Inspection on 16/01/06 for Abercorn House Nursing Care Home

This inspection was carried out on 16th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Abercorn House Nursing Care Home 22/10/07

Abercorn House Nursing Care Home 19/09/06

Abercorn House Nursing Care Home 25/05/05

Abercorn House Nursing Care Home 20/01/05

Abercorn House Nursing Care Home 17/06/04

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Abercorn House Nursing Care Home Fernhill Road Blackwater Camberley Surrey GU17 9HS Lead Inspector Anita Tengnah Unannounced Inspection 16th January 2006 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 Abercorn House Nursing Care Home DS0000036926.V278308.R01.S.doc Version 5.1 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. Abercorn House Nursing Care Home DS0000036926.V278308.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Abercorn House Nursing Care Home Address Fernhill Road Blackwater Camberley Surrey GU17 9HS 01276 32773 01276 34136 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) The Royal United Kingdom Benificent Association Mrs Olivia Ten Kate Care Home 95 Category(ies) of Dementia - over 65 years of age (95), Old age, registration, with number not falling within any other category (95), of places Physical disability (10), Physical disability over 65 years of age (10), Terminally ill over 65 years of age (95) Abercorn House Nursing Care Home DS0000036926.V278308.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. One single room identified does not meet the National Minimum Standards and will not be used to accommodate further service users when the current occupier has moved. A maximum of 10 service users in the PD category may be accommodated at the home All service users in the PD category must be at least 50 years of age Date of last inspection 25th May 2005 Brief Description of the Service: Abercorn house is a registered care home that provides nursing and personal care to 96 service users in the older person category. The home has one bedroom that is below the required spatial standard that has a condition attached to accommodate the present service user. This bedroom will not be available to accommodate other service users when this becomes vacant. The service is located in the rural setting of Blackwater in a residential area and close to some local amenities. The Royal United Kingdom Benevolent Society owns the home, with a sister home across the road. All of the bedrooms are single with passenger lifts to allow access to all parts of the home. The home has extensive well-maintained gardens that are accessible to service users including wheelchair users. Abercorn House Nursing Care Home DS0000036926.V278308.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection took place over one day on the 16th of January 2006. This was the second inspection for the year 2005-2006. As part of the inspection process a tour of the building was undertaken. The inspection took place over four hours. The inspector spoke to 9 service users, staff and visitor including the GP who was visiting the home. The process included examining care records, staff records and discussions with service users, staff and visitors. Positive comments were received from all those spoken to with regards to the care that they were receiving. What the service does well: What has improved since the last inspection? Abercorn House Nursing Care Home DS0000036926.V278308.R01.S.doc Version 5.1 Page 6 The care plans have improved since the last inspection. There were comprehensive assessments of the service users’ needs and evidence of regular review and the involvement of service users/ advocates. A programme to fit single lever locks top all bedrooms have 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. Abercorn House Nursing Care Home DS0000036926.V278308.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Abercorn House Nursing Care Home DS0000036926.V278308.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this occasion. EVIDENCE: Abercorn House Nursing Care Home DS0000036926.V278308.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The home has a good system of care planning ensuring that care needs are met. The health care needs of service users are well met with evidence of multi disciplinary work. The medication management is satisfactory. However staff should ensure that the administration records are up to date. Personal support in the home is offered in an away as to promote the service user’ privacy and dignity. EVIDENCE: Care plans were viewed for four service users living at the home. Detailed assessments were completed and the care plans included references to all aspects of daily living, including assistance with personal care, interests, social care needs and mental health assessments were recorded. Abercorn House Nursing Care Home DS0000036926.V278308.R01.S.doc Version 5.1 Page 10 Risk assessments were in place and included manual handling assessments. Care plans seen were detailed and services users’ healthcare needs are set out in care plans, which reflect how care is to be met. The plan showed that service user’s / advocate consent was sought and recorded. All service users are registered with a GP and the manager said that the home has a good relationship with other health care professionals and are supported when advice /help is required. The home facilitated access to healthcare for all service users. The GP visits the home four days a week and is available at all other times as required. Equipment for the prevention and treatment of pressure ulcers were available. The wound care plans were detailed and there was evidence of regular review and any changes in treatment are recorded. The home undertakes monthly audit of the wound care plans as part of their internal monitoring. The home has a medication procedure in place. All medication was stored safely. It was noted that in some cases records on the Medication Administration Record (MAR) sheets were not fully completed. These included lack of records of varying dosages and in some cases medication received were not recorded. Staff must also ensure that appropriate codes are recorded for medication not administered. This was discussed and the manager who will be addressing these issues. The home has secured an external contractor for the disposal of medication following the recent changes in legislation. A number of service users spoken to say that their privacy and dignity are respected and that they are treated very well. It was evident from practices observed that staff attended to service users in a respectful and compassionate manner. Comments included “staff are very good”, “they help me and I am grateful”. “This is a good place to live”. Abercorn House Nursing Care Home DS0000036926.V278308.