Inspection on 14/11/05 for Maplehurst Nursing Home

This inspection was carried out on 14th November 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

Maplehurst Nursing Home 18/07/06

Maplehurst Nursing Home 17/08/05

Maplehurst Nursing Home 18/01/05

Maplehurst Nursing Home 15/06/04

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

CARE HOMES FOR OLDER PEOPLE Maplehurst Nursing Home 53 Oathall Road Haywards Heath West Sussex RH16 3EL Lead Inspector Mrs A Peace Unannounced Inspection 14th November 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Maplehurst Nursing Home DS0000054762.V265726.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. Maplehurst Nursing Home DS0000054762.V265726.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Maplehurst Nursing Home Address 53 Oathall Road Haywards Heath West Sussex RH16 3EL 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) 01444 458165 01444 458165 Newcare Homes Limited Mr Sylvain Lew Kum Hoi Care Home 38 Category(ies) of Dementia - over 65 years of age (38) registration, with number of places Maplehurst Nursing Home DS0000054762.V265726.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th August 2005 Brief Description of the Service: Maplehurst is a care home registered to provide accommodation and nursing care for up to thirty-eight elderly people with dementia. The registered provider is Newcare Homes Ltd for whom the responsible individual is Mr Brijmohun Beeharee. Mr Sylvian Lew Kum Hoi is the registered manager in charge of the day-to-day running of the home. Maplehurst is situated in a residential area close to the town centre of Haywards Heath with it’s shops, train station and other amenities. It is a threestorey detached house with a parking area to the front and secure gardens to the rear. The accommodation is arranged in sixteen single rooms and eleven double rooms; some of the doubles are used for single occupancy only. Communal areas are on the ground floor and consist of a large lounge/dining room and two smaller lounges. All rooms above ground floor can be accessed by a passenger lift. Maplehurst Nursing Home DS0000054762.V265726.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 14th November 2005 by one inspector. Prior to the inspection the latest inspection report was read along with other documents and correspondence relating to the home. Most residents were unable to comment to any degree upon their care but careful observation was made. Six members of staff were spoken with, discussion took place with the registered manager and a tour of the building was undertaken. Records and other documents were also examined as part of the inspection process. The inspector concluded that a good standard of care is provided at Maplehurst from a caring staff team. Where the situation in the home is unchanged from previously the report will remain the same. What the service does well: What has improved since the last inspection? What they could do better: All staff including ancillary staff should have access to training they require for their jobs, this should include adult protection, communication and infection control. Maplehurst Nursing Home DS0000054762.V265726.R01.S.doc Version 5.0 Page 6 The basic induction plan for the home must include the adult protection procedure. One bathroom was not up to the same standard of hygiene as the rest of the home. The use of bathrooms in the home should be reviewed and all should be in good working order for resident’s comfort. The call bell system should be available for resident who are able to use it. The home should have more familiar picture clue signs and other helpful mental health promotion aids which research has shown does help people with dementia. More nursing beds should be available for residents. Two staff that were spoken to did understand adult protection procedures. A robust and comprehensive quality assurance system must be implemented. 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. Maplehurst Nursing Home DS0000054762.V265726.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 Maplehurst Nursing Home DS0000054762.V265726.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): 1, 2, 3, 4, 5. The admission procedure ensures that there is a proper assessment carried out prior to a person moving into the home. This provides assurance that their care needs can be met. Residents do have contracts. EVIDENCE: Resident’s files were seen to contain copies of their statements of terms and conditions. There is a comprehensive written procedure which is adequate to guide staff on the actions to be taken to ensure that new residents needs are properly assessed and planned for. Individual records are kept for each resident and contain full assessment information. A Statement of Purpose and Service Users Guide is available for prospective residents and their representatives. Mr Lew Kum Hoi told the inspector that he would be reviewing this in the near future. Maplehurst Nursing Home DS0000054762.V265726.R01.S.doc Version 5.0 Page 9 Mr Lew Kum Hoi was advised to ensure that a copy was accessible in the home. Maplehurst Nursing Home DS0000054762.V265726.