Inspection on 23/11/06 for Mais House

This inspection was carried out on 23rd November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 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 Debbie Calveley Key Unannounced Inspection 23rd November 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Mais House DS0000039554.V320679.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.V320679.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 The Royal British Legion Vacant Care Home 54 Category(ies) of Old age, not falling within any other category registration, with number (54) of places Mais House DS0000039554.V320679.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. 7th December 2005 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 high. The rooms vary in size and included one room that was being shared. 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 2006 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.V320679.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. 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 was a key inspection that included an unannounced visit to the home and follow up contact with resident’s representatives and visiting health and social care professionals. This unannounced inspection was carried out over 7 hours on the 23rd of November 2006. There were 52 residents in residence on the day, 25 of which receive care with nursing. Eight were case tracked and also spoken with. During the tour of the premises ten other residents both male and female were also spoken with. The purpose of the inspection was to check that the requirements of previous inspections had been met and inspect all other key standards. 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. Four members of care staff, two trained nurses and the chef were spoken with in addition to discussion with the Acting Manager. The pre-inspection questionnaire was received back from the registered manager on the 20th November 2006 completed in full. Comment cards received from four residents and three relatives were positive and indicated that both groups were satisfied with the services provided. Two comment cards were received from social and healthcare professionals, and two staff surveys were received from staff. The information contained in the returned surveys has been incorporated into this report. What the service does well: There is a Statement of Purpose and Service Users Guide (brochure) that gives prospective residents the information required to enable them to make an informed choice about where they live. Returned surveys all confirmed that they were visited by the Manager prior to admission to the home and also invited to visit the home to see if they liked it enough to live there. ‘I was shown over the premises, including the bedroom and was able to ask questions’ ‘ Apart from brochures, we also came for a personal tour of the home, were able to ask various questions. The matron also visited us at home’. Mais House DS0000039554.V320679.R01.S.doc Version 5.2 Page 6 Systems are in place to regularly consult with residents via service users meetings and surveys. There is an open-house policy, which welcomes visitors at all reasonable times. Satisfactory arrangements are in place to safeguard residents’ finances. Staff provision is well maintained with a robust recruitment practice being followed and appropriate numbers of suitably qualified staff working in the home. The atmosphere of the home is pleasant with good interaction seen between residents and staff. The Comments received from residents and families regarding the care received included: ‘ Staff efficient, courteous and kindly’ ‘ there has to be a bit of give and take on both sides’ ‘ a drs visit can always be arranged either at the surgery or in the home. Nursing care is always available’ ‘ She receives excellent nursing care and care workers are kind, considerate and supportive of her every need’ The residents are enabled to exercise the choice and control of their every day life. Residents are supported to follow outside interests. Mais House provides a clean, safe and well-maintained environment, which is appreciated by the residents and their relatives. Comments regarding Mais House generally were very positive and included: ‘I have been here for over five years. I am unable to walk very much and I cannot place on record too high praise for Mais House and its staff’ ‘ Mais house is an excellent home I would recommend it to anyone’ ‘ On the whole the home meets our needs. The staff are invariably kind and patient’. ‘ My mother is a resident and requires 24 hr nursing care. Her care is of the highest quality. ‘ We would like to congratulate the matron and her delightful staff we are totally impressed by mums care- she is treated with love and respect- the family are most grateful’. What has improved since the last inspection? What they could do better: The care plans and risk assessments do not all accurately reflect the individual residents actual needs, both long and short term identified problems. Therefore the care plans are not providing guidance for staff to provide a Mais House DS0000039554.V320679.R01.S.doc Version 5.2 Page 7 consistent approach to meeting the needs of the residents. Risk assessments were inaccurate in several care plans and there was little evidence seen of what action was taken or what specialist input was sought as a result of using a specific risk assessment tool. There was little evidence seen in care plans of resident/relative consultation. There were some recommendations made regarding audit trails of controlled medication, and staff all being aware of the homes policies regarding oxygen and resuscitation. Residents are missing the activities previously offered in the home and whilst the post is being advertised, there is a gap that indicates the resident’s social needs and expectations are not being fulfilled. ‘The manager is trying hard’ ‘activities lady off on long term sick leave at present, so there is not a lot going on’. Regular resident consultation regarding food would ensure that all residents are satisfied with the quality and choice, as some resident’s comments were not positive. ‘Cooks do not adhere strictly to recipes therefore dishes such as milk puddings stews, curries etc may vary from liquid to stodge. The same applies to seasoning, thus making some vegetables tasteless’ ‘ There is no taste when having roast chicken, very bland’. 