Inspection on 05/06/07 for The Maypole Nursing Centre

This inspection was carried out on 5th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

The Maypole Nursing Centre 23/01/06

The Maypole Nursing Centre 10/10/05

The Maypole Nursing Centre 03/02/05

The Maypole Nursing Centre 07/07/04

The Maypole Nursing Centre 03/02/04

The Maypole Nursing Centre 11/02/03

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE The Maypole Nursing Centre Lower Northam Road Hedge End Southampton Hampshire SO30 4FS Lead Inspector Mrs Ann Peace Key Unannounced Inspection 10:00 5th June 2007 X10029.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 The Maypole Nursing Centre DS0000011451.V336248.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 and Care Homes for Adults 18 – 65*. 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. The Maypole Nursing Centre DS0000011451.V336248.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Maypole Nursing Centre Address Lower Northam Road Hedge End Southampton Hampshire SO30 4FS 01489 782698 01489 781937 simpsnik@bupa.com 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) ANS Homes Limited Nichola Claire Simpson Care Home 68 Category(ies) of Old age, not falling within any other category registration, with number (68), Physical disability (68), Physical disability of places over 65 years of age (68), Terminally ill (68), Terminally ill over 65 years of age (68) The Maypole Nursing Centre DS0000011451.V336248.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd January 2006 Brief Description of the Service: The Maypole Nursing Centre is a purpose built care centre providing nursing care and accommodation for up to 68 people who are over 19 years of age. The residents require nursing care for physical disabilities, terminal illness or old age. The home has recently been acquired by BUPA, which has not affected the smooth running of the home. Mrs Simpson, a registered nurse, is the Registered Manager. The Maypole is located in Hedge End, on the outskirts of Southampton, with easy links to all community facilities and public transport systems. All of the bedrooms are single and have en-suite facilities. There are three lounges and two dining rooms. A passenger lift links the two floors. The home has been adapted to meet the needs of service users with physical disabilities. There are raised flowerbeds in the courtyard garden in the centre of the home and the building is surrounded by landscaped gardens, which include car-parking areas. The home is inspected as a ‘Mixed Category’ home because of the age range of the residents; the report includes the National Minimum Standards (NMS) for Older People (OP) and Care Homes for Younger Adults [18 - 65] (YA). The fees at the home are between £750-£1200 per week. The Maypole Nursing Centre DS0000011451.V336248.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 inspection on the 5th June 2007. This inspection is the first inspection in 2006-2007. It is called a key inspection and will determine the frequency of inspections hereafter. Prior to the visit to the home the inspector reviewed information gathered about the home and comments made in satisfaction questionnaires returned from four residents and two health professionals. The Annual Quality Assurance Assessment was returned to The Commission for Social Care Inspection (CSCI) and this was used to address areas of improvement which the manager and provider had carried out and also identified areas for further improvement. During the visit a tour of the home took place with all communal areas and private accommodation visited. A case tracking exercise for six residents was undertaken to look at how the assessed needs of this group of residents with diverse needs were being met. Residents and visitors were spoken with to gain some information about what it is like to live at the home either in the privacy of their rooms or in the lounge. Staff were observed assisting and interacting with residents. The atmosphere at The Maypole Nursing Centre was relaxed and staff were observed to speak to residents in a friendly but respectful way. During this visit the records of six staff were inspected and staff were spoken with informally to find out what it is like to work at the home and to discuss aspects of residents care plans and assessed needs. The conclusion was that an excellent standard of care is delivered at the home from a dedicated, caring and well trained staff team. Some comments from the satisfaction surveys were: “The managers, nurses and carers have a good in depth understanding of residents needs and desires. They liaise well with the families and other health care professionals”. “The home respects resident’s dignity and provides an environment that is not institutional”. The Maypole Nursing Centre DS0000011451.V336248.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? At the residents request a room has been refurbished to be used as a coffee shop for residents to go to and take their visitors. Staff have been trained to implement a “Personal Best” system which has improved staff’s insight into residents needs and conditions. A new air conditioning unit has been installed in the laundry which has improved conditions for staff. Part of the garden has been adapted into a sensory and wildlife garden. Eighteen new nursing profiling beds have been purchased. The Maypole Nursing Centre DS0000011451.V336248.