Care Home: Maplehurst Nursing Home

What the care home does well The home provides care for twenty-eight older people with dementia. Although registered to care for thirty-eight people, the manager believes that people need single rooms, and " to maintain their dignity" has made the majority of double rooms into single rooms. These have been pleasantly decorated and arranged to create a domestic type environment, some rooms having small reading tables and chairs placed in the centre of the room, with the manager saying that there has been no increase in accidents or other incidents since rearranging the rooms. Wherever possible toilet facilities have been separated into `ladies` and ` gentlemen` and residents said that they appreciated this as it helped to maintain their dignity. All bathrooms and toilet facilities had pictorial and written signage. Staff were giving constant attention to residents and sitting and talking to them, there was very good interaction seen between staff and residents throughout the day. One survey received said ` I am very impressed with the manager`s attitude and approach to residents needs, staff are very attentive and I have found the staff helpful within their capabilities and they act appropriately." The standard of personal care delivered to residents was seen to be good with residents appropriately dressed and care had been taken with their general grooming. Registered nurses were knowledgeable about the physical and mental health needs of the residents and care plans reflected this. What has improved since the last inspection? All requirements made at the last inspection that fall within the manager`s remit had been met. These included issues identified by the fire officer and documentation within personnel files. A bathroom has been refurbished in a domestic manner whilst still retaining assisted toilet and bathing facilities. Plans for refurbishing other bathrooms are in place. New carpets have been put in some resident`s rooms and along upper floor corridors and the communal rooms have been redecorated. An activities co-ordinator has been recently employed and the home is in the process of forming an activities programme.Residents meetings (residents` forums) have been commenced on a weekly basis, there are five or six residents in the home who are able to participate in these and they are well attended. Residents spoken with said that they enjoyed these meetings and that ideas that they have asked to be considered have been commenced. These include the provision of cooked breakfasts and alcoholic beverages. What the care home could do better: Care plans should be signed by the member of staff that compiles them, and risk assessments should be put in place for those residents that require the use of bedrails. A requirement has been made relating to these issues. It is good practice to regularly audit those drugs used as a controlled drugs which have been prescribed for a resident but required infrequently. Whilst most residents said that they enjoyed the food, the choice of food available at each meal was limited. Residents only have a choice of one menu with alternatives available which consisted mainly of sandwiches or egg dishes, likewise the supper menu could be improved to offer a choice of a cooked option and sandwiches or soup. Portions of food offered appeared small but staff said that residents could, and did, have second helpings. The frequency of staff supervision should be increased in line with the directives of the National Minimum Standards. The provider is required to undertake monthly visits to the home and produce a report, which is kept in the home. These have not been undertaken since June 2007 and the requirement made at the last inspection has been repeated. CARE HOMES FOR OLDER PEOPLE Maplehurst Nursing Home 53 Oathall Road Haywards Heath West Sussex RH16 3EL Lead Inspector Elizabeth Dudley Unannounced Inspection 6 December 2007 10:00 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.V354226.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.V354226.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 Ltd 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.V354226.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th July 2006 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 its 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; the majority of the rooms are now used as doubles and the planned occupancy of the home is now for twenty-eight people. The manager does not intend to apply for a change of registered numbers at this stage. Two people attend for day care. 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. Current fees (as per information given on 6th December 2007) range between £550 and £625 per week; fees do not include extra services such as chiropody, hairdressing, newspapers and toiletries. Information relating to extra charges is available from the home. Maplehurst Nursing Home DS0000054762.V354226.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection took place on the 6th December 2007 and was facilitated by Mr Sylvian Lew Kum Hoi, the registered manager. Methods used to collect information about the home included examination of documentation in the home, observation of staff working with residents, the serving of lunches and conversations with residents, staff and visitors to the home. All residents were spoken with during the inspection, and six residents were spoken with in depth and gave their views on life in the home. There were two visitors in the home and conversations were held with them to determine their satisfaction in the way that the home looked after their relative. Documentation examined included care plans, personnel files, staff training and supervision records, catering records and health and safety files. Prior to the inspection ten questionnaires were sent out to residents and ten were sent out to