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 10, 11. Health care needs of residents are identified and met. Residents have access to other health professionals as required. Staff treat residents in a respectful manner. EVIDENCE: Individual plans of care are available which provide good information on all aspects of health, personal and social care needs. The plans identify the action needed by nursing and care staff to ensure that the assessed needs are met. They provide evidence of regular reviews of care and daily entries of any significant changes or events. Discussion with staff suggested they have good knowledge of resident’s individual needs and receive clear direction and communication about their care. The Inspector concluded that residents and their relatives would be cared for with care, sensitivity and respect at times of death. Since the last inspection service users with cot sides have been reassessed and appropriate action taken. Maplehurst Nursing Home DS0000054762.V265726.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, 13, 14, 15. Social activities and meals are both well managed and provide daily variation and interest for residents living in the home. Residents are encouraged to exercise choice and control over their routines where possible. EVIDENCE: Due to their mental frailty residents need to be observed and attended to constantly and it was observed that staff were on hand to do so. Where known, the interests of residents are recorded in their care plans so that staff can be aware of what type of activities may best stimulate and suit them. A member of staff is employed to co-ordinate activities and activities are arranged 6 out of 7 days. Samples of resident’s handicraft work was displayed on the walls of the lounge. During the inspection a number of residents through choice were watching television in one lounge and others were sitting in another supervised by staff. Staff were seen to sit with residents talking to some or simply holding the hands of others more infirm. Maplehurst Nursing Home DS0000054762.V265726.R01.S.doc Version 5.0 Page 12 One resident who was a bit agitated and continually moving around was being monitored by a member of staff who provided help when necessary. Another resident was still in bed through choice at 11am. Residents who could offer an opinion said that the meals were very good. The chef stays in the dining room while meals are served to supervise and is clearly aware of individual needs. Menus are planned on a four weekly rotating basis and the chef reviews these in accordance with how well certain meals are received and the need to cater for degrees of frailty. Maplehurst Nursing Home DS0000054762.V265726.R01.S.doc Version 5.0 Page 13 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, 17, 18. The home has a complaints procedure which states that complaints are listened to, recorded and addressed. The majority of the staff but not all are aware of the need to protect vulnerable people. EVIDENCE: The home has a detailed complaints procedure and copies were seen to be displayed clearly in various parts of the home including the entrance hall. CSCI has not received any complaints since the last inspection. The home’s policies and procedures protect resident’s legal rights. Two staff whose first language was not English who were spoken with were not aware of the adult protection procedure and did not know what they would do if abuse was witnessed. The inspector found it very hard to establish verbally if they had received appropriate induction. Maplehurst Nursing Home DS0000054762.V265726.R01.S.doc Version 5.0 Page 14 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): 19, 20, 21, 22, 23, 24, 25, 26. The home is warm and comfortable. The majority of areas are clean and hygienic. In the majority of cases specialist equipment is available to meet needs. Not all of the bathrooms meet the needs of residents. EVIDENCE: Communal areas were seen to be bright and cheerful and seating suitable for the resident group accommodated was available. The home was warm and had a nice homely atmosphere. Special mattresses were seen to be on beds where residents had, or were in danger of developing pressure sores. Various aids and adaptations are installed throughout the premises to assist residents with daily living such as handrails, ramps, grab rails etc. Maplehurst Nursing Home DS0000054762.V265726.R01.S.doc Version 5.0 Page 15 A large door from the lounge leads to a split-level garden which has a patio made of special flooring which should minimize injuries if residents were to fall. Garden seating is available. One resident who was being nursed in bed was in an ordinary divan bed Mr Lew Kum Hoi was reminded that the home is registered for nursing care and so adjustable nursing beds should be available. Access to the call bell system should be reviewed as a number of residents who would be able to use a call bell did not have one near their beds. The bathrooms on all floors in the home still need to be made suitable for residents. There are bathrooms/shower rooms