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.V320679.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.V320679.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, 4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives are provided with information about the home in order to make an informed choice about whether to live at the home. The pre-admission assessment procedures ensure residents admitted can have their care needs met within the home by experienced staff. EVIDENCE: The Statement of Purpose and Service Users Guide are combined in to one document and was on display in the reception area of the home. It was found to be up to date and contained information that prospective residents need to make an informed choice of where to live. Not all residents spoken with were aware of the Service Users Guide and it would benefit all residents to have their own copy. Mais House DS0000039554.V320679.R01.S.doc Version 5.2 Page 10 There is a written contract/statement of terms and conditions that all residents receive on admission to the home. This contract is confirmation of the room booked, the type of admission, either respite or permanent and the fees to be paid. The pre-admission assessment document is part of the care planning system used in the home. Six were viewed in depth and four were found completed in full and signed and dated. All staff that are involved in pre-admission assessment need to ensure the document includes the people present and venue and that they are signed and dated on the day undertaken. The pre-admission assessment are used to ensure new admissions to the home are suitable and that the home have the staff and environment to meet the care needs of the new resident. The information contained in these assessments is then used to provide the basis of the care documentation in the home. The prospective residents’ are seen either in their home or hospital before admission and the manager confirmed that wherever possible the family or representative is involved. The following are comments from resident/relative surveys received. ‘I was shown over the premises, including the bedrooms and was able to ask questions’ ‘Apart from brochures, we also came for a personal tour of the home, were able to ask various questions. The matron also visited us at home’. ‘ The matron/ manager at that time visited me at my home in Hove on two occasions and I visited Mais house twice for lunch before deciding to move in’ ‘we were given a tour of the home prior to my mothers discharge from hospital’. Trial visits/respite visits to the home can be arranged. The manager confirmed that residents are invited to a trial period to ensure suitability of the home; this is clearly stated in the Statement of Purpose and in the statement of terms and conditions. Mais House DS0000039554.V320679.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally care plans provide a good framework for the delivery of care, however these need to provide clear guidance to care staff on all the care needs of all the residents. The home was found to be meeting resident’s health and general needs with accessed additional specialist support when needed. Procedures and practice in the home allow for the safe administration of medicines and promote the privacy and dignity of residents. EVIDENCE: The care documentation pertaining to six residents was reviewed as part of the inspection process. These were found to include plans of care, nutritional assessment, personal histories and risk assessments. On the whole the care documentation demonstrated that the care was reviewed and evaluated, however it was noted that the plans of care did not always cover all the care needs of residents. For example one resident who has communication problems did not have any guidance in the documentation to facilitate this vital need, a number of residents have recently been commenced on antibiotics, but Mais House DS0000039554.V320679.R01.S.doc Version 5.2 Page 12 no short term care plan was in place to guide staff in this new need. One resident who was on anti-seizure medication did not have a plan of care for staff to follow if a seizure occurred. Risk assessments for health needs are included in the care planning format used by the home, however not all risk assessments were found to be correctly completed and did not follow through with an appropriate plan of action when identified as required. The manager is aware that there is work to be done on improving the standard of the documentation and confirmed that a new care plan format was to be introduced next year. From talking to staff it was confirmed that a number of residents are experiencing frequent infections and this should be clearly demonstrated in the care plan as to guide staff on preventing reoccurrence. Staff