Inspection on 17/06/05 for Mais House

This inspection was carried out on 17th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 14/03/08

Mais House 23/11/06

Mais House 07/12/05

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 Paul Endersby Unannounced 17 June 05 9:00 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 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 H59-H10 S39554 Mais House V226700 170605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Mais House Address 18 Hastings Road Bexhill on Sea East Sussex TN40 2HH 01424 215871 01424 732197 None The Royal British Legion (Organisation) Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Jane Alison McAulay Care Home 54 Category(ies) of Old age, not falling within any other category registration, with number (OP), 54. of places Mais House H59-H10 S39554 Mais House V226700 170605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. That only older people may be accommodated. 2. That service users accommodated will be aged 65 years or over on admission. 3. That the maximum number of service users to be accommodated will not exceed 54. 4. Service users can be accommodated who in addition to old age may have a physical disability. Date of last inspection 17 January 2005 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. The home, which is owned by The Royal British Legion, is situated in a cul-de-sac in a quiet residential area of Bexhill. The premises comprise an older house with two large modern wings added. One wing is set aside for nursing patients, and the other for people requiring residential care. The building is well maintained both internally and externally and the standard of décor is high. The building is set on three floors and has two shaft lifts either end of the building to facilitate access for the residents. The bedrooms vary in size and include one room that is being shared. Facilities for service users in the home include a bar, hairdressers, activities room, conservatory, complementary therapy room and a very well maintained and attractive garden. Mais House H59-H10 S39554 Mais House V226700 170605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place through much if the day. The Inspector met with the manager and deputy manager plus other staff members. He met many of the residents including spending time specifically with eight of them. The inspection included a tour of the premises as well as a review of some care plans, records and other documentary information. The inspection lasted 6½ hours. What the service does well: 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. Mais House H59-H10 S39554 Mais House V226700 170605 Stage 4.doc Version 1.30 Page 6 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 Standards Statutory Requirements Identified During the Inspection Mais House H59-H10 S39554 Mais House V226700 170605 Stage 4.doc Version 1.30 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, & 5 Prospective residents are provided with a range of relevant information prior to entering the home. This assists them and their families in coming to an informed decision about where to live and to experience some aspects of life in the home. Pre-admission visits and the terms and conditions of residence add to information available. EVIDENCE: A comprehensive Statement of Purpose and Service Users Guide has been prepared which provides considerable information to prospective and current residents. In addition an information guide has been prepared which includes a range of practical information for new residents. All residents, or their representatives, are given a wide-ranging statement of Terms and Conditions prior to entering the home. All prospective residents are encouraged to visit the home prior to admission to familiarize themselves with the home and meet other residents and staff. Such visits can vary in length and often involve sharing a meal with other residents. Mais House H59-H10 S39554 Mais House V226700 170605 Stage 4.doc Version 1.30 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, & 9 Care plans ensure that a comprehensive record is maintained of residents needs and that there is a consistent response made by staff. The systems for administering and recording medication provide protection for residents. EVIDENCE: A sample group of care planning documentation was examined both in respect of nursing patients and residents. These included information and guidelines on most aspects of residents personal and health care, including risk assessments on mobility and pressure sores. Most plans are signed and agreed by residents or their relatives. There is input in the care plans and reviews from different members of the multi-disciplinary team. They are then discussed with individual residents who invited to sign them. Since the last inspection action has been taken to clarify the social needs, interests and preferences of residents and include them in the individual care plans. A monitored dosage medication system is used for dispensing medication to residents. Records of medication administered are maintained. Since the last inspection action has been taken to ensure that these records are accurate and reflect the actual situation in regard to medication taken. Appropriate arrangements have been made in regard to the storage and recording of controlled drugs. Mais House H59-H10 S39554 Mais House V226700 170605 Stage 4.doc Version 1.30 Page 9 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13, 14 & 15 Residents are enabled to maintain contact with their families and receive visitors of their choice. Choice in daily living is an important part of the ethos of the home. A varied and wholesome menu, with choices, is provided for residents. EVIDENCE: Residents can receive visitors in their own rooms as well as the communal areas including the lounge areas and garden. Meals are provided for visitors if required. Residents are able to choose who they wish to see. There is no time or access restriction for visitors, other than residents may themselves impose or request. Volunteers from the local community are used to staff the home’s bar at lunchtimes. From observations and discussions with residents it was evident that they are given choices in all aspects of daily living. Residents are encouraged to bring their own possessions with them including furniture. As a result most residents do so, with the outcome that there are many comfortable and personalized bedrooms. Mais House H59-H10 S39554 Mais House V226700 170605 Stage 4.doc Version 1.30 Page 10 Meals are taken in the very pleasant dining room. All meal times are flexible. A five week menu plan has been devised with seasonal changes. This confirmed that a varied and nutritious diet is provided. Alternatives are available and special diets are provided. Since the last inspection the registered manager has introduced a survey of residents regarding meals provided. However this has not yet been completed. In discussion with the Inspector, responses by residents in regard to the quality of meals were varied. Some were very positive, whilst others were less enthusiastic. A record of meals served is maintained. Mais House H59-H10 S39554 Mais House V226700 170605 Stage 4.doc Version 1.30 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 Arrangements for protecting residents