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. The Maypole Nursing Centre DS0000011451.V336248.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) The Maypole Nursing Centre DS0000011451.V336248.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 1-5 standard 6 is not applicable to the home. 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. The personalised needs assessment means that people’s diverse needs are identified and planned for before they move to the home. Staff have the skills and training to meet identified needs. All residents have contracts/terms and conditions. EVIDENCE: The statement of purpose is clear and comprehensive and gives up to The Maypole Nursing Centre DS0000011451.V336248.R01.S.doc Version 5.2 Page 10 date information to prospective residents. The need to maintain confidentiality for staff was discussed with Mrs Simpson. Case tracking confirmed good practice. All new residents are only admitted following a pre assessment being carried out to ensure the home will be able to meet their needs, this involves the relatives or friends when necessary. A random selection of records were examined and contained pre assessments and full assessments once residents are admitted. There is a welcome pack in each bedroom which gives information about the running of the home. Residents and relatives spoken to during the visit all said they were welcomed into the home and had been given enough information to be able to make a decision, satisfaction surveys returned to the Commission also confirmed this. It was noted that where possible residents do sign to say they agree with their plans of care. Staff have the training and skills to meet specific and general needs and also general training. New residents are provided with a statement of the terms and conditions/contract. The home is registered for a varied age group and many of the residents and relatives spoken to say that this is beneficial and adds to the positive atmosphere of the home, in some cases that’s why residents and relatives had chosen the home. The Maypole Nursing Centre DS0000011451.V336248.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents using this service are in control of their lives and are involved in running the home. Well-trained and skilled staff are committed in supporting residents and providing an excellent standard of care. Residents are supported to take risks as part of an independent lifestyle. EVIDENCE: The Maypole Nursing Centre DS0000011451.V336248.R01.S.doc Version 5.2 Page 12 All residents have current care plans and where possible these have been signed by the residents to say they agree to the plan of care. Three residents spoken to confirmed they had been consulted about the plans. The plans are generated from the needs assessment and are regularly updated. Care plans include comprehensive risk assessments which are regularly reviewed and show that risks are managed to help people in the home to lead the life they want. There are plans to introduce a new system of record keeping for care records in the near future in which care records would be person centred so they would be more specific to individual needs. Residents have been kept informed about this. Minutes of the Resident’s meetings confirmed this. In recent months to improve the quality of care for residents, the home has been introducing a system called “Personal Best”. With the full cooperation and agreement from residents, staff have been following a training plan that puts them in role-play as a resident. For example staff may attend exercise classes with residents but in a wheelchair, they may be fed pureed food by another member of staff, they may have to role-play a disability which affects their mobility or speech. Twenty four staff have already attended so far and said that it has given them insight into the feelings and problems faced by residents which has enabled them to have more insight into residents needs. Staff said they feel that they can give a better quality of care because of the training. Two residents said that they thought it was a very good idea and that it had added something to the care provided in the home. This indicates that the home is looking at ways to improve the positive individual support given to residents. During the visit by speaking to residents and staff and by examining records we could confirm that staff are fully committed in supporting residents to lead an independent fulfilling life. Surveys indicated that the home provides a very good standard of care. Relatives and residents spoken to were all very complimentary about the managers and the staff and all said they were very well looked after. One lady said that she goes out and about in the community independently, and another said she comes and goes as she wishes. One resident who is very heavily dependent and relies on staff to do everything for him said that he sometimes wants to stays in bed, other times he gets up late or goes to bed late but staff are always on hand to help and always respect his wishes. One relative whose husband has been at the home for some years said that she could not fault the home and that her husband is very well looked after. She visits daily so has a good insight into the running of the home. The Maypole Nursing Centre DS0000011451.V336248.R01.S.doc Version 5.2 Page 13 Another relative whose father has recently been admitted to the home said that his health had improved because of the excellent care he has