staff and the home were taking appropriate action in Mais House DS0000039554.V360685.R01.S.doc Version 5.2 Page 13 dealing with this. However, the home had failed to notify the Commission of the situation. Medication was examined in two cabinets in bedrooms. The majority of the medication is stored in a monitored dosage system. It was noted that the liquid medication in use had been in use for a long time. On the MAR chart records showed that the medication which was prescribed on an ‘as required’ basis, was very rarely administered. Medication audits are carried out on a monthly basis and records of the last audit were seen. It was not possible to determine if the cabinets in individual residents’ bedrooms were assessed as part of this audit. However, following this inspection the home confirmed that there is a section to cover this area within the monthly audit. It was not possible to determine from records when staff have last had training in medication. It was reported that at least three staff have completed a medication course in recent weeks but two of the three have failed the course. The manager advised that all trained nurses and team leaders are expected to do this training and several staff are currently studying for this course. Staff who failed the course will be expected to resubmit their work. It was also not possible to determine from records when trained staff have last had any specialist training to update their knowledge. As required at the last inspection there is now a detailed policy in place on the use of oxygen. In relation to the care plans seen, records showed that residents’ wishes in the event of dying and death had not been assessed. In relation to one resident there was a statement that the relative should be contacted at any time night or day. There is detailed information in the statement of purpose explaining that this subject will be explored as part of the assessment process. Mais House DS0000039554.V360685.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): 12,13,14,15 People who use 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. There is a wide range of interesting activities on offer to those residents who choose to participate. Residents enjoy good quality meals in pleasant surroundings. EVIDENCE: Since the last inspection a new activity co-ordinator has been appointed and a second person is also employed on a part-time basis to assist with activities. A weekly programme of activities is displayed on a notice board and in addition the co-ordinator advises residents of the programme. Activities are also discussed during the weekly residents’ meetings. Activities for the week of the inspection included: - games morning, bingo, recalling the past, chair based exercises, team quiz, individual physio, residents’ meeting, garden project, music for all and a possible outing. One Mais House DS0000039554.V360685.R01.S.doc Version 5.2 Page 15 resident spoken with advised that up until recently she took part in all the outings and really enjoyed them. Other residents advised that they pick and choose the activities they participate in. Two residents stated that the team quiz was too easy and a bit ‘insulting to their intelligence’. Residents advised that in relation to religious needs, if they have any special requests then the home makes arrangements for religious or lay visitors to visit. On the first day of inspection there were three volunteers running a shop in the lounge area. Residents spoken with advised that they really value this, ‘it’s a very good service’ particularly if they do not have regular visitors. They stated that if there is something they want but it is not in stock they tell the volunteers who do their best to make sure it is available next time. There is a licensed bar in the home which is run on regular basis, staff permitting. On the first day of inspection four residents were heard to ask about the bar but unfortunately there was no one to run the bar on that occasion. It was reported that volunteers have been recruited and CRB checks are currently being carried out. Some of the residents spoken with stated that they enjoy this facility. Residents meetings are held weekly. Minutes of a meeting held in February were seen and it was noted that fourteen residents attended. A wide range of issues were discussed, including food, activities, response time to call bells and storage of equipment. A resident spoken with stated that they have not experienced any delays when they ring the bell. There is a five-week menu in place, which is varied and well balanced. A cooked breakfast is available daily. There is a choice of two hot meals or salad/cold meats seven days a week. A roast dinner is available twice a week. Supper consists of a hot meal, sandwiches, boiled egg or soup. All the residents spoken with stated that the food is good and that there are home baked cakes served every afternoon. A staff member spoken with advised that following the last inspection the home ensures that those residents who use a wheelchair whilst eating their meals are enabled to do so comfortably. Where residents require staff support with feeding, staff make sure that they are facing the resident whilst assisting with feeding. Mais House DS0000039554.V360685.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): 16,18 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Systems are in place to enable anyone wishing to make a complaint to do so. There is inconsistent knowledge and practice in relation to adult protection and this could place people at risk. EVIDENCE: The home’s complaint procedure needs to be updated to include the changes to the management of the home and the changed address for the Commission. There is a procedure in place for recording all complaints received. The manager reported that there have been no complaints received since she took over. However there is no complaint folder and it was not clear when the last complaint had been received by the home. Five adult protection alerts were made to Social Services in November 2007. Two of the alerts were rejected and investigations were carried out in relation to three. There is currently no adult protection folder in the home. The outcome of the three investigations will need to be forwarded to the Commission. As a result of the alerts disciplinary action needed to be taken in a number of cases. Mais House DS0000039554.V360685.R01.S.doc Version 5.2 Page 17 There is a detailed procedure in place in respect of adult protection and prevention of abuse, which was updated in January 2008. Twelve care staff and two trained staff received training on the subject in February 2008 but there is still a high percentage of staff that need training in this area. A staff member spoken with confirmed that she is due to attend a course in April. Mais House DS0000039554.V360685.