representatives of residents. Of these four were returned from visitors to the home and two from residents. These gave information about the daily life in the home and helped to inform the judgements made in this report. Thanks are extended to those people who responded. The Annual Quality Assurance Assessment required by the CSCI to assess the current status of the home was not due to be returned until after the inspection. The manager had a completed copy in the home and this was examined during the inspection and seen to accurately reflect what was happening in the home. Comments received from questionnaires and from residents and relatives were mainly positive “ I am well looked after, get taken out for walks and the food is good”. “Good home and well looked after, more activities would be good. Staff lovely, food isn’t bad”. “More activities needed. The manager is helpful in trying to resolve any problems. More could be done to form social groups with other residents”. “ I am very happy here, I like the food and the staff and am well looked after”. What the service does well: The home provides care for twenty-eight older people with dementia. Although registered to care for thirty-eight people, the manager believes that people need single rooms, and “ to maintain their dignity” has made the majority of double rooms into single rooms. These have been pleasantly decorated and Maplehurst Nursing Home DS0000054762.V354226.R01.S.doc Version 5.2 Page 6 arranged to create a domestic type environment, some rooms having small reading tables and chairs placed in the centre of the room, with the manager saying that there has been no increase in accidents or other incidents since rearranging the rooms. Wherever possible toilet facilities have been separated into ‘ladies’ and ‘ gentlemen’ and residents said that they appreciated this as it helped to maintain their dignity. All bathrooms and toilet facilities had pictorial and written signage. Staff were giving constant attention to residents and sitting and talking to them, there was very good interaction seen between staff and residents throughout the day. One survey received said ‘ I am very impressed with the manager’s attitude and approach to residents needs, staff are very attentive and I have found the staff helpful within their capabilities and they act appropriately.” The standard of personal care delivered to residents was seen to be good with residents appropriately dressed and care had been taken with their general grooming. Registered nurses were knowledgeable about the physical and mental health needs of the residents and care plans reflected this. What has improved since the last inspection? All requirements made at the last inspection that fall within the manager’s remit had been met. These included issues identified by the fire officer and documentation within personnel files. A bathroom has been refurbished in a domestic manner whilst still retaining assisted toilet and bathing facilities. Plans for refurbishing other bathrooms are in place. New carpets have been put in some resident’s rooms and along upper floor corridors and the communal rooms have been redecorated. An activities co-ordinator has been recently employed and the home is in the process of forming an activities programme. Maplehurst Nursing Home DS0000054762.V354226.R01.S.doc Version 5.2 Page 7 Residents meetings (residents’ forums) have been commenced on a weekly basis, there are five or six residents in the home who are able to participate in these and they are well attended. Residents spoken with said that they enjoyed these meetings and that ideas that they have asked to be considered have been commenced. These include the provision of cooked breakfasts and alcoholic beverages. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Maplehurst Nursing Home DS0000054762.V354226.R01.S.doc Version 5.2 Page 8 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. Maplehurst Nursing Home DS0000054762.V354226.R01.S.doc Version 5.2 Page 9 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.V354226.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5,6 People who use the service experience good quality outcomes in this area. Prospective residents or their representatives receive sufficient information about the home to enable them to make a decision over whether the home can meet their needs. Residents do not at present receive a copy of the Service User Guide, and may not be able to recall verbal information given to them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose meets the regulations and the National Minimum Standards and is available for interested parties to view. The home provides a Service User Guide which is written in a #format suitable for use by those living in the home, and explains in full the routines of daily life in the home. Residents in the home have not been given a copy of Maplehurst Nursing Home DS0000054762.V354226.R01.S.doc Version 5.2 Page 11 this, following discussions with the manager; assurances were given that this would be given to all residents living at the home. All residents are assessed by the manager prior to their admission to the home and two assessments of more recently admitted residents were examined, these were comprehensive addressing all the health and social care required by the resident and formed the basis of the care planning process. The manager does not at present confirm in writing to prospective residents or their representatives whether the home can offer them a place, as required by National Minimum Standards associated regulations, regulation 14(1)(2). Assurances were given by the manager that this would take place following future assessments. The terms and conditions needs an amendment to show the breakdown of fees, the manager stated that this would be done, all residents or their representatives are given a copy of this document following admission. Residents are admitted for respite care but not for intermediate care. Maplehurst Nursing Home DS0000054762.V354226.