Inspection on 25/05/05 for Abercorn House Nursing Care Home

This inspection was carried out on 25th May 2005.

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 16/01/06

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, Lead Inspector Anita Tengnah Unannounced 25/5/2005 10:00am 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 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 H54 S36926 Abercorn House V229203 250505.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Abercorn House Nursing Care Home Address Fernhill Road, Blackwater, Camberley, Surrey, GU17 9HS Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01276 32773 01276 34136 The Royal United Kingdom Benificent Association Mrs Olivia Ten Kate CRH 95 Category(ies) of DE(E)- Dementia over the age of 65 years: 95 registration, with number OP- Old Age: 95 of places PD- Physical Disability: 10 PD(E)- Physical Disability over tha ge of 65 years: 10 TI(E)- Terminally ill: 10 Abercorn House Nursing Care Home H54 S36926 Abercorn House V229203 250505.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1- One single room identified does not meet the National Minimum Standards and will not be used to accomodate further service users when the current occupier has moved. 2- A maximum of 10 service in the PD category may be accomodated at the home. 3- All service users in the PD category must be at least 50 years of age. Date of last inspection 20/1/2005 Brief Description of the Service: Abercorn house is a registered care home that provides nursing and personal care to 95 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 user 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 home is owned by The Royal United Kingdom Benevolent Society 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 H54 S36926 Abercorn House V229203 250505.doc Version 1.30 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 25th of May 2005. As part of the inspection process a tour of the building was undertaken. The inspection took place over five and a half hours. The inspector spoke to 14 service users, 8 staff and 3 visitors that were at the home on the day of the inspection. The process included examining care records, staff records and discussions with service users, staff and visitors. What the service does well: What has improved since the last inspection? An ongoing programme of refurbishment was in place and four rooms have been completed. On the day of the visit refurbishment of the outside of the building was being undertaken. A complete review of fire procedure was now in place following an inspection by the fire safety officer. Staff spoken to were familiar with the fire procedure and stated that this was working well. Abercorn House Nursing Care Home H54 S36926 Abercorn House V229203 250505.doc Version 1.30 Page 6 The manager reported that plans are underway to link bedroom doors to the main fire alarms that would allow for automatic door closures. This would allow service users to keep their bedroom doors open as many prefer to do so and maintain their safety. He home has employed a menu coordinator that discusses menus on a daily basis with service users. This was reported to be working well and a menu display board has been ordered for the dining room area on each wing. 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 H54 S36926 Abercorn House V229203 250505.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Abercorn House Nursing Care Home H54 S36926 Abercorn House V229203 250505.doc Version 1.30 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 standard(s) 3,6 Arrangements for assessing service users prior to admission are good and ensure that clients are appropriately admitted. EVIDENCE: The home has a pre-assessment procedure and the manager or her deputy assesses all service users prior to admission to the home to ensure that the home can meet the service users needs. Records of pre-assessment were seen for three service users and were satisfactory. Staff reported that the preassessment were used on admission to formulate care plans and further assessments are undertaken in order that a fuller history could be obtained. Staff reported that prospective service users’ family visit instead of service users who are often frail and cannot undertake a visit. A trial period is offered to all newly admitted service users. Information as per the statement of purpose was available as required to inform practice. The home does not provide intermediate care. Abercorn House Nursing Care Home H54 S36926 Abercorn House V229203 250505.doc Version 1.30 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 standard(s) 7,8 There is a clear and consistent care planning system in place to provide staff with the information in meeting the needs of service users. The lack of procedure for reviewing care plans in the absence of the named nurse may be detrimental to the welfare of service users. Access to GP and other healthcare professionals is well managed. EVIDENCE: Care plans were formulated on admission and included risk assessments and manual handling assessments. These were detailed and were reviewed and updated on a regular basis to reflect any changes in the needs of service users. Wound care plans and records of pressure areas were maintained. There was clear and comprehensive care plans that included wound mapping, grading and evaluation. Staff reported that the home has considerable success in pressure ulcer management as service users for service users admitted with these. A record of pressure ulcers was maintained and the manager audits these on a regular basis. Pressure relieving mattresses for the relief and treatment of Abercorn House Nursing Care Home H54 S36926 Abercorn House V229203 250505.doc Version 1.30 Page 10 pressure ulcers were available, the home must ensure that pressure relieving cushions are also available when service users are sat out in their chairs. A procedure needs to be developed for the review and update of care plans in the absence of the nominated staff in order to ensure that the evaluation/ review of care plans remains consistent and meet the needs of service users. This was discussed at the time of the inspection as this process had failed recently when a staff member went on annual leave. Service users and relatives spoken to stated that they liked living at the home and that staff were kind and helpful. Relatives were confident in approaching the manager with any issues and felt that these would be dealt with as required. Good interaction was observed between staff and service users. The GP visits weekly and can be contacted at other times as required. It is recommended that record of all visits and any changes in treatment are maintained in service users plan such as a multidisciplinary record sheet that can be easily accessible. Abercorn House Nursing Care Home H54 S36926 Abercorn House V229203 250505.doc Version 1.30 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 standard(s) 12,15 The meals and activities are both well-managed providing service users with choice, variety that meet service users needs. EVIDENCE: The home has three activity coordinators that manage the social activities. These are facilitated either in groups or 1:1 such as sensory sessions. Service users spoken to stated that