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,14 There is a good programme of activity for service users offering variety and choice. Service users have the autonomy and choice of visits from family and friends and supported to maintain links with the local community. EVIDENCE: The home has a varied programme of activities for the service users. A list of forthcoming events was displayed at the home. Service users spoken to say that they enjoyed the activities and they were planning to attend communion that afternoon. Activities included themed lunches in small group, musical interludes, singers, games and trips out. The service users confirmed that there are able to choose which activity they attend. Families are invited to some of the activities that are organised for the service users. Staff reported that recent celebrations included the 100th birthday party for a service user and the pantomime show that a number of relatives attended. Abercorn House Nursing Care Home DS0000036926.V278308.R01.S.doc Version 5.1 Page 12 The home has an open visiting policy, which was evidenced by the visitor’s book maintained at the home. Service users said that there are no restrictions to visiting and they usually entertain their visitors in their rooms, various lounges and the garden in the good weather. Abercorn House Nursing Care Home DS0000036926.V278308.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The procedures for dealing with complaints and the prevention of abuse are satisfactory. EVIDENCE: A complaint policy and procedure was in place that was also available to service users. The manager deals with all complaints and refers to the Responsible Person as appropriate. A complaint log was maintained. Service users and staff spoken to were aware of the complaint procedure and felt able to use it. Two service users said that they did not have any complaint, however they would approach” sister” and the matron if they had any issues. There are two complaints that have been referred to the home for investigation at the time of the inspection. The home has procedures for the prevention of abuse and the Hampshire adult protection procedure. Training and updates in the prevention of abuse is available for all staff and the next planned update is on the 20th of January 2006. Abercorn House Nursing Care Home DS0000036926.V278308.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23 The environmental standard at the home was good and provided service users with a safe and homely place to live in. Service users bedrooms were personalised and reflected their choice, assuring their autonomy. EVIDENCE: A tour of the service was undertaken as part of the inspection. The home was clean, warm and homely in appearance. The home has adequate communal lounges and dining rooms to meet the needs of the service users. There is an ongoing programme of refurbishment in place. Staff reported that plan was in place to decorate the vacant bedrooms prior to new admission. The home has a variety of equipment including a passenger lift, hoists, and assisted baths, grab rails and ramps to promote and maintain the service users’ independence. Abercorn House Nursing Care Home DS0000036926.V278308.R01.S.doc Version 5.1 Page 15 The service users’ bedrooms seen were personalised and call bells were available in all bedrooms and accessible to the service users. Furnishing was of good standard, clean and appropriate to meet the service users’ needs. A number of the service users spoken to on the day were complimentary regarding their personal environment. Comments included” I have everything I need in here”. “I like my room and the views of the garden is nice”. The home has large well-maintained gardens that are accessible to wheelchair users and seating is available in the garden. A programme to fit single lever locks to all bedrooms has been completed. Staff reported that some service users do hold keys to their bedrooms. Abercorn House Nursing Care Home DS0000036926.V278308.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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): 30 The home’s training programme is well managed and ensures that staff have the skills to deliver care safely. EVIDENCE: The home has an ongoing training programme to ensure that all staff undertake the mandatory training in health and safety and update their skills. Some of the other training plan included infection control, prevention of abuse and managing challenging behaviour. The home has two staff members who have completed train the trainer course and staff said was beneficial in facilitating training for new staff at induction. The home also supports nurses who are placed by external agencies as part of the supervised programme for overseas nurses. The home has a number of staff from overseas who have poor command of the English language. Staff reported that these were causing some difficulties. This was discussed with the manager and an action plan is in place in supporting these staff with English lessons and working with another staff member. Abercorn House Nursing Care Home DS0000036926.V278308.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): 33,38 There is a robust audit system in place ensuring that the home is run in the best interests of the service users. The procedures for the promotion of the health and safety of service users and staff are satisfactory. EVIDENCE: There is an ongoing internal audit in place whereby care plans, incidence of pressure ulcers are reviewed and monitored. Regular meetings are held with service users and their advocates as part of the quality control. A copy of the recent service users’ satisfaction survey had been undertaken and positive comments were received regarding the care the home provides. The home has in place policies and procedures for the promotion of the health and safety of service users and staff. Record shows that these were updated Abercorn House Nursing Care Home DS0000036926.V278308.R01.S.doc Version 5.1 Page 18 regularly taking into account any changes in regulation. These were available in the staff rooms to facilitate access for staff. The environmental Health Officer visited the home last year and report seen was satisfactory. Staff were observed to adhere to the procedures for infection control ensuring the safety of the service users. Equipment such as protective clothing and gloves were available and staff were observed using them as appropriate. Abercorn House Nursing Care Home DS0000036926.V278308.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X 3 X X X STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X 3 Abercorn House Nursing Care Home DS0000036926.V278308.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. Refer to Standard Good Practice Recommendations Abercorn House Nursing Care Home DS0000036926.V278308.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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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