Inspection on 07/12/05 for Mais House

This inspection was carried out on 7th December 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Mais House 14/03/08

Mais House 23/11/06

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 Paul Taylor Unannounced Inspection 7th December 2005 11:40 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.V256719.R01.S.doc Version 5.0 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.V256719.R01.S.doc Version 5.0 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 The Royal British Legion Jane Alison McAulay Care Home 54 Category(ies) of Old age, not falling within any other category registration, with number (54) of places Mais House DS0000039554.V256719.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. That only older people may be accommodated. That service users accommodated will be aged 65 years or over on admission. That the maximum number of service users to be accommodated will not exceed 54. Service users can be accommodated who in addition to old age may have a physical disability. 17th June 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. Mais House DS0000039554.V256719.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two Inspectors performed an unannounced inspection of Mais House on 6/12/05. The inspection started at 11.40 a.m. and finished at 4.45 p.m. The Inspectors met with a number of service users and members of staff as well as the acting manager. A tour of the building was also undertaken. A number of care plans were examined and numerous other records were seen during the day. What the service does well: What has improved since the last inspection? There is active monitoring of the home by external mangers to ensure that service is monitored until a permanent manager is appointed. The acting manager is aware of the challenge she has undertaken. The care plans are in the process of being changed into a more ‘user friendly’ format. Mais House DS0000039554.V256719.R01.S.doc Version 5.0 Page 6 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 DS0000039554.V256719.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mais House DS0000039554.V256719.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. The assessments seen were thorough and contained detailed information. Care plans involve input from service users and relatives as part of the process of assuring them that their needs will be met. EVIDENCE: A number of assessments were examined. These contained a lot of information which outlined the needs of the service users. One service user met with an Inspector and described her admission process as well thought out, planned and welcoming. Further information for prospective service users is contained in the home’s Statement of Purpose and service user guide. The Senior nurse on duty told the Inspectors that relatives and service users are actively involved in the setting up of care plans. Mais House DS0000039554.V256719.R01.S.doc Version 5.0 Page 9 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 the following standard(s): 8,9 and 10. There is a well-equipped clinical room. Controlled drugs are appropriately stored. All medication that is administered needs to recorded in all instances. Health care needs are well assessed and monitored. Staff respect service users privacy and interactions observed between members of staff and service users especially during assisted feeding, were sensitive, patient and done at a speed appropriate to the service users’ wishes. EVIDENCE: Care plans that were examined were thorough and contained a lot of information. Health needs had been assessed and risk assessments had been completed on an individual basis. Care plans were in the process of being transferred to another format at the time of the inspection and the Senior Nurse on duty reported that the new format will be an easier document to follow. It was reported to the Inspectors that the care plans are regularly reviewed and monitored. The Inspectors recommend that the monitoring and review of the care plans is endorsed in writing and dated when it occurs. There is a well equipped clinical room and the controlled drugs are appropriately stored and signed for. A member of staff had requested a Mais House DS0000039554.V256719.R01.S.doc Version 5.0 Page 10 pharmacy inspection on 6/12/05 in order to improve the practice of monitoring and administrating medication. Concerns had been raised during the pharmacy inspection that medication prescribed to one service user had been given to another. Records of medication administered were examined and some gaps were seen where medication had assumed to have been administered but had not been recorded. The senior nurse on duty told the Inspector that she would address this issue immediately. Members of staff were seen to knock on doors before entering service users rooms. Interactions between service users and members of staff were observed and members of staff feeding service users during lunch were observed. Mais House DS0000039554.V256719.R01.S.doc Version 5.0 Page 11 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 the following standard(s): 12 The home has a well equipped activities room and a dedicated activities coordinator. There are ample opportunities for service users to partake in activities. Numerous alternative therapies are available to service users. Service users are able to follow their own religion and beliefs. EVIDENCE: There are numerous activities in which service users can partake in the home. There is a member of staff who is the activities co-ordinator. Activities include outings, painting and rug making. There is a bar, hairdressing salon and very well equipped activities room. Service users also have access free of charge to alternative therapies which are administered in the therapy room. Therapies available include Bach Flower Remedies, Indian Head Massage, Kinesiolology, Reiki and meditation. On the day of the inspection the service users had the opportunity to listen to visiting school children sing Christmas carols. The Inspectors saw a programme of activities planned for the Christmas period. Members of staff were involved in putting up Christmas decorations during the inspection. BA minister of religion conducts a service in the activities room once a month. Service users are able to have ministers visit them if they wish. One service user said ‘This is a nice place to live.’ Mais House DS0000039554.V256719.