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): 19,20,21,25,26 People who use 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. Residents benefit from living in a clean and comfortable environment where they are able to personalise their own rooms. EVIDENCE: Mais House provides a well-maintained and comfortable environment for its residents, and for those who visit. The bedrooms are well furnished and comfortable with domestic lighting and adjustable radiators. There are a wide choice of communal areas to spend time in including activity rooms, a licensed Mais House DS0000039554.V360685.R01.S.doc Version 5.2 Page 19 bar and a kitchen where residents can make use of tea/coffee making facilities independently. Residents are encouraged to personalise their rooms with furniture and items from home and this was confirmed during the tour of the premises. The lighting in the home is of domestic quality and there are above bed lights as well as the main ceiling lights. There are adequate communal bathrooms and shower rooms in the home with specialist equipment, which enables frail residents and those with a physical disability to enjoy the facilities available. Specialised equipment to encourage independence is provided e.g. handrails in bathrooms, hoists, wheelchairs and lifts to all areas of the home. A residents spoken with confirmed that she never has to wait too long when she uses the call bell. Water temperatures are controlled and monitored monthly and a record kept. There are systems in place for monitoring safety issues such as fire checks, PAT testing, electrical tests and gas and boiler checks and all the rooms are routinely checked for safety and maintenance issues. The records in the home confirmed they were up to date. The home was clean and free from offensive odours at the time of inspection. Hand cleaning sprays are conveniently displayed to promote good hygiene practices. Mais House DS0000039554.V360685.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): 27,28,29,30 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care staff are provided with good opportunities to update their skills and knowledge. Some of the trained staff have not updated their knowledge and skills to meet the specialist needs of the people accommodated and this could compromise the quality of the care provided. EVIDENCE: Over the past few months there has been a high use of agency and bank staff. This has been necessary due to staff shortages and also due to the high incidence of staff disciplinary actions being taken. On the first day of inspection there was one permanent trained staff and one agency nurse on duty along with care staff. On the afternoon of the second day in addition to care staff there was one bank nurse and one agency nurse. It was reported that both the bank and agency nurse had worked in the home previously. Mais House DS0000039554.V360685.R01.S.doc Version 5.2 Page 21 Staff spoken with talked about low morale and how difficult it has been over recent months. A member of care staff spoken with stated that they need a ‘clear sense of direction’. In relation to staff spoken with on the day it is evident that the extent of individual roles and responsibilities needs to be clarified. Two staff talked of ‘not enough hours in the day to complete all tasks to be undertaken and one staff member said that ‘expectations are too high’. In relation to staff recruitment two files were seen in respect of two staff recently recruited to work in the home. In both cases there was a detailed application form and two references. One of the references seen was not satisfactory but the manager advised that the circumstances had been discussed with the applicant and on balance it was felt that the issues would not be a problem in this employment. In one file there was a first day induction checklist. The manager advised that both staff would complete a more detailed induction in the coming weeks. There is a staff-training matrix in place, which shows that all staff have regular opportunities to participate in mandatory training. A high percentage of care staff have attended all mandatory courses. In relation to nursing staff there was one staff member on maternity leave, one very new member of staff and one on long-term sick leave. Leaving them out of the equation records showed that four staff have yet to complete fire safety training, five need training in manual handling, six training in infection control and eight training on the protection of vulnerable adults. Only one member of nursing trained staff has up to date training in first aid and that is due to be renewed this year. A staff member spoken with stated that on occasions they have been booked to attend training but due to staff shortages they have been unable to attend. It was not clear from records what specialist training staff had undertaken to enable them to carry out their role within the home. Records as at February 2008 showed that fifteen out of twenty eight care staff have completed NVQ at either level two or three. There is currently one disciplinary matter still outstanding and this is under investigation. Mais House DS0000039554.V360685.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): 31,32,33,36,37,38 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The operation of this home does not fully safeguard residents. However, the organisation is taking action to support the new manager in her efforts to improve the quality of the care provided. EVIDENCE: Mais House DS0000039554.V360685.R01.S.doc Version 5.2 Page 23 Since the last inspection the registered manager retired from her position as manager. An agency manager was then appointed on an interim basis until a new manager could be recruited. A new manager was appointed in December 2007 and has yet to submit her application for registration. She advised that in addition to her nursing qualifications she has also completed the Registered Manager’s Award. For a period of time there was an acting head of care in post but this is no longer the case. The home is actively recruiting for this position. It was evident from speaking with staff throughout the inspection that staff morale is extremely low and has been for a period of time. Staff stated that they are pleased with the appointment of the new manager. One staff member said ‘its great, I hope she stays’. The manager advised that since taking up the position she has had staff meetings and arranged a night out to try to boost morale. She is keenly aware of all the