spoken to confirmed that they received a full report on each resident daily and read the care documentation that is kept in the main nurses station. They felt that their views were taken into account when planning resident’s care. Relatives and residents spoken to were very satisfied with the care provided at the home one saying that the home ‘should be commended for its care’ ‘my relative receives excellent nursing care and care workers are kind, considerate and supportive of her every need’ ‘Staff are efficient, courteous and kindly’. Residents spoken to were also very satisfied, comments included ‘they look after me very well’ ‘I am very lucky living in Mais House’ ‘ I like it here’. Medication procedures have been reviewed since the appointment of the acting manager in February 2006. Issues found on her appointment have been addressed and there is an on-going medication audit in place to monitor practice. Medication practices were found to be satisfactory at the time of this visit. The clinical room was seen, and was found clean, tidy and well stocked. The systems for recording and checking controlled drugs were found to be thorough. Medication Administration Charts were found to be competently completed. Some areas of good practice were discussed with the senior nurse on duty during the inspection. Staff were seen to be respectful and considerate to all residents and visitors. Each of the residents were addressed by their preferred term and dressed appropriately in well-laundered clothing. ‘We always receive good communication- are shown compassion and understanding in facing the illness my mother has’. Mais House DS0000039554.V320679.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The lifestyle experience by residents at this time does not always match their expectations, choice or preferences. Meals remain good in respect of both quality and variety that meets the majority of residents’ tastes and choice. EVIDENCE: The activities co-ordinator is currently on long-term leave and the organisation are advertising for a replacement. The manager is endeavouring to provide activities and trips out during this time. The activities offered include piano recitals, bingo sessions, theatre shows- videos, physiotherapy-musical exercises and outside performers. There is a bar lounge which is run by volunteers open everyday for several hours, it is now a non smoking area and is more widely used. There is a trolley shop also run by volunteers enabling those that are unable to leave the building to choose personal items. There is a well-equipped activity room with computers and access to the internet, but it is acknowledged that the room is underused at present and there is not a large range of activities to participate in. Mais House DS0000039554.V320679.R01.S.doc Version 5.2 Page 14 Residents living in Mais House are encouraged to attend facilities away from the home; these include Royal British Legion Clubs, shopping trips, church services and Day centres. One gentleman regularly attends tea dances. Comments received regarding activities include: ‘We have in –house entertainment from time to time-also outings in the minibus, country drives, theatre visits etc. mostly C of E services in the home and transport each Sunday for those who wish to go to church’ ‘ the resident, my wife enjoys the entertainment laid on from time to time’ ‘ mum is bedridden, so unable to participate, but we her family are impressed by the activities offered’. One resident said that ‘the activities were disappointing at this time, but the staff try’. Activities are an important part of life to the residents of Mais House, as there are some very independent people living there and therefore it is identified as requiring development to meet all the residents’ social needs. Residents are facilitated to maintain their independence for as long as they are able. There are no restrictions on visiting times as long as consideration is shown to all the residents. There are communal areas throughout the home that are available to residents and their visitors for private meetings if required. Many of the residents have individualised their bedroom with items from home and residents and relatives spoken with confirmed that they are encouraged to make it homely. The home has an advocacy policy in place and the information regarding this is available to all residents. The dining area is large and attractive with tables set for up to four residents. The kitchen lies adjacent to the dining area and is open plan. The menus rotate on a five weekly basis and the menus viewed demonstrated choice and a wellbalanced dietary content. However the views on food was mixed: ‘Although mum eats little, great care is paid to her needs regarding food and liquids’ ‘Cooks do not adhere strictly to recipes therefore dishes such as milk puddings stews, curries etc may vary from liquid to stodge. The same applies to seasoning, thus making some vegetables tasteless’ ‘ A five week rotation of menus invariably becomes a bit monotonous after a while. Perhaps the suppers could be improved a bit’ ‘ The cooked breakfast is appreciated by those who want it. - On the whole the food is good’ ‘The resident, my wife has eating problems the advice from the nurses and help by the chef has been most helpful’. The chef has worked in the home for six years and feels supported by the staff and manager. He is at present reviewing the in-house surveys received from residents regarding the meals and is planning some changes to the menu as a result of some feedback. Mais House DS0000039554.V320679.R01.S.doc Version 5.2 Page 15 Staff were seen assisting residents with their meal in a respectful and dignified manner. The positioning of some residents in wheelchairs was noted to be hindering independence rather than enabling and specialist advice should be sought fro occupational therapists. Mais House DS0000039554.V320679.