that are suitable and staff tend to use these all of the time. Virtually all residents are still taken to a shower room on the ground floor because this is the most and only practical facility suitable for their needs. The majority of the home was clean and fresh but one bathroom needed to be thoroughly cleaned and the waste bin replaced with a suitable bin that would conform to infection control policies. This was bought to the attention of Mr Lew Kum Hoi at the conclusion of the inspection. Maplehurst Nursing Home DS0000054762.V265726.R01.S.doc Version 5.0 Page 16 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, 28, 29, 30. The deployment and number of staff available throughout the day and night is sufficient to meet the needs of residents. The procedures for the recruitment of staff are robust. Not all staff have the training to ensure residents would be protected from abuse. EVIDENCE: During the inspection duty rotas were examined. An adequate number of staff were seen to be on duty throughout the day to attend to the needs of the very dependent resident group. Staff went about their work in a quiet, discreet and professional manner. Residents seemed to be relaxed and happy in the company of the staff and there was no sense of anyone being rushed. The files of new staff were examined and showed that the home had undertaken all the necessary recruitment checks to ensure the protection of residents. All of the required documentation was present in these files. Mr Lew Kum Hoi was aware of the process for Protection of Vulnerable Adults (POVA) checks. Maplehurst Nursing Home DS0000054762.V265726.R01.S.doc Version 5.0 Page 17 A recognised formal induction training programme for new staff is in place which leads on to further training including National Vocational Qualification (NVQ). One new member of staff bought her induction book in for the inspector to see. Mr Lew Kum Hoi was reminded that all staff including ancillary staff must undergo a comprehensive induction programme, following the basic one. It was noted that adult protection is not listed on the basic induction to the home, staff do undertake a very basic induction immediately they start at the home and it is important that this subject be included. Maplehurst Nursing Home DS0000054762.V265726.R01.S.doc Version 5.0 Page 18 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, 33, 34, 35, 36, 37, 38. There is leadership; guidance and direction to staff to ensure residents receive consistent quality care. This results in practices which promote and in the majority of cases safeguard the health, safety and welfare of those living and working in the home. EVIDENCE: The registered manager is a qualified nurse and is currently undertaking the Registered Managers Award. Since taking over as manager he has worked hard to raise standards in the home and to introduce new systems, policies and procedures. Staff spoken with said that they feel well supported to carry out their jobs. A staff supervision system is in operation at the home. A quality assurance system is still in the process of being developed, the inspector was shown a new resident/relative questionnaire, which was good. Maplehurst Nursing Home DS0000054762.V265726.R01.S.doc Version 5.0 Page 19 The auditing of accidents is carried out and records were seen. Records were found to be well maintained and up to date. Training records and discussion with staff confirmed that staff have had and are continuing to have regular fire training and training in other health and safety topics. All radiators are covered and windows fitted with restrictors for safety and security. Maplehurst Nursing Home DS0000054762.V265726.R01.S.doc Version 5.0 Page 20 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 3 8 3 9 X 10 3 11 3 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 3 18 2 3 3 1 2 2 3 3 2 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 3 2 2 Maplehurst Nursing Home DS0000054762.V265726.R01.S.doc Version 5.0 Page 21 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 OP30 Regulation 13 (6) Requirement Train staff to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. Ensure persons have training appropriate to their work. Keep the premises in good repair and provide sufficient baths, showers and lavatories. CSCI to be informed of action plan by Timescale for action 14/12/05 2 3 OP30 OP25 18 (1) 23(2) b 14/12/05 14/12/05 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 OP22 Good Practice Recommendations Provide picture clue signs and other signs around the home to aid in the mental health promotion of residents accommodated. Review residents ability to use call bells and provide where indicated. Review the provision of nursing beds in the home. DS0000054762.V265726.R01.S.doc Version 5.0 Page 22 2 3 OP22 OP24 Maplehurst Nursing Home 4 OP33 Implement a robust and comprehensive quality assurance and monitoring system in the home. Maplehurst Nursing Home DS0000054762.V265726.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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. 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