Inspection on 07/09/05 for Aldbourne Nursing Home

This inspection was carried out on 7th September 2005.

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

Aldbourne Nursing Home 20/02/07

Aldbourne Nursing Home 26/01/06

Aldbourne Nursing Home 03/03/05

Aldbourne Nursing Home 16/11/04

Aldbourne Nursing Home 26/03/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Aldbourne Nursing Home South Street Aldbourne Marlborough Wiltshire SN8 2DW Lead Inspector Steve Cousins Unannounced 7 -8 September 2005 th th 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. Aldbourne Nursing Home DD51_D01_S15884_ALDBOURNE_V245783_070905_STAGE4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Aldbourne Nursing Home Address South Street Aldbourne Marlborough Wiltshire SN8 2DW 01672 540919 01672 540997 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) Aldbourne Nursing Home Limited Mr Robert Gaetan Montezuma Nursing Home 40 Category(ies) of DE(E) Dementia - over 65 1 registration, with number OP Old age 40 of places PD Physical disability 2 TI Terminally ill 2 TI(E) Terminally ill 2 Aldbourne Nursing Home DD51_D01_S15884_ALDBOURNE_V245783_070905_STAGE4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users who may be accommodated in the home at any one time is 40 2. No more than a total of 2 service users with a terminal illness may be accommodated at any one time and these must not be less than 50 years of age 3. No more than 2 physically disabled users between the ages of 18 and 64 years may be accommodated at any one time. 4. The only service user who may be accommodated in the category DE(E) is the female service user named in the application dated 1st July 2004. Records, including care plans and risk assessments, must demonstrate that the care home is able to meet this service user`s mental health needs. In addition, the the well-being of other service users must not be compromised. 5. Only rooms 2, 3, 4, 7, 9, 10, 11, 17 and 19 may be used for double occupancy and no more than 2 double rooms may be occupied at any one time 6. That the registered manager is on duty in the home in a managerial capacity for a minimum of 21 hours per week, over 3 days, 7. That the deputy matron is on duty in the home in a managerial capacity for a minimum of 14 hours per week, over 2 days 8. That these conditions of registration are formally reviewed on 1st March 2006 9. The minimum staffing levels set out in the notice of decision dated 18th April 2005 must be met at all times. Date of last inspection 3 March 2005 Aldbourne Nursing Home DD51_D01_S15884_ALDBOURNE_V245783_070905_STAGE4.doc Version 1.40 Page 5 Brief Description of the Service: Aldbourne Nursing Home provides care with nursing for up to 40 people. The majority of these will be aged over 65. The home is also registered to care for