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. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The home has a formal complaints system with evidence that residents feel that their views are listened to and acted upon. Staff receive training to protect residents from abuse. EVIDENCE: The home has a clear complaints procedure and a copy of this is readily available in the home. A system of recording complaints was demonstrated to the inspector during her visit to the home. Systems have been developed in the home where residents and relatives can raise any niggles before they become a complaint. Relatives and residents spoken to confirmed that they were confident that any complaints or concerns that they had would be listened to and responded to effectively. The home has relevant guidelines on the protection of vulnerable adults and staff have received appropriate training. The management team has a clear understanding of adult protection guidelines and are aware of how to initiate an investigation if required. Mais House DS0000039554.V320679.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable, clean and safe environment for those living there and visiting. Residents are enabled and encouraged to personalise their bedroom, and rooms are homely and reflect the resident’s personalities and interests. There is specialist equipment in the home for residents’ use to maximise their independence. EVIDENCE: Mais House provides a well-maintained and comfortable environment for its residents, and for those who visit. There is a maintenance programme and over the past year, all bedrooms and communal areas have been re-carpeted, the residents’ bedrooms have been painted, as has the clinical room. The bedrooms are well furnished and comfortable with domestic lighting and adjustable radiators. Mais House DS0000039554.V320679.R01.S.doc Version 5.2 Page 18 Residents are encouraged to personalise their rooms with furniture and items from home and this was confirmed during the tour of the premises. 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. Call bells are provided in all areas. Comments received include: ‘A certain amount of waiting is inevitable in a place like this. But emergency calls are answered quickly’. ‘The bell in rooms can be rung at two levels, a) for non-urgent needs b) emergency’. The lighting in the home is of domestic quality and there are above bed lights as well as the main ceiling lights. Beds and chairs were seen to be placed appropriately for maximum benefit of those wishing to read. Water temperatures are controlled and monitored monthly and a record kept. Random temperatures were taken and were of the recommended level. There are systems in place for monitoring safety issues such as fire checks, fire drills, 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 tour of the home confirmed that staff are aware of the fire safety policies, no doors were found inappropriately wedged open and the manager confirmed that electronic fireguards are being installed gradually. Polices and procedures for infection control are in place and are updated regularly. The home was clean and free from offensive odours on the day of the inspection. Comments from surveys include:‘ Very Good cleanliness’ ‘excellent cleanliness’ ‘ first thing we noticed when we visited the home- no smell’. Good practice by staff was observed during the day and there were gloves and aprons freely available in the home. Sluice and laundry areas were found clean and safe, however the staff need to ensure that communal equipment such as hoists and commodes are kept clean. The home provides a good laundry service. Mais House DS0000039554.V320679.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing arrangements are good and suitable and ensure the needs of the residents living in the home are met. Residents are protected by the home’s recruitment policy and practices. EVIDENCE: The staffing rota was viewed and the staffing levels were seen to be sufficient to meet the needs of the residents at this time. It was confirmed by the manager that there is flexibility of the staffing levels and they are adjusted according to the changing needs of the residents. Care staff spoken to said that the levels of staff on duty were sufficient to give the care required, they also said that the trained staff always helped out. Residents also confirmed that they had no complaints regarding the amount of staff, one resident said the ‘staff are always helpful, they look after me very well’. Another said, ‘ The staff are really nice, always take time to talk to me’. A survey received stated, ‘the resident my wife is always attended, night as well as day’. Staff files of five employees were viewed and evidenced that the home management team follow robust procedures when employing staff. They contained the required information and demonstrated that the appropriate induction training had been completed in respect of the job they were to undertake in the home. One member of staff that had recently been employed Mais House DS0000039554.V320679.R01.S.doc Version 5.2 Page 20 said ‘ I had had a very good induction and orientation to the home which took place over one month. Staff interviewed confirmed a satisfaction with the training provided and stated that recent training was interesting and informative. Three staff surveys received stated that they were satisfied with the standard of training provided and records seen confirmed that they had undertaken compulsory training such as moving and handling, adult protection, and food hygiene and fire safety. Mandatory training will be on-going and organised by the training officer for the Organisation. In addition specialist training in understanding dementia, supra pubic catheterisation updates are also provided. NVQ training is available and staff are encouraged to complete this, at present only 25 of staff have an NVQ qualification, but the projected level will reach 50 in February 2007 with further staff enrolling. Mais House DS0000039554.V320679.