they attend the main lounge on the ground floor regularly and enjoyed the programmes available. Two service users reported that the day’s activity had been cancel as the passenger lift was out of order on the day of the visit. Communion was available bi monthly in the drawing room and also available individually as requested. The home operates an open visiting policy; relatives spoken to confirmed this. One relative reported that he visited twice a day and others visited at varying times daily. The manager reported that she was taking a service user for a week vacation to Lourdes in the summer and trips for other service users are planned. The manager reported that the home has employed a menu coordinator whose role is to help service users in filling up their daily menus. Lunchtime meal was observed which appeared nourishing, well presented. Staff were available to offer support with meals in a sensitive manner and a choice was available. Abercorn House Nursing Care Home H54 S36926 Abercorn House V229203 250505.doc Version 1.30 Page 12 Service users and relatives confirmed that meals were nice and hot and cold drinks were available at all times. Abercorn House Nursing Care Home H54 S36926 Abercorn House V229203 250505.doc Version 1.30 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 standard(s) 16,18 The home has a satisfactory complaint procedure and staff awareness to report all allegation of abuse was evident. EVIDENCE: A complaint policy and procedure was in place that was also available to service users. The manager deals with all complaints and a complaint log was available. There has been one report of alleged theft at the home. This was reported to Social services and the Police and has not yet been resolved. The home has the Hampshire Adult Protection procedure, the manager is aware of the needs to report and record all incidences of alleged abuse to the appropriate authority. Staff spoken to stated that they were aware of the procedure and would report to the manager. Abercorn House Nursing Care Home H54 S36926 Abercorn House V229203 250505.doc Version 1.30 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 standard(s) 19,20,23,24 The environmental standard at the home was good and provided service users with a safe and homely place to live in. Service users bedrooms reflect their choice and personalised assuring their autonomy. The home provides equipment that allows service users to maintain their independence. EVIDENCE: Accommodation is provided in a large well maintained and clean surrounding. Furnishing was of good standard and appropriate to service users needs. There is an ongoing programme of refurbishment in place. The manager reported that all rooms are redecorated when vacant and prior to new admission. Work was underway on the external paintwork on the day of the visit. The home has a number of large rooms on the ground floor where a variety of activities are undertaken and used by service users to receive their visitors. Abercorn House Nursing Care Home H54 S36926 Abercorn House V229203 250505.doc Version 1.30 Page 15 Service users bedrooms were personalised and it was evident that they are encouraged to bring in items of personal belongings as preferred. Call bells were available in all bedrooms and communal areas that were accessible to service users. Equipment for the promotion and support of service users’ independence were in place that included assisted baths, grab rails and passenger lifts that allowed access to all floors. The home has large well-maintained and safe gardens that were accessible to wheelchair users. Three service users said that they were looking forward to the nice weather in order to go out in the garden. Seating was available in the garden. There are a number of service users’ bedrooms that still require the fitting of single lever locks. The provider has confirmed the programme will be completed by the end of this year. Abercorn House Nursing Care Home H54 S36926 Abercorn House V229203 250505.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 The arrangement for the induction of staff was satisfactory with staff demonstrating an understanding of their role. The recruitment procedure was good and ensures that the welfare and safety of service users are protected. The structured training programme available ensures that care practices are safe and that staff are equipped with the skills required. EVIDENCE: The home has a number of staff that has worked there for a long time and has recently recruited some more staff from overseas. There is an induction procedure in place to ensure that staff equipped in delivering care safely. Staff spoken to stated that there is good team working and support among colleagues to manage the workload. Records of newly recruited staff were examined and it was evident that the home had a robust recruitment procedure in place. All checks were undertaken prior to employment, staff were issued with contract and terms and conditions of employment. Records were maintained as per schedule 2. The home has a training plan in place. A sample of the training plan was seen and included the management of stroke, adult protection, data protection, tissue-viability/ pressure areas care and mandatory health and safety trainings. Abercorn House Nursing Care Home H54 S36926 Abercorn House V229203 250505.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,37 The manager has a clear development plan and is supported by staff. The record keeping at the home is well managed and assures safety of service users. EVIDENCE: The home has a manager and there were clear lines of accountability within the home. Staff and service users stated that they would approach the manager if they had any concerns. Staff demonstrated good understanding of their roles and assisted the inspector as required. This was evident on the day of the inspection as the manager and senior staff left for a company’s meeting in London. All records were maintained securely. Reports as per Regulation 37 are maintained and copies are forwarded to the Commission. The Responsible Abercorn House Nursing Care Home H54 S36926 Abercorn House V229203 250505.doc Version 1.30 Page 18 Person undertakes monthly reviews at the home and reports of these are forwarded to the Commission. Abercorn House Nursing Care Home H54 S36926 Abercorn House V229203 250505.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 x x 2 x x STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x x x x 3 x Abercorn House Nursing Care Home H54 S36926 Abercorn House V229203 250505.doc Version 1.30 Page 20 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. 1. Standard 7 Regulation 15(2) Requirement The home must ensure that there is a procedure for reviewing care plans in the absence of the nominated key worker. The provider is required to have a programme of fitting appropriate locks to service users bedrooms and an action plan with timescale. Timescale for action 15/07/05 2. 24 12(4) 15/07/05 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. Refer to Standard 8 Good Practice Recommendations It is recommended that a procedure is developed and separate records of any change in treatment is available in service users records and easily accessible. 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