received and that nothing was too much trouble. Another resident who is very heavily dependent on staff said they were wonderful to him, very friendly but professional and when his family visited they were made very welcome. Approximately twelve residents were spoken to during the visit and without exception all said they were very happy at the home, were very well looked after and that all of the staff were very kind and caring. During the visit staff were noted to knock on doors and wait for permission to enter resident’s rooms and in general staff were indirectly observed in their interaction with residents so we could confirm that staff do respect the privacy and dignity of residents. Residents are protected by the home’s policies and procedures for dealing with medication. We observed part of the medication round and staff were questioned about their procedure and the medicines they were administering. We could confirm from this that safe practices are followed. None of the residents are self-medicating at present. Records showed that residents have access to NHS facilities in the area and that they are supported to be involved in managing their own healthcare. There were some very poorly heavily dependent residents in the home and from observing staff caring for them and through general observation of residents being nursed in bed we concluded that residents in the end stages of their lives are very well looked after, they are cared for with respect and sensitivity.There were also numerous thank you cards and letters to evidence this. The Maypole Nursing Centre DS0000011451.V336248.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents have access to a wide variety of activities and the home promotes liaisons with the local community. The daily routines in the home promote independence and resident’s rights are recognised. Residents are offered a healthy diet and enjoy their mealtimes. EVIDENCE: The Maypole Nursing Centre DS0000011451.V336248.R01.S.doc Version 5.2 Page 15 None of the residents are able to carry out any employment at present due to their high dependency needs, however the home is monitoring this and will try to access education for residents if needed. The home encourages residents to maintain an independent lifestyle when possible by encouraging them to go out and about in the local community. They have unrestricted access to the home and the grounds. Staff do take residents into the village when able. Other residents say they access private taxies or dial a ride to take them out. When asked many of the residents and staff said they thought it would be beneficial if the company had minibuses that the home could access this was discussed with Mrs Simpson at the end of the visit. There are appropriate activities in house for residents to take part in. There are activity co- coordinators employed seven days a week and a program of activities is displayed on all notice boards every week it is also taken around to residents rooms. There is also a monthly newsletter to keep residents and visitors up to date. All residents have a social life plan formatted when they come into the home, this describes their previous lives, families, interests, wishes and occupations so that one to one sessions can be tailored to individual needs. There were two activity co-ordinators working on the day of the visit and we were impressed with their enthusiasm and commitment to the residents. The activity room decoration and contents showed that the activities are tailored to all ages to meet needs. An exercise class was taking place in the morning and was attended by approximately twelve residents and bingo was taking place in the afternoon. This was at the resident’s request. Staff said that one to one sessions could mean reading a book, newspapers, just talking or hand massages etc. Residents who could talk to us confirmed this. A number of residents have personal computers in their rooms. There are pleasant well-maintained gardens with adequate seating around, there are some raised beds for residents to work in if they wish, a number of residents who used to be keen gardeners said that they are encouraged to help out and they do enjoy this. A sensory/wildlife garden has recently been planted and children from a nearby school are making bird boxes for the home. When talking to relatives and visitors they confirmed that they are always welcomed into the home and can be involved in daily routines and activities if the residents wish. The Maypole Nursing Centre DS0000011451.V336248.R01.S.doc Version 5.2 Page 16 Through observation during the visit, looking at records, speaking to residents, relatives and staff we could confirm that the daily routines are flexible to meet residents needs and wishes. All bedroom doors can be locked, and staff do not enter bedrooms without permission. The staff’s interaction with residents is good-humoured and friendly and there was a very positive atmosphere throughout the home. Residents were seen to be at ease with all of the staff in the home. All residents have nutritional assessments carried out and care plans formatted if necessary. Weights are recorded monthly. Residents are involved in deciding what food is served, minutes of meetings confirmed this. Satisfaction surveys all said they residents were very happy with the quality of the food served. The menu for the week is displayed around the home and looked varied and well balanced. There are corporate