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 16 and 18. There is a clear complaints procedure in the home. All members of staff who met with the Inspectors were aware of what to do in the event that they had concerns about service users welfare. Service users are protected by the home’s procedures. EVIDENCE: The home has a complaints policy and procedure in place. Copies of the complaints procedure are displayed at different locations in the home and details of the process are also in the Statement of Purpose and service user guide. The complaints procedure contains all the details necessary including the contact details of the Commission for Social Care Inspection. There had been one complaint made in the home since February and the written record was comprehensive. The Inspectors met with different members of staff who were all aware of what to do in the event that they had concerns about service users welfare. All were aware of local adult protection procedures and the whistle blowing procedure. Mais House DS0000039554.V256719.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 25 and 26. The home is clean and airy and the bedrooms well maintained and comfortable. The laundry provides a good service. There are good systems in place for monitoring safety checks. Fire doors should not be wedged open. EVIDENCE: The home was clean and well maintained. The bathrooms were well equipped and the members of staff had access to a variety of lifting devices and hoists. The corridors were bright and airy and the bedrooms were large, well lit and had facilities in which service users could lock their possessions and securely store their own medication. Service users are able to decorate their own rooms and bring their own furniture with them. The home has a well-organised and efficient laundry. The gardens and grounds were well maintained. The maintenance man has a thorough and well thought out system for monitoring safety issues such as fire checks, fire drills, PAT testing, electrical tests and gas and boiler checks. There is an audit system in the home whereby all the rooms are routinely checked for safety and maintenance issues. Mais House DS0000039554.V256719.R01.S.doc Version 5.0 Page 14 During a tour of the home the Inspectors noticed that fire doors had been propped open to a service user’s bedroom and to the conservatory on the ground floor where the members of staff smoke. This is not acceptable. A strong smell of cigarette smoke had permeated up the stairs outside the smoking area and could be detected in the bedroom areas. A door to the loft area had been left unlocked and this posed a potential hazard to service users. A window outside Room 11 was in need of window restrictors as there was a potential access to the roof via the window. A fire exit on the top floor was in need of a sign to make everyone aware that there were steps directly outside the door. Mais House DS0000039554.V256719.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 29. The home has relied on agency staff to make sure staffing ratios can be maintained. Recruitment for new care assistants had been undertaken. Training is made available to the staff team. The service users needs are met by the staffing complement. EVIDENCE: The home has been using a number of agency staff to ensure that staffing levels are maintained. The acting manager informed the Inspectors that seven new members of staff were waiting to start work in the home pending pre employment checks. Members of staff who met with the Inspectors reported that staffing levels have been maintained in the home although consistency was not always maintained due to the numbers of agency staff. Staffing ratios were on 8:2 basis on the morning shift (Care Assistants to Registered Nurses), 6:1 on a late shift and 3:1 on the night shift. The acting manager reported that the staffing ratio on the night shift is to be discussed with the Operations Manager for homes. The Inspectors met with different members of staff who reported that they had been provided with a variety of training including moving and handling, first aid, fire training, food hygiene and N.V.Q. 2. A new member of staff reported that she was undergoing an induction but said that no written record was being kept of the process. The Inspector examined a sample of staff files and found these to contain all the necessary information. Mais House DS0000039554.V256719.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32 and 38. There is a need for a permanent manager to be appointed so that consistent management can be achieved. The home has various risk assessments in place. The home is well equipped and designed. EVIDENCE: The home has had a number of different managers over the past three years. There was an acting manager in place on the day of the inspection, she was an experienced member of staff who has worked in residential homes for a number of years.. The Inspectors were informed that the recruitment process was well advanced in the search fro another permanent manager for the home. The home needs an established manager so that all the systems in the home such as induction, supervision and appraisal can be consistently applied. The home has numerous risk assessments in place to ensure that the safety of service users and staff can be monitored. The building is spacious and well laid Mais House DS0000039554.V256719.R01.S.doc Version 5.0 Page 17 out and as mentioned earlier in the report the staff have access to well equipped bathrooms and various lifting devices. The home has been regularly visited by external managers to monitor it’s performance and the Commission for Social Care Inspection has been regularly updated by managers from The Royal British Legion on their efforts to recruit a permanent manager. Mais House DS0000039554.V256719.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X 2 3 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 X X X X X 3 Mais House DS0000039554.V256719.R01.S.doc Version 5.0 Page 19 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 2 3 4 5 Standard OP9 OP25 OP25 OP25 OP25 Regulation 13 (2) 13 (4) (a) 13 (4) (a) 13 (4) (a) 13 (4) (a) Requirement That the recording of medication administered is accurately and promptly completed. That the door to the loft is kept locked. That a window restrictor is fitted to the window outside room 11. That the top floor fire exit has a sign warning service users that there are steps outside the door. That fire doors are not propped open. Timescale for action 31/12/05 06/12/05 06/12/05 06/12/05 06/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP8 Good Practice Recommendations That care plans are endorsed and dated when they have been reviewed. Mais House DS0000039554.V256719.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection East Sussex Area Office 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 DS0000039554.V256719.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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