are satisfactory. EVIDENCE: Since the last inspection the policy on the protection of vulnerable adults has been revised and now includes the multi-agency guidelines for East Sussex. Most staff have undertaken relevant training and further training is planned for later this month. Training is provided by a British Legion trainer. Relevant policies and procedures for the instruction and guidance of staff have been prepared in regard to physical restraint should this be required. Mais House H59-H10 S39554 Mais House V226700 170605 Stage 4.doc Version 1.30 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 25 & 26 The overall standard of the environment and maintenance of the home is good, providing residents with an attractive and safe place to live. EVIDENCE: The location and layout of the home is suitable for its stated purpose. The home consists of an older central house with two added new wings. Accommodation is on three floors. The home has very large well-tended gardens that are very popular with residents during the summer months. The building and grounds are well maintained to a high standard. There are annual checks by an external health and safety firm to ensure compliance with the fire safety requirements plus visits from the Fire Brigade. The Environmental Health Department also visit. All parts of the home are centrally heated and radiators are guarded. Hot water delivered to baths and wash hand basins is at a safe temperature. There are regular checks of the hot water outlets and the result recorded On the day of the inspection the premises were clean and hygienic throughout. The laundry is well equipped and appropriately sited well away from food preparation areas. There is a policy for the control of infection which provides guidance and instruction to staff. Mais House H59-H10 S39554 Mais House V226700 170605 Stage 4.doc Version 1.30 Page 13 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 28 The staffing levels are sufficient to meet the needs of the current residents. The training of staff contributes to the overall safety of residents. EVIDENCE: There is a large staff team including management, registered nurses, care staff, an activities co-ordinator, kitchen, domestic and maintenance staff. A complementary therapist is on-site 4 days a week. In addition there as an office based administration team. Normal staffing levels include two nurses plus eight carers during the morning/early afternoon with two nurses plus six carers for the afternoon/early evening. Night staffing comprises one nurse plus three carers. Since the last inspection action has been taken to include all care and nursing staff in handovers. Some discussion took place with the manager and deputy manager regarding providing smaller groups of residents, a process which has already begun. The advantages of having more individual teams would increase the ability of staff to provide consistent care and have closer awareness of individual service users needs, were part of that discussion. Currently eight care staff have successfully achieved NVQ levels 2 or 3. In addition a further ten are in training. It is anticipated that all will complete their training by the end of the year. This will result in just over half the care staff being qualified, which is the recommended minimum level. Mais House H59-H10 S39554 Mais House V226700 170605 Stage 4.doc Version 1.30 Page 14 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35, 36 & 38 The home is well managed by a suitably qualified and experienced manager. The quality assurance systems assist in ensuring that the home is run in the best interests of residents. Appropriate arrangements have been made for providing a safe environment for residents. EVIDENCE: The registered manager is a qualified nurse with many years experience. She also has considerable experience as a manager including the past year at Mais House. More recently the manager has been studying to achieve the Registered Managers Award (RMA) which she hopes to complete shortly. However she is due to leave Mais House in August 2005. All the feed back from both residents and staff was very positive about the overall management of the home. The manager was described as knowledgeable and competent and both staff and residents said they felt she is approachable and listens. Regular staff meetings are held for the different staff groups. In addition resident meetings are held. Mais House H59-H10 S39554 Mais House V226700 170605 Stage 4.doc Version 1.30 Page 15 Since the last inspection a quality assurance survey has been introduced using a wide ranging questionnaire which both residents and relatives have been invited to complete. It is intended that when all have been returned they will be analysed and the results included in the Service Users Guide. Monthly visits by an external manger are undertaken on behalf of the service providers. However these are not always unannounced as required. There is only very limited involvement by staff in residents finances. This is confined to holding small amounts of money on behalf of some them. Records of income and expenditure are maintained. A sample were checked and found to be in order. Staff are now receiving regular personal supervision primarily from the manager. This includes observing them performing routine caring tasks. It is intended that the supervision should be shared with the deputy manager and other senior staff. Currently neither the manager or deputy manager have undertaken any specific training in staff supervision. It is evident that appropriate steps are taken to ensure a safe working and living environment for service users and staff. Relevant training supported by written policies contribute to this situation. There is regular testing of gas and electrical systems and equipment and records maintained. Risk assessments of the building are undertaken and the results recorded. An annual fire risk assessment is undertaken by an external health and safety organisation. An accident record is maintained. Similarly an annual health and safety risk assessment of the building is undertaken. There are regular checks of hot water temperatures and the results recorded. Mais House H59-H10 S39554 Mais House V226700 170605 Stage 4.doc Version 1.30 Page 16 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 x x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x 3 3 STAFFING Standard No Score 27 3 28 3 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 3 3 3 x 3 2 x 3 Mais House H59-H10 S39554 Mais House V226700 170605 Stage 4.doc Version 1.30 Page 17 YES Are there any outstanding requirements from the last inspection? 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 33 Regulation 26 (1)(3)(4)( 5) Requirement Monthly visits to the home on behalf of the registered provider must be unannounced Timescale for action 17.06.2005 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 36 Good Practice Recommendations Staff involved in the formal supervision of staff should undertake relevant training. Mais House H59-H10 S39554 Mais House V226700 170605 Stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection Ivy House, 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mais House H59-H10 S39554 Mais House V226700 170605 Stage 4.doc Version 1.30 Page 19 - 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!