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CQC report explained · a nursing home, run by The Royal British Legion
Mais House
18 Hastings Road, Bexhill-on-Sea, TN40 2HH
Goodpublished 20 May 2023, 3 years ago
Rated Good: inspectors found the service performing well and meeting their expectations.
The five questions inspectors ask
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found enough staff, safe recruitment, safe medicine procedures, suitable risk assessments and effective infection control.
- Effective?
- Good
- This key question was not inspected during this visit. Its previous rating was used to help calculate the overall rating.
- Caring?
- Good
- This key question was not inspected during this visit. Its previous rating was used to help calculate the overall rating.
- Responsive?
- Good
- This key question was not inspected during this visit. Its previous rating was used to help calculate the overall rating.
- Well-led?
- Good
- Inspectors found an open and supportive management culture, regular audits and opportunities for people, relatives and staff to give feedback.
The latest report, explained
What inspectors found, May 2023
Rated Good; inspectors found safe, well-managed care, but some care plans and records were not kept up to date.
This was an unannounced inspection on 4 and 6 April 2023. One inspector reviewed records, the building, medicines and infection control. They spoke with 15 people, staff, visitors, a relative and health professionals.
Safe and well-led were both rated Good. Inspectors found enough trained staff, safe medicine practices, suitable risk assessments, a clean home and systems for learning when things went wrong.
The management team was described as open and supportive. People and relatives were able to give feedback and staff said they felt supported. However, some care plans needed updating and there were inconsistencies in records.
The overall rating stayed Good, as it was at the previous inspection published in October 2018. The other three areas were not inspected during this visit, so their previous ratings were used when calculating the overall rating.
What inspectors praised
Enough trained staff
Staffing levels were based on people's needs. Call bells were answered promptly and people said they did not have to wait for support.
“There were enough staff to support people safely.” from the report
Safe medicines
Medicines were stored, given and disposed of safely. Staff had the training and competence needed to administer them.
“Medicines were stored, administered, and disposed of safely.” from the report
Open management
People, relatives and staff described the management as approachable and supportive. Feedback was collected and used to improve the home.
“The management team were open and transparent and welcomed feedback from people.” from the report
Learning from incidents
The home recorded and reviewed incidents, complaints and safeguarding concerns to identify lessons and reduce the chance of problems happening again.
“Incidents were recorded and analysed to determine the cause and identify changes that would prevent a re-occurrence.” from the report
What inspectors were concerned about
Care records needed updating
needs fixingSome care plans did not reflect people's changed needs. Audits had identified this, but the updates had not yet been completed.
“It had been identified but not progressed.” from the report
Inconsistent records
needs fixingInspectors found inconsistencies in some people's records. These were corrected during the inspection and the report says risk was reduced.
“There were inconsistencies in people's records which were addressed immediately and risk was mitigated.” from the report
Questions to ask them, based on this report
- 01How quickly are care plans updated when a person's needs change?
- 02What checks make sure information is consistent across all care records?
- 03What were the previous ratings for Effective, Caring and Responsive, which were not assessed during this visit?
- 04How will you show families that the care-record shortfalls have stayed corrected?
- 05How are relatives involved in care reviews and changes to care plans?
This was a focused inspection of Safe and Well-led; Effective, Caring and Responsive were not inspected and their previous ratings were used for the overall rating. This explanation was written from the published report of 20 May 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
The story over the years
Every inspection of Mais House
5 rated inspections over 7 years: the service has improved, from Inadequate to Good.
- May 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- September 2017Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2016Requires improvementup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2016InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- May 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 24 January 2011.
Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.
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