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11. People who use the service experience good quality outcomes in this area Care plans identify the health and social care needs of individual residents and provide clear instruction to ensure that the care given meets the needs of the resident. Not all parts of the care plan have been reviewed on a regular basis, which may mean that changes to some areas of care required may not receive attention. The standard of medication administration safeguards the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the course of the inspection four care plans (16 ) were examined in depth. The initial care plans are computer generated but individualised to show the specific physical and mental health needs of the resident. Whilst these give all Maplehurst Nursing Home DS0000054762.V354226.R01.S.doc Version 5.2 Page 13 the information required, ongoing and changing needs are written separately from the main plan. Not all parts of the care plan are being reviewed monthly or signed by the person completing the care plan; this should commence and include reviews of the skin integrity, pressure risk and nutritional assessments. Risk assessments were in place regarding risks generated by specific residents behaviour but there were no risk assessments in place for the use of bed rails, the manager showed the inspector a draft copy of the risk assessments being prepared, these should be put in place as a priority. The home has a retained General Practitioner and maintains links with Psychiatrists and Community Psychiatric Nurses. A Physiotherapist visits the home if ordered by the General Practitioner, and Opticians and Dentists visit as required and at times residents are taken out to access these facilities. Residents appeared appropriately dressed and groomed. Staff were seen to be spending time with all the residents on a continuing basis, sitting and talking to individual residents or helping them to mobilise throughout the day, there was a very good interaction between all grades of staff and the residents. Surveys received identified that generally staff communicate well with the residents and the visitors and that the representatives were happy with the care received by the resident. “ Staff very attentive” “ I have found the staff helpful within their capabilities and they act appropriately.” Residents spoken with said that they found the staff ‘ Very good and helpful’, ‘ really good – wouldn’t get better’, ‘ They look after us very well’. Medication policies are in place, although these have not been updated to show the current method of disposal of medication. Residents currently at the home do not self medicate but a policy should be in place to give people this opportunity should a risk assessment show that they are able to do so and if they so wish. All medications were signed for following administration and showed evidence of regular review; the supplying pharmacist had undertaken a recent medication audit. It is recommended that in the case of a resident being prescribed controlled drugs but needing these infrequently, that the staff audit and record these drugs on a regular basis. Staff signatures are required to be put in place both on receipt of drugs and when a prescription is hand written on the medication charts. Residents can remain at the home for the last stages of their lives and letters were seen that thanked the manager and staff for the care given. The manager said that some staff have attended training in end of life care. Maplehurst Nursing Home DS0000054762.V354226.R01.S.doc Version 5.2 Page 14 Maplehurst Nursing Home DS0000054762.V354226.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. People who use the service experience adequate quality outcomes in this area. Activities do not provide sufficient scope for those residents who are more cognitively able, although staff spend time talking with them and one to one sessions. The lunch menu is made available to residents in a photo format but this does not extend to other meals of the day, which would benefit resident recall. This judgement has been made using available evidence including a visit to this service. EVIDENCE: An activities co-ordinator has recently commenced on a part time basis, but no activities programme is yet in place. Some activities are taking place and the manager states that he recognises the need for therapeutic activity within the home and the importance of outings, which are not provided by the home at present. There is need to improve on the activities offered by the home. Staff were seen to be spending one to one time with residents and two residents were seen enjoying playing a tabletop game. Maplehurst Nursing Home DS0000054762.V354226.R01.S.doc Version 5.2 Page 16 A residents’ forum is held on a weekly basis and residents attend these, the minutes seen identified that residents would like alcohol to be provided at times, a cooked breakfast and more activities. The former two requests have been implemented. The television and radio were on at the same time and it was not clear how residents can select the programme they wish to watch, the sound on the television was turned down so that they could only listen to the radio, which could lead to residents becoming confused. This was discussed with senior staff and the manager. Some surveys received identified insufficient activities, lack of stimulation for residents, and both radio and television being on. Residents spoken with said that they had choices over their activities of daily living and could choose what time they get up and go to bed. Preferred times of rising and retiring should be included in the care plan, particularly for those residents who cannot communicate, as there was evidence that some residents