guidelines for the chefs to follow to ensure that the meals are nutritionally well balanced for the residents and they also have access to professional dietary advice. Meals are offered three times a day and residents can access snacks at any time. There is a kitchen where residents if able and their visitors can make tea and coffee. There is a dining room on each floor and the tables were attractively laid with damask tablecloths, cruets and flowers. Taking into account the results of the satisfaction surveys and by speaking to residents and their relatives we can confirm that residents are offered a healthy diet and that they enjoy their meals. Residents were noted to treat mealtimes as a social occasion and there was a lot of good-humoured banter between residents. During the visit it was noted that staff sat down with individual residents who needed help with their meals and they were helped in a sensitive, discreet and unhurried manner. Following request from residents, one of the rooms is being changed and refurbished into a coffee shop where residents will be able to take friends and relatives; residents said they were looking forward to the opening. The Maypole Nursing Centre DS0000011451.V336248.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an open culture that allows residents to express their views and concerns in a safe and understanding environment. The complaint procedure is clear and easy to understand. Residents are protected by staff who are trained to safeguard vulnerable people. EVIDENCE: There is a complaint procedure in place in the home and complaints are recorded and investigated according to the procedure. The Commission has received no complaints or concerns. Satisfaction surveys indicated that residents and relatives/visitors knew who to complain to and all that were asked during the visit said they would feel able to complain. Staff records indicated that all staff are trained in safeguarding vulnerable adults and during the visit five members of staff were asked about the procedure and all knew what to do if abuse was suspected. The Maypole Nursing Centre DS0000011451.V336248.R01.S.doc Version 5.2 Page 18 The Maypole Nursing Centre DS0000011451.V336248.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables residents to live in a safe well-maintained and comfortable environment, which encourages independence. EVIDENCE: The Maypole Nursing Centre DS0000011451.V336248.R01.S.doc Version 5.2 Page 20 The tour of the home showed that the home is safe, comfortable, bright and airy there were no unpleasant odours. Furnishings, fittings, adaptations and equipment are good quality. The cleanliness and hygiene standards are very high, the home and premises are well maintained and the communal rooms are furnished in a homely fashion. Resident’s rooms are comfortably furnished to their personal preferences and are very homely with their personal furniture, ornaments and picture/photos around. There is a dining room on each floor and the tables were attractively laid with damask tablecloths, cruets and flowers. The gardens are well maintained and pleasant. There is seating in the garden and residents and their visitors were using the garden during the visit. Some of the bedrooms have patio doors into the enclosed garden so residents have direct access. The home has links with the local community and various people told us during the visit that the community considers the home an asset to the locality. The home has a planned maintenance and renewal programme for the fabric and decoration of the premises and records are kept. There are call bells throughout the home but there are no mobile or pendant type alarms which would be beneficial to residents to make them feel more independent. Three residents said that they would be happier if they could have better access to call bells when in the lounges or in the garden. This was discussed with Mrs Simpson and a recommendation has been made. All bedrooms are lockable however staff could override them in the event of an emergency. There are sufficient well-equipped toilets and bathrooms to meet resident’s needs. The home is well equipped with specialist equipment to meet resident’s needs and to safeguard the health and safety of staff. Mrs Simpson said that there are eighteen profiling nursing beds on order and when these are delivered all residents will have a specialist bed if they wish and if their needs dictate. Staff are provided with adequate facilities for changing and to store belongings. The home employs two maintenance men who were noted to work hard to keep the home in good condition and residents and staff safe. Maintenance records are orderly and well maintained and showed that regular safety checks are carried out throughout the home and on equipment. The home is very clean and hygienic and free from offensive odours. Systems are in place to control the spread of infection and staff were noted to observe The Maypole Nursing Centre DS0000011451.V336248.R01.S.doc Version 5.2 Page 21 safe practice. Records showed that staff are trained in infection control procedures. The Maypole Nursing Centre DS0000011451.V336248.