Inspection on 18/07/06 for Maplehurst Nursing Home

This inspection was carried out on 18th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 14/11/05

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 Key Unannounced Inspection 18th July 2006 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.V301464.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. Maplehurst Nursing Home DS0000054762.V301464.R01.S.doc Version 5.2 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.V301464.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th November 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, one smaller lounge and a separate small dining room. All rooms above ground floor can be accessed by a passenger lift. Maplehurst Nursing Home DS0000054762.V301464.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Mrs Ann Peace carried out this unannounced fieldwork inspection on 18th July 2006. This is the first inspection for the year 2006-2007. It is called a key inspection and will determine the frequency of visits/inspections hereafter. Before this fieldwork visit, records held on file and information received from the home since the last inspection were reviewed. A completed pre inspection questionnaire should have been received by CSCI before the inspection, unfortunately this was only partially completed CSCI now await the full copy. CSCI received 4 satisfaction survey forms from relatives of the residents. They were all complimentary. Satisfaction surveys which are part of the home’s quality assurance system were also available and were generally complimentary. One relative visiting the home at the time of the visit asked to see the Inspector and told her that the home was fabulous and the staff care for his mother well. He said that staff at the home were friendly and supportive to relatives and he had nothing but praise for the home. Mr Lew Kum Hoi the Registered Manager for the home was present for the inspection. A general tour of the home was undertaken and all of the rooms visited, the home was clean tidy and hygienic. There was a nice homely atmosphere and staff were friendly and helpful during the visit. Residents looked comfortable and at ease with the staff. A case tracking exercise from records of admission to care given was carried out for a number of residents. Staff records and relevant records relating to the administration and management of the home were examined. The majority of records seen were maintained in a satisfactory manner. Due to the diminished mental capacity of the residents they were unable to offer an opinion of the home. Staff said they enjoyed working at the home; they were trained for the jobs they have to do and had support from senior staff. The inspector sampled the midday meal which was very tasty and nutritionally well balanced. The Inspector concluded that a good standard of care is given at Maplehurst by a caring and professional staff team. Maplehurst Nursing Home DS0000054762.V301464.R01.S.doc Version 5.2 Page 6 One immediate requirement was made relating to the recruitment procedure in the home. Other issues identified, which needed action, were discussed with Mr Lew Kum Hoi at the conclusion of the visit. What the service does well: What has improved since the last inspection? The home is focusing more on residents suffering from dementia, through specialist training for staff and visual aids for residents. Mr Lew Kum Hoi and the majority of the qualified nursing staff have completed an open learning course in understanding Dementia. The chef has also recently attended an updating course on nutrition in the elderly. The administrator of the home has worked hard and the organisation of the home’s general records has improved. A quality assurance system has been started and the views of relatives have started to be collated and analysed. One of the rooms on the ground floor has been converted into an extra dining room which has been tastefully decorated and furnished. Following Maplehurst Nursing Home DS0000054762.V301464.R01.S.doc Version 5.2 Page 7 requirements by The Environmental Health Department the kitchen has been refurbished and the providers have also purchased five more specialist nursing beds. Extra storage space has been allocated away from resident’s rooms. Mrs Lew Kum Hoi stated that all the outstanding requirements made by The Fire Service had been completed. 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. Maplehurst Nursing Home DS0000054762.V301464.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 Maplehurst Nursing Home DS0000054762.V301464.