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The overall management of this home is good with effective systems in place to protect residents. EVIDENCE: An acting manager has been in post since February 2006, her application for Registered Manager has been completed, but as yet no processed. The Manager is a Registered General Nurse and worked in a senior position in the National Health Service for some years, she has been a Registered Manager in three Care Homes prior to Mais House. She has enrolled on the Registered Managers Award (RMA) and will commence the course in the early part of 2007. After a year of no clear leadership, the management structure of the home at this time is strong, competent, with clear lines of accountability. Two residents Mais House DS0000039554.V320679.R01.S.doc Version 5.2 Page 22 stated that ‘they wanted to keep this one’. There are still areas to improve within the home, but the Manager is aware of these areas and they are being managed in a competent and confident manner. The feedback from residents, relatives and staff indicated that they felt supported and were able to approach the management team at any time. ‘Matron and staff are always available’. The ethos of the home is to focus on the residents and the staff were observed doing this. Regular staff meetings and resident/relative meetings are held and records of the meetings are kept. The staff mentioned the staff meetings and that they were beneficial and the staff felt that areas of improvement they put forward were acted for the benefit of the residents. These form part of the quality assurance systems in the home. The quality assurance systems in the home are annually appraised by the organisation. The Responsible Individual visits unannounced monthly and these also form part of the quality assurance system. Residents’ financial interests are safeguarded by the homes policies and procedures. The residents spoken with said they had no worries regarding their financial status, and felt they were supported in managing their affairs efficiently. Nineteen residents take responsibility for their own finances, and every resident has a lockable facility in their room. The Manager confirmed and the staff training records show that all staff are kept updated on the Health and Safety policies, the manual is available to all and clearly defined. Staff were able to discuss the training they received and said that they were kept up to date with changes to policies in connection with fire safety and health and safety. The staff are issued with certificates yearly for Moving and Handling, twice yearly for Fire Safety. At present only four members of staff have a first aid certificate; further training is planned for the New Year. The home has a comprehensive set of policies and procedures, which govern the running of the home. All relevant legislation and procedures are in place in respect of Health and safety. The Manager has devised a delegation system for performing supervision sessions since her arrival in February 2006. Evidence was seen of regular supervision sessions and all staff spoken with confirmed that the supervision sessions are held regularly now. Mais House DS0000039554.V320679.R01.S.doc Version 5.2 Page 23 Throughout the inspection good practice was observed in regards to ensuring the safety and well being of the residents when being moved around the building. The accident forms were seen and had been correctly completed with appropriate referrals made as necessary. Mais House DS0000039554.V320679.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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 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 3 3 3 3 3 3 3 Mais House DS0000039554.V320679.R01.S.doc Version 5.2 Page 25 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. Those risk assessments concerning service users nutritional status are kept up to date and accurate. That continence assessments are regularly completed. That all service users are consulted about the programme and range of activities and are enabled to attend the activities on a regular basis. Timescale for action 01/01/07 2. OP8 13(1b) 17(1a) Sch3 23/12/06 3. OP12 16(2m) 23(2h) 12(4b) 01/01/07 Mais House DS0000039554.V320679.R01.S.doc Version 5.2 Page 26 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 OP9 OP15 OP38 Good Practice Recommendations That the home have an appropriate policy in place regarding the use of oxygen. That specialist advice is sought regarding the positioning of staff at the dining tables when in a wheelchair. That staff receive training in first aid, and that all staff are aware of the homes’ policy for resuscitation. Mais House DS0000039554.V320679.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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.V320679.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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