are being got up very early. There is an open visiting policy with relatives saying that they are kept well informed of any progress made or concerns about the resident. A church service is held once a month and ministers of religion visit the home. There is a printed monthly menu but the menu given to residents on a daily basis was seen not always to correspond with this. The menu is put on a notice board with photos of the meal to be provided that day, this was good, clear and informative but at present only refers to the lunch menu. The choice of alternative meals available at both supper and lunch were limited. Residents generally said that the food was good and that they enjoyed it, portions appeared small, but extra helpings were available on demand, staff should continually observe those who cannot ask for extra portions at mealtimes to ensure that the resident is satisfied. Meals were well presented including liquidised meals and staff were seen to be assisting residents in an empathetic and unhurried manner. In some instances the meals were not very hot and staff must be aware of this. The kitchen was clean and both he cook and the relief chef have received training on the nutritional needs of the older person. Maplehurst Nursing Home DS0000054762.V354226.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People who use the service experience good quality outcomes in this area. Residents are confident that any complaints that they may have will be dealt with in an open, transparent and timely manner. Staff are aware of their responsibilities in safeguarding those in their care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has received no complaints in the past 12 months, three minor concerns have been generated and these were addressed immediately and satisfactorily. Residents and relatives were comfortable with taking complaints to the manager but said that if they had any problems it did not need to go to complaint stage because they could approach the manager at any time. Staff have received training in the safeguarding of the vulnerable adult. There have been no adult safeguarding alerts in the past 12 months. Maplehurst Nursing Home DS0000054762.V354226.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,24,25,26 People who use the service experience adequate quality outcomes in this area. A plan of redecoration and refurbishment has commenced and areas completed provide a pleasant and comfortable home for residents. Some odours are apparent in the communal areas of the home, which is unpleasant for both residents and visitors. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is well maintained and there was evidence of redecoration to some of the home and new carpets in the corridors. There are plans to extend the kitchen and update an existing shower room on the top floor and to refurbish the entire area of the home. Maplehurst Nursing Home DS0000054762.V354226.R01.S.doc Version 5.2 Page 19 There is a large lounge/ dining room and a small dining room and quiet lounge on the ground floor with resident’s personal accommodation over three floors. The manager has reviewed the number of residents in the home, and has changed many double rooms into singles. This has provided larger single rooms which have been thoughtfully decorated and fitted out, the manager has provided centre reading tables in these rooms with chairs around them, all rooms were pleasantly decorated and domestic in character, although most rooms have variable height beds, these have been furnished with non institutional bed linen and therefore this is not immediately noticeable. Some call bells were missing from rooms, the manager could evidence that these were checked regularly, but that residents often carried them around with them. The standard of carpeting in bedrooms is adequate and in some rooms impermeable flooring is provided, this is changed back to carpet when possible. Radiator covers are gradually being replaced with more domestic wooden designs and all windows are restricted. Water temperature monitoring is carried out by the maintenance person on a regular basis and is within recommended parameters. A first floor bathroom has been refurbished to a good standard and is comfortable and welcoming. The other bathrooms are also due for a similar refurbishment. Where toilet facilities are either adjacent or on the same floor, these have been segregated into male and female facilities “ to allow residents dignity” and all bathrooms and toilets are clearly signed for recognition. Whilst the majority of the home was odour free, the lounge was malodorous and the carpet was very stained. Surveys received stated that the home was malodorous at times and one visitor also identified this. There are various aids to maximise resident’s independence and staff have received training in infection control issues. In one bathroom various toiletries were seen to be kept in an unlocked cupboard, which could limit choice and endanger residents and there was a pot of prescription barrier cream which was being used on residents, all residents should have individual pots of barrier creams to minimise the risk of infection and prescription items must only be used for the resident for whom they are prescribed. The manager removed these before the end of the inspection and gave assurances that it would not be repeated. Maplehurst Nursing Home DS0000054762.V354226.R01.S.doc Version 5.2 Page 20 The home was clean and domestic staff have undertaken the National Vocational Qualification level 2 relevant to their role. Maplehurst Nursing Home DS0000054762.V354226.