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service have good information about the home in order to make an informed decision about whether the service is right for them. All residents have a personalised needs assessment to ensure their needs can be identified and met. Intermediate care is not provided. EVIDENCE: The Statement of purpose for the home is comprehensive but needs updating, Mr Lew Kum Hoi said he is aware of this and will send a copy of the updated version to CSCI. The statement of purpose should also mention that day care could only be offered when the home is not full. All files contained contracts whether they are privately funded or funded by Social Services, but only privately funded residents had terms and conditions. Mr Lew Kum Hoi was reminded that all residents/relatives should have a copy of the statement of terms and conditions. This should include rooms to be Maplehurst Nursing Home DS0000054762.V301464.R01.S.doc Version 5.2 Page 10 occupied, overall care and services, fees payable and by whom, additional services not included in the fees, the rights of service user or registered provider and who is liable if there is a breach of contract and terms of occupancy, including period of notice. The records of five residents were inspected and case tracked to individual needs and the home’s ability to meet needs. All residents had appropriate pre assessments, initial assessments related to their needs including mental health and risk assessments, all had up to date care plans. The free nursing care assessments were available. Maplehurst Nursing Home DS0000054762.V301464.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has started to focus more on the specific needs of dementia sufferers. Residents have up to date assessments, care plans and risk assessments, which identify individual needs and instruct staff how to meet their needs. Privacy and dignity are respected in the home. The inspector concluded that residents and their families would be treated with care, sensitivity and respect at times of death. The medication administration procedures in the home should be reviewed to ensure treatment i.e. creams prescribed for one resident are not used for others. EVIDENCE: All residents had up to date care plans generated off the computer, these had been personalised. They all had personal profiles, daily routine, information sheet, observations, dependency scoring sheet, full assessments, basic social history, although it was recognised that with some of the residents this is difficult as they cannot remember and many do not have relatives. They had Maplehurst Nursing Home DS0000054762.V301464.R01.S.doc Version 5.2 Page 12 risk assessments related to their problems and for moving and handling. Care plans included mobilising, comfort and safety, confusion; continence, personal cleansing and dressing, wound care. All those seen had care plans for cognitive loss and dementia. New nutritional risk assessments and monitoring forms have recently been introduced which should improve the monitoring and recording of food intake and highlight any risks. The home is now more focused to the need of dementia sufferers and the manager and all qualified nurses have either completed or almost completed a course in understanding dementia. Mr Lew Kum Hoi said that carers would now be encouraged to complete the course. The majority of residents are very high dependency and so the majority do not mobilise and are chair bound, staff were seen to interact with them and try to stimulate them during the visit. Staff were observed directly and indirectly when caring for the residents and all displayed a friendly and caring approach. Daily records indicated that other professionals visit the home to see residents so they do have access to outside professionals, however records of these visits are not recorded adequately. Since the last inspection 5 more specialist beds have been purchased and Mr Lew Kum Hoi stated that all residents who need one had one. Specialist mattresses were in evidence where risk assessments indicated the need. One resident who likes to be outside was sat in a shaded area as it was very hot and also had his midday meal outside. He did manage to tell the inspector that the staff made sure he could get out when the weather allowed. Another resident who was very poorly and being nursed in bed looked clean and comfortable, it was a very hot day and there was a fan on in his room. Medication records were seen and were in order, medication for residents who were being case tracked were checked against care plans and medication administration sheets were in order. A random check of controlled drugs confirmed that these were in order. The inspector noted that tubs of medicated cream labelled for one resident were being used in rooms belonging to other residents. Mr Lew Kum Hoi was asked to remove these and reminded that medicines supplied for individual users are the property of the named resident and the Medicines Act clearly defines that prescribed medicines/treatments must only be administered to the person they have been prescribed for. None of the residents could offer an opinion on the home due to their diminished mental capacity, but all seemed at ease with the staff. Maplehurst Nursing Home DS0000054762.V301464.R01.S.doc Version 5.2 Page 13 One relative came to see the inspector and said the home could not look after his mother any better the family felt well supported when they visited. Through looking at complimentary letters and one CSCI survey form from relatives of residents who have died, by observing the state of poorly residents being nursed in bed and by speaking to staff the inspector concluded that residents and their families would be treated with care. Maplehurst Nursing Home DS0000054762.V301464.R01.S.doc Version 5.2 Page 14 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. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The routines of the home are planned around residents needs and staff encourage residents to make decisions where possible. Sufficient staff resources are provided for activities and stimulation. Families and friends are welcomed into the home. An experienced cook is responsible for providing good quality varied and nutritious meals. EVIDENCE: The residents are heavily dependent on staff and staff were noted to attend to residents constantly and appropriately. Staff sat with the more agitated residents. In some cases it has been difficult for the staff to get know the past interests and lifestyles of residents so activities tend to be general and dependent on the capacity of the residents on the day. Artwork was displayed around the lounge and a member of the nursing staff has recently taken on the job of activities. This will be beneficial for residents because the nurse knows the residents well having cared for them. Maplehurst Nursing Home DS0000054762.V301464.R01.S.doc Version 5.2 Page 15 The chairs are grouped where possible. Music was playing in the lounge and a number were watching television. There is a safe soft surface patio area outside the lounge for residents to wander in and out. Stable garden furniture is provided. There is also a secure raised garden which can be accessed through a gate which is kept locked; residents do use this garden under supervision of staff. The routines of daily living are flexible within resident’s capabilities; one resident prefers to stay in his room and was regularly monitored by staff during the visit. The home is focusing more on the needs of dementia sufferers and have started by personalising the bedroom doors with photographs of the residents and the toilet and bathrooms have large picture signs on them. The Inspector discussed whether photographs of residents when they were younger would also be beneficial to some. One of the unused bedrooms has been changed into another dining room and has been tastefully decorated and furnished. Since the last inspection the routine for breakfast has changed, breakfasts are now earlier and the majority of residents have breakfast in bed. The Inspector was told this was to allow more time between breakfast and lunch to allow more interaction between staff and residents and also make time for walks outside, spend time in the garden or go to the shops. The Chef was spoken to at length and displayed a good knowledge of the nutritional needs of people suffering from dementia; she has recently been on a nutrition course and plans to implement some new ideas. She is very involved in the care of the residents and always looks at the assessment of new residents so that she knows what they like, dislike or can or cannot eat. The main meal on the day was pork and leek casserole with creamed potatoes and vegetables, followed by spiced apple and ice cream. The Inspector sampled the meal and found it to be very tasty and well balanced. The meals were well presented and met the dietary needs of residents. Hot and cold drinks were served regularly throughout the day and snacks available, one survey said fruit should be offered and this was discussed with Mr Lew Kum Hoi. The Inspector observed the midday meal and noted that residents were not hurried and staff ready to offer assistance when needed. The Inspector was told that there are plans to produce pictorial menu cards to try to stimulate residents. Visitors to the home are encouraged and a visitor told the inspector that he was always made welcome. Maplehurst Nursing Home DS0000054762.V301464.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18. The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a complaint procedure which meets national minimum standards and which is displayed prominently in the home. Advocates are used to help residents who need assistance. Staff are trained to protect vulnerable adults, but the recruitment process is not robust. EVIDENCE: The complaint procedure was displayed prominently in the hallway of the home. The Commission has not received any complaints and the complaint record in the home indicated that no recent complaints had been received. The surveys received indicated that relatives would complain to the manager if needed. Policies and procedures for Adult Protection training are in place and the staff records seen, confirmed that this had taken place. There was also a timetable on the notice board to indicate who was to attend next. Staff spoken to knew the procedure and surveys from the home and CSCI indicated that relatives felt residents were safe. Maplehurst Nursing Home DS0000054762.V301464.R01.S.doc Version 5.2 Page 17 The records of 2 new staff showed that they had not had the relevant safety checks for working with vulnerable people before being employed. An immediate requirement form was left that no one was to work at the home until they had the relevant safety checks carried out. Maplehurst Nursing Home DS0000054762.V301464.R01.S.doc Version 5.2 Page 18 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 quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service Residents live in a safe, homely, clean and comfortable environment with equipment to meet their needs. Resident’s rooms meet their individual needs and they have personal possessions around them. Residents have access safe outside facilities. Not all of the bathrooms meet the needs of residents. EVIDENCE: Maplehurst Nursing Home DS0000054762.V301464.R01.S.doc Version 5.2 Page 19 The exterior of the home is well maintained and the grounds tidy. A car park is to the front of the property and the entrance to the home was inviting, clean and with pots of flowers. The patio to the rear of the home is safe for residents to wander around, the patio that has a safe surface if residents should fall it should minimise the risk of injury. The raised garden can only be accessed through a locked gate to minimise risks to residents. The garden was laid to lawn with shrubs around and sturdy wooden furniture is available on the patio for use of residents. Residents live in an environmentally safe, comfortable and well-maintained environment. They have access to safe and comfortable indoor and outdoor facilities. Specialist equipment is provided for residents and residents who can use call bells have them available following a risk assessment. The home was clean, tidy and fresh throughout with homely decoration and furnishings. The hallway is very inviting and has been reverted to the original features of the building. Bedrooms are on all three floors all accessible by lifts. Communal areas are comfortable, there is a large lounge/dining room, and a smaller lounge, since the last inspection a new dining room has been created which has been tastefully decorated and furnished. Residents rooms are furnished and decorated in a homely fashion and they have their personal possessions around them. The kitchen was very hot and ventilation poor. The Inspector was told that a new ventilation system is due to be installed within the next year. The Environmental Health department inspected the home earlier this year and made requirements for the kitchen units to be updated, this has been carried out. The kitchen was clean, a hazard analysis was in place and appropriate records were in place. The updating to the bathrooms has still not been carried out as required at the last inspection and staff tend to use to downstairs ones for convenience. Mr Lew Kum Hoi will now be asked to submit a plan for the updating of the bathrooms. One bathroom with a toilet in had clean towels stored on an open shelf. Mr Lew Kum Hoi was told this could constitute an infection control risk and was asked to take action. Records indicated that maintenance and safety checks on equipment are being carried out. Mr Lew Kum Hoi told the Inspector that all outstanding requirements from fire service have been completed, he is asked to confirm in writing. Maplehurst Nursing Home DS0000054762.V301464.R01.S.doc Version 5.2 Page 20 Maplehurst Nursing Home DS0000054762.V301464.R01.S.doc Version 5.2 Page 21 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 quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service There are sufficient well-trained staff employed to ensure that resident’s needs are met but the recruitment process for the home is not robust and does not protect residents. EVIDENCE: Staff duty rotas were available and indicated that the staff numbers and skill mix are adequate to meet the needs of the residents over the 24-hour period. Staff were clear regarding their roles and what was expected of them. Staff when spoken to by the Inspector were positive about working with residents suffering from Dementia. The home recognises the importance of training and is encouraging all staff to gain a qualification in Dementia Care. Mr Lew Kum Hoi told the Inspector that 40 of the staff have now achieved an NVQ qualification. The pre inspection questionnaire said that training undertaken in the past 12 months had been for: Maplehurst Nursing Home DS0000054762.V301464.R01.S.doc Version 5.2 Page 22 First aid (they have 3 full first aiders) that all mandatory training has been undertaken also health and safety and disease related training. Mr Lew Kum Hoi has completed a course in Dementia awareness he told the Inspector that the qualified nurses were in the process of completing the course and that the carers at the home were due to start the course in the near future. The inspector could see that the home and the staff were now more focused to caring for residents with dementia and this is benefiting the residents. Mr Lew Kum Hoi told the Inspector that the ratio of NVQ staff was 40 . The home’s recruitment procedure is not adequate and does not promote the safety of residents. Two members of staff working at the home did not have the required clearance from the Criminal Records Bureau or the POVA register to work with vulnerable people, the Inspector also was uncertain as to the eligibility of some references. An immediate requirement was made that no person to be working at the home unless they have had the required safety checks carried out and the home has the evidence. Maplehurst Nursing Home DS0000054762.V301464.R01.S.doc Version 5.2 Page 23 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. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed by a well-qualified, caring and competent manager and in the majority of cases is run in the best interests of residents. Staff are well supported. Resident’s financial interests are safeguarded and the health and safety of residents are promoted and protected. In the majority of cases the health, safety and welfare of the residents is safeguarded. The views of residents, their families and friends have been sought by the home and are being measured to see if the home is meeting its aims and objectives and their statement of purpose. Maplehurst Nursing Home DS0000054762.V301464.R01.S.doc Version 5.2 Page 24 EVIDENCE: Mr Lew Kum Hoi is presently undertaking the Registered Managers Award but is aware under Standard 31 that although he is a registered nurse the qualification should have been achieved by 2005 so understands the reason why this standard will not be met. Mr Lew Kum Hoi was present for inspection; he and all of the staff were open, friendly and helpful. The Inspector could see that there were clear lines of accountability in the home and that residents and staff benefit from his leadership. The Providers have not provided monthly reports on the conduct of the care home as required under Regulation 26. This should inform the Commission that the home is being monitored on a regular basis. A requirement will be made. Appropriate policies and procedures were available and Insurance cover was available in the home and was displayed on the wall in the hall. Service users are encouraged to manage their own affairs with the help of relatives or advocates if necessary. A staff supervision and appraisal system has started in the home there was a timetable of supervision sessions for staff on the notice board and a timetable of when their fire training was due. From reviewing records, speaking to residents and staff the Inspector concluded that in the majority of cases service users rights and best interests were safeguarded by the home’s record keeping. The administrator has worked hard to re organise records and the majority were in good order, however the staff recruitment records are not up to standard and do not protect residents. Staff training records were available to indicate that staff have received training in appropriate health and safety procedures and that further training is been planned throughout the year. The fire safety systems have been tested in accordance with fire service recommendations. The views of residents, their families and friends have recently been sought by the home to measure how successful the home is at meeting its aims and objectives and the statement of purpose of the home. Eleven surveys had been received and a when examined seemed to be on the positive side, this information has still to be collated and a copy of the results sent to CSCI. Four surveys have been received by CSCI and these were positive. Mr Lew Kum Hoi was advised to extend the survey to visiting professionals. Maplehurst Nursing Home DS0000054762.V301464.R01.S.doc Version 5.2 Page 25 One visitor who was at the home during the inspection said his mother has been in the home 2 years and the home was fabulous, staff are good always welcoming and friendly and always offer the family a cup of tea. He said they look after Mum very well and he has nothing but praise for the home. Maplehurst Nursing Home DS0000054762.V301464.R01.S.doc Version 5.2 Page 26 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 2 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 1 3 3 1 3 3 3 3 3 STAFFING Standard No Score 27 3 28 1 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 3 3 2 1 2 Maplehurst Nursing Home DS0000054762.V301464.R01.S.doc Version 5.2 Page 27 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 OP19 Regulation 23(4) Requirement The registered person shall ensure that the premises comply with the requirements of the local fire service. The registered providers to confirm in writing that all outstanding requirements have been met by 2. OP32 26 The registered providers shall visit the home and provide a monthly report on the conduct of the care home according to legislation by 23/08/06 Timescale for action 23/08/06 3. OP25 23(2) b The registered providers shall 23/08/06 provide sufficient baths, showers and lavatories. The previous date for compliance was 14/12/05. An action plan to be submitted to CSCI by The registered providers shall 18/07/06 ensure that no person shall work at the home unless they have had clearance by criminal records bureau or POVA and they have had references taken up. DS0000054762.V301464.R01.S.doc Version 5.2 Page 28 4. OP29 19 Maplehurst Nursing Home An immediate requirement was made. The registered person was required to inform CSCI in writing within 7 days that this requirement has been met RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Maplehurst Nursing Home DS0000054762.V301464.R01.S.doc Version 5.2 Page 29 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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