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to support residents and to support the smooth running of the home. EVIDENCE: On the day of the visit Mrs Simpson the registered manager was assisted by a deputy manager, four qualified staff, fourteen carers plus a good number of ancillary staff. The staffing levels and skill mix meet the high dependency needs of the residents accommodated to a good standard. Staff have clearly defined job descriptions and were able to tell us what were the limits of their roles. The Maypole Nursing Centre DS0000011451.V336248.R01.S.doc Version 5.2 Page 23 With the introduction of “Personal Best training” staff said they have a clearer understanding about the aims and values that the home is promoting. Staff take trouble to get to know the residents and this was confirmed by speaking to residents, visitors and staff and by looking at communication records. Staff in the home are well trained to be able to care for and keep safe the residents accommodated. National Vocational training is encouraged in the home and more that 50 of staff have achieved level 2 and above. Regular staff meetings take place and the minutes of these were available for examination, the minutes showed that staff are able to air concerns or good ideas. There is an award system running in the home and residents, relatives, staff or visitors can nominate a member of staff if they think they have done more that what is expected of them. During the visit one relative approached Mrs Simpson to say she wished to nominate a member of staff who she though had been exceptionally helpful. The Maypole Nursing Centre DS0000011451.V336248.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37,38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, has effective quality assurance systems developed by a qualified competent manager. The Maypole Nursing Centre DS0000011451.V336248.R01.S.doc Version 5.2 Page 25 EVIDENCE: Mrs Simpson the registered manager is a registered nurse, has NVQ level four and has achieved the registered manager award. Mrs Simpson has been at the home for ten years and runs the home very well. Residents and staff benefit from her leadership style and this could be seen by looking at records in general, records of meetings, observing the workings of the home during the visit, general observation of the staff working in the home and with residents and by speaking to residents visitors and staff. We were impressed by the plans to improve the wellbeing and daily lives of residents with the use of new ways of working. Mrs Simpson was able to evidence during discussion that she keeps up to date with relevant training. The home does have an open inclusive and positive atmosphere. Residents and their visitors confirmed that they are always included when changes are planned in the home and that Mrs Simpson operates an open door policy if they want to see her, but also that she has a high profile in the home so is seen around a lot. Records also showed that communication is good in the home both with residents and staff. One method of feedback to the company is by resident’s meetings the minutes of which are taken by a relative. Managers only go to these meetings by invitation. The views of friends, family and other visitors to the home such as health professionals are included in this report. At the time of writing this report the Commission received eight satisfaction surveys from residents and relatives and two from visiting health professionals. All comments were favourable. “The managers, nurses and carers have a good in depth understanding of residents needs and desires. They liaise well with the families and other health care professionals”. “The home respects resident’s dignity and provides an environment that is not institutional”. There is a quality assurance system in operation in the home, Mrs Simpson carries out regular audits around the home and a corporate quality assurance system is in operation, the results of the last survey were available. Mrs Simpson said that another is planned for July 2007. The home does not manage any monies for the residents a float of pocket money is kept that residents can access at any time and they confirmed this. Records are kept of any money taken out or put in. Records are well maintained, accurate and up to date. Safe working practices are promoted in the home with individual and general risk assessments in The Maypole Nursing Centre DS0000011451.V336248.R01.S.doc Version 5.2 Page 26 place. All residents have a safe working practice related to their needs and these are kept with the care records. Staff are given training in safe working practice such as fire safety, moving and handling, food hygiene, COSHH and general health and safety. The Maypole Nursing Centre DS0000011451.V336248.R01.S.doc Version 5.2 Page 27 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 3 2 3 3 4 4 3 5 3 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 ENVIRONMENT Standard No Score 19 4 20 4 21 3 22 3 23 3 24 4 25 4 26 4 STAFFING Standard No Score 27 4 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No Score 31 4 32 4 33 4 34 x 35 3 36 3 37 4 38 4 The Maypole Nursing Centre DS0000011451.V336248.R01.S.doc Version 5.2 Page 28 No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA29 YA14 Good Practice Recommendations Residents would benefit from having access to pendent alarms or portable alarms. Residents would benefit from having access to a minibus. The Maypole Nursing Centre DS0000011451.V336248.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. The Maypole Nursing Centre DS0000011451.V336248.R01.S.doc Version 5.2 Page 30 - 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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