problems and what needs to be done to tackle them but it will take time. Not having a head of care is a disadvantage at the moment and it is evident that there is too much work for one individual to do on their own. There was an opportunity to meet with the operations manager for a short time on the second day of inspection. She acknowledged the problems the home was facing and advised that they are hoping to get an acting head of care in post as a temporary measure until they recruit a suitable person to this post. In addition she intends to meet with the agency to get a well-trained nurse on a temporary contract for a few months. A new arrangement, yet to be introduced, has been put in place highlighting supervision responsibilities. The manager will supervise the trained staff and they in turn will supervise the team leaders. Team leaders will soon be taking over responsibility for supervising care staff. Within this arrangement responsibilities for updating and overseeing care plans are identified along with who is keyworker to each resident. Residents have yet to be notified of their keyworkers. For a period of time some staff have not received regular supervision but it is hoped that the new system will assist the home in getting back on track in this area. Staff reported that one of the main drawbacks holding this back is the staff shortage and until this is resolved it may hinder moving forward in this area. It was reported that a new quality assurance system is to be brought into the home in the near future. The manager advised that satisfaction questionnaires were obtained from residents and staff at the end of January 2008. The results have yet to be collated and feed back to each group of Mais House DS0000039554.V360685.R01.S.doc Version 5.2 Page 24 people. The manager advised that it is her intention to join a residents meeting to provide feedback on their survey. There is a detailed fire risk assessment in place that was carried out in July 2007. It was noted that a few recommendations were made to the home as a result. It was not clear if they have been addressed yet. Records are in place showing that alarms and emergency lights are tested at regular intervals. A fire drill was held on 21/2/08 and a list of staff in attendance was recorded. There was no other information recorded such as time of drill, how long it took or if staff responded appropriately when the alarms sounded. The previous fire drill was in June 2007. A Legionella risk assessment was carried out in July 2007 and portable appliances are also tested regularly. Records were seen in relation to Regulation 26 visits carried. Records showed that a visit was carried out in September 2007 and there were two separate reports both dated the same day in January 2008. Neither of the two reports carried out in January reflect accurately how the home is running although it does state that the home is going through a difficult period. There is no space on the report for the manager to sign receipt of the report. A number of notifyable incidents have been reported to the Commission since the last inspection. However, two incidents were discussed that should have been reported to the Commission as notifyable events. In relation to one of these incidents the organisation were carrying out an internal investigation and this was ongoing at the time of the second visit to the home. Staff seen during this time were upset about the way in which this was being handled. Mais House DS0000039554.V360685.R01.S.doc Version 5.2 Page 25 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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 1 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 3 3 X X X 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X X 1 1 1 Mais House DS0000039554.V360685.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1)(2) 12 Requirement That the care plans accurately reflect the needs of the service users in respect of their health, social and behavioural needs. That service users (where practical) or the representatives are consulted on the formation of care plans. This requirement was made at a previous inspection and remains unmet. Timescale given was 01/01/07. In relation to medication: All staff with responsibility for administering medication must receive up to date training on the subject. Medication prescribed on an ‘as required’ basis must be reviewed regularly to ensure it is still necessary. All medication must be checked regularly to ensure that it remains in date. The wishes of residents in DS0000039554.V360685.R01.S.doc Timescale for action 31/07/08 2. OP9 13(2) 30/04/08 3. OP11 12(2) 30/06/08 Page 27 Mais House Version 5.2 4. 5. OP16 OP18 22(7) 13(6) 6. OP30 18(1a,ci) 7. 8. OP31 OP33 9(1) 24 9. OP33 26(5a) 10. OP37 37(1e) 11. OP38 23(4a,e) residents in relation to dying and death must be assessed. The home’s complaint procedure must be updated. The home must keep detailed records of all adult protection alerts made including details of the outcome. Staff training records must show that nursing staff are updating both their mandatory and specialist knowledge and skills to maintain competence and meet the changing needs of the residents accommodated. The manager must submit an application for registration. In relation to quality assurance, the outcome of the satisfaction questionnaires must be collated and feedback given to all relevant people. Detailed monthly reports carried out by the provider or a representative on their behalf must be copied to the Commission until notified otherwise. Any incident that affects the well-being of a resident must be reported to the commission without delay. In relation to fire safety, Records must show that the recommendations made as part of the fire risk assessment have been addressed. The frequency of fire drills must be increased and records detailing the outcome must be kept. 30/04/08 12/05/08 31/05/08 30/06/08 19/05/08 30/04/08 30/04/08 31/05/08 Mais House DS0000039554.V360685.R01.S.doc Version 5.2 Page 28 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. 3. Refer to Standard OP7 OP30 OP38 Good Practice Recommendations Daily records should show the progress made or otherwise in meeting the assessed needs of the residents. Job descriptions must be reviewed and the extent of each worker’s individual roles and responsibilities clarified. That staff receive training in first aid, and that all staff are aware of the homes’ policy for resuscitation. Mais House DS0000039554.V360685.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Mais House DS0000039554.V360685.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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