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 People who use the service experience good quality outcomes in this area Staff are employed in suitable numbers and care staff have sufficient training to ensure that residents needs are being met. Additional training for registered nurses would ensure that the nursing care given to residents is in line with current research and developments This judgement has been made using available evidence including a visit to this service. EVIDENCE: The duty rotas and staff and residents spoken with showed that there are sufficient staff on duty to meet the needs of the residents and to allow staff to work in an unhurried manner. Five care staff (35 ) have the National Vocational Qualification level 2 in Care and two are working towards level 3. Domestic staff also have the National Vocational Qualification level 2 relative to their roles. New staff undertake an induction course which meets the national guidelines and registered nurses undertake a local induction course. Training offered to staff includes mandatory health safety and fire training and all care staff and registered nurses have undertaken dementia care training. Maplehurst Nursing Home DS0000054762.V354226.R01.S.doc Version 5.2 Page 22 The administrator is undertaking the National Vocational Qualification level 4 in care, Registered Managers Award and a course in “Equality and Diversity”. The catering staff have undertaken training in catering for the older person. Whilst the registered nurses spoken with said that they had kept themselves updated through private study, there is no specific training or development programme for registered nurses and this was discussed with the manager. Four staff personnel files were examined (13 ), these had all documentation as required by the National Minimum Standards and associated regulations. Staff do not commence employment until the full Criminal Records Bureau check is received and staff receive the General Social Care Code of Conduct. Maplehurst Nursing Home DS0000054762.V354226.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38 People who use the service experience good quality outcomes in this area This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is registered with the CSCI and has the relevant experience to ensure that the home meets the expectations and needs of the residents in the home. There was good interaction between residents and staff seen and visitors said that they were able to approach the manager and found him caring and knowledgeable about the residents. Maplehurst Nursing Home DS0000054762.V354226.R01.S.doc Version 5.2 Page 24 All staff including domestic and catering staff were aware of the different residents needs and behaviour. Staff spent a lot of time during the day sitting and talking to residents and ensuring their needs were met and promoting a good sense of belonging with less able residents. The home gains residents and relatives views by annual surveys and it is recommended that this be extended to other stakeholders, including health and social care professionals, that visit the home. Resident forums have been commenced on a weekly basis and residents’ views were seen in the minutes generated at these meetings. The Annual Quality Assurance Assessment accurately reflects the current situation in the home. The home does not act as appointee or keep any money for residents. The staff receive formal supervision but not all staff have received this at times directed by the national minimum standards. The manager stated that he is currently in the process of amending this. Some regulation 26 visits (monthly visits by the provider required by regulation) have taken place but these are not being done at times required by the regulation, the last one being June 2007. Not all policies and procedures have been reviewed this year and the manager said that this was gradually being attained. The home currently keeps residents records for three years in line with the regulations; it is recommended that the manager liaise with the Nursing and Midwifery Council as their guidelines may differ. All equipment and utilities have been serviced and this was evidenced at inspection. The home should ensure that residents’ access to the steep flight of stairs from the second floor is either risk assessed or restricted. The CSCI has received notices informing of any incidents or accidents that affect residents and a review of the accident records showed that these were not in excess of what would be expected. Maplehurst Nursing Home DS0000054762.V354226.R01.S.doc Version 5.2 Page 25 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 2 3 x 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 2 3 3 Maplehurst Nursing Home DS0000054762.V354226.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation Reg 15 Requirement All records relating to service users should be dated and signed by the staff compiling them; the Nursing and Midwifery Council require this. That a risk assessment be put in place for service users requiring the use of bedrails. That prescribed medication including creams are only used by the individual for whom they are prescribed. The registered providers shall visit the home and provide a monthly report on the conduct of the care home. (This was a previous requirement due to be complied with by 23/08/06) Timescale for action 10/01/08 2 3 OP7 OP9 Reg 13(4) Reg 13(2) 10/01/08 10/01/08 3. OP32 Reg 26 10/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Maplehurst Nursing Home DS0000054762.V354226.R01.S.doc Version 5.2 Page 27 No. 1 2 Refer to Standard OP9 OP38 Good Practice Recommendations That staff sign for medication on its receipt into the home and that handwritten drug orders are signed for by two persons. That restricted access or risk assessment is put in place for the steep flight of stairs between second and first floor. Maplehurst Nursing Home DS0000054762.V354226.R01.S.doc Version 5.2 Page 28 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 Maplehurst Nursing Home DS0000054762.V354226.R01.S.doc Version 5.2 Page 29 - 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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