Inspection on 17/08/05 for Maplehurst Nursing Home

This inspection was carried out on 17th August 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

Maplehurst Nursing Home 18/07/06

Maplehurst Nursing Home 14/11/05

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 L Riddle Announced 17 August 2005 at 09:00am V231163 th 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. Maplehurst Nursing Home H60-H11 S54762 Maplehurst Nursing Home V231163 170805 Stage 4.doc Version 1.30 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 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 Ltd Mr Sylvian Lew Kum Hoi CRH-N, Care home with nursing 38 Category(ies) of DE(E) - Dementia over 65, 38 places registration, with number of places Maplehurst Nursing Home H60-H11 S54762 Maplehurst Nursing Home V231163 170805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th January 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 Limited 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 its shops, train station and other amenities. It is a three-storey detached house with parking area to the front and secure gardens to the rear of the property. The accommodation is arranged in sixteen single and eleven double rooms but some of the doubles are now used for single occupancy only. Communal areas, consisting of a large lounge/dining room and two smaller lounges are situated on the ground floor. All rooms are accessed by a passenger lift. Maplehurst Nursing Home H60-H11 S54762 Maplehurst Nursing Home V231163 170805 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This annual announced inspection was carried out over a period of 8.75 hours by one inspector. Prior to the inspection the previous two reports were read along with other documents and correspondence relating to the home. A preinspection questionnaire was completed by the registered manager and returned to the Commission for Social Care Inspection and some of the information included in this contributed to the inspection process. Fourteen comment cards were received from relatives/visitors most of which were very complimentary in relation to the care and services provided. Three issues raised in these were discussed with the registered manager and found to have already been addressed. Most residents were unable to comment to any degree upon their care but careful observation was made. Five 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. What the service does well: What has improved since the last inspection? What they could do better: The necessity of using so many cot sides on beds should be reviewed. This practice could prove to be more hazardous for residents who are at risk of trapping limbs or falling greater distances than without such restraints. The quality assurance system needs to be extended and developed to include questionnaires and an annual development plan. Maplehurst Nursing Home H60-H11 S54762 Maplehurst Nursing Home V231163 170805 Stage 4.doc Version 1.30 Page 6 The accident reporting documentation needs to comply with current legislation in line with Data Protection. 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 H60-H11 S54762 Maplehurst Nursing Home V231163 170805 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Maplehurst Nursing Home H60-H11 S54762 Maplehurst Nursing Home V231163 170805 Stage 4.doc Version 1.30 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 standard(s) 2, 3 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. EVIDENCE: Residents 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 the six inspected contained full assessment information. Maplehurst Nursing Home H60-H11 S54762 Maplehurst Nursing Home V231163 170805 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9 Good progress has been made on improving arrangements to ensure that the health care needs of residents are identified and met. One shortfall could have a potential to place residents at risk. 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 practice of using cot sides on beds to keep residents in bed at night is not best practice and has the potential to cause accidents. It was noted that consent forms from resident’s relatives/representatives had been obtained but the practice should be reviewed. It may be necessary in extreme circumstances, in which case a detailed risk assessment would need to be undertaken, but should not be necessary as a general rule. Maplehurst Nursing Home H60-H11 S54762 Maplehurst Nursing Home V231163 170805 Stage 4.doc Version 1.30 Page 10 More regular observation/checking by night staff might be a better and safer way of ensuring residents are in bed. A recommendation has been made in respect of this matter. No residents are able to have control of their own medications due to their infirmity. Records of receipt and administration of medicines were seen to be maintained up to date. Medicines are stored securely and only handled by qualified nursing staff. The registered manager said that he had not yet made arrangements for the disposal of medication in accordance with the recent required procedures but will pursue this with an approved contractor. In the meantime disposal arrangements were still being handled by the supplying pharmacy. Maplehurst Nursing Home H60-H11 S54762 Maplehurst Nursing Home V231163 170805 Stage 4.doc Version 1.30 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 standard(s) 12, 15 Social activities and meals are both well managed and provide daily variation and interest for residents living in the home. 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. Samples of resident’s handicraft was displayed on the wall in the lounge. Staff said that they are able make time to take some residents out in their wheelchairs and help the more able with puzzles and other activities. Pleasant soothing music was playing as background at the time of inspection. Staff were seen to sit with residents talking to some or simply holding the hands of others more infirm. Residents were observed to enjoy their main midday meal. Some made comments such as “it’s good food” and “there’s plenty of it”. The chef was in the dining room while meals were served and was clearly aware of individual needs. Staff were having to feed a number of very infirm residents but this was seen to be done with patience and understanding of their difficulties. Maplehurst Nursing Home H60-H11 S54762 Maplehurst Nursing Home V231163 170805 Stage 4.doc Version 1.30 Page 12 Menus are planned on a four weekly rotating basis and the chef said that she is constantly reviewing these in accordance with how well certain meals are received and the need to cater for degrees of frailty. Menus showed good variety and balance. Maplehurst Nursing Home H60-H11 S54762 Maplehurst Nursing Home V231163 170805 Stage 4.doc Version 1.30 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 standard(s) 16 Complaints are handled objectively and residents/representatives can be confident that their concerns will be listened to, taken seriously and acted upon. 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. One complaint had been received in the past year which had been appropriately dealt with, recorded and resolved. A further complaint had been made to the registered manager one day prior to this inspection which was being dealt with according to procedure. Comment cards received from relatives and representatives indicated that where one or two had found it necessary to make complaints in the past, these had been resolved to their satisfaction. Maplehurst Nursing Home H60-H11 S54762 Maplehurst Nursing Home V231163 170805 Stage 4.doc Version 1.30 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 standard(s) 19, 22, 21, 23, 24 Continuing improvements to the décor of rooms and the provision of new bedroom furniture means that residents are living in pleasant and comfortable surroundings. Some of the bathing facilities are not suitable for use by very infirm residents. EVIDENCE: Since the last inspection the home has continued with it’s programme of redecoration and several bedrooms have been redecorated and new furniture provided. Communal areas were seen to be bright and cheerful and seating suitable for the resident group accommodated. One or two special recliner chairs have been provided for residents who can no longer sit comfortably in ordinary armchairs. There appears to be no shortage of adjustable nursing beds for those requiring these. A senior trained member of staff when asked, said that if further nursing beds are needed they only have to ask and these are provided. Similarly with any equipment that is required. Maplehurst Nursing Home H60-H11 S54762 Maplehurst Nursing Home V231163 170805 Stage 4.doc Version 1.30 Page 15 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. One bathroom is out of order and has been for some time, another was seen to be in need of refurbishment. The hoist in this room is an older fixed model and there is little space in the room for staff assistance. The wooden bath panel was seen to be splintering and could cause injury to a person. The floor covering is not in good condition. Currently virtually all residents are taken to a shower room on the ground floor because this is the most and only practical facility suitable for their needs. A requirement has been made in respect of these matters. The noise level in one bedroom next to the laundry had been disturbing the resident of that room. To resolve this the registered manager said that he will offer him the room opposite which is currently a medical room of similar size. The room will be redecorated prior to the person moving into it. This will resolve the problem permanently as the room next to the laundry will become the medical room. The home was clean and fresh throughout and procedures for the control of infection were seen to be in place. Maplehurst Nursing Home H60-H11 S54762 Maplehurst Nursing Home V231163 170805 Stage 4.doc Version 1.30 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 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, 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 and provide protection for people living in the home. An active training programme means that staff are competent and knowledgeable about caring for older people. EVIDENCE: Staffing details were provided in the pre-inspection questionnaire and during the inspection duty rotas were examined. Good numbers of staff were seen to be on duty throughout the day to attend to the many needs of the very dependent resident group. Tasks were seen to be carried out 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 five staff examined 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. A recognised formal induction training programme for new staff is in place which leads on to further training including National Vocational Qualification (NVQ). Staff spoken with said that they had received a lot of training in the past few months and six were due to be interviewed by a local college to commence NVQ training. Records of training, including individual training profiles and certificates achieved, were examined. Maplehurst Nursing Home H60-H11 S54762 Maplehurst Nursing Home V231163 170805 Stage 4.doc Version 1.30 Page 17 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, 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 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 receive very clear direction and support and considered that there is good communication from the manager down. They confirmed that they have received formal one to one supervision with the manager and documentation for these sessions was seen. Maplehurst Nursing Home H60-H11 S54762 Maplehurst Nursing Home V231163 170805 Stage 4.doc Version 1.30 Page 18 A quality assurance system is still in the process of being developed. Some auditing of procedures has been introduced. An annual development plan is not yet in place and as yet there are no arrangements for seeking the views of relatives and others to ensure that the aims and objectives of the home are being met. The registered manager said that he will be working towards putting these in place. 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. Documents examined showed that all equipment is tested and serviced under contractual arrangements at regular intervals. Accidents are recorded and regularly reviewed but the manager was advised to obtain the current official recording documentation. Maplehurst Nursing Home H60-H11 S54762 Maplehurst Nursing Home V231163 170805 Stage 4.doc Version 1.30 Page 19 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 x 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x 1 3 3 3 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 3 2 x x 3 3 3 Maplehurst Nursing Home H60-H11 S54762 Maplehurst Nursing Home V231163 170805 Stage 4.doc Version 1.30 Page 20 Are there any outstanding requirements from the last inspection? NO 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 25 Regulation 23(2)(b)(j ) Requirement Keep the premises in good repair and provide sufficient baths, showers and lavatories. Timescale for action 17/11/05 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 8 Good Practice Recommendations Review the practice of using cot sides on residents beds. Maplehurst Nursing Home H60-H11 S54762 Maplehurst Nursing Home V231163 170805 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI Maplehurst Nursing Home H60-H11 S54762 Maplehurst Nursing Home V231163 170805 Stage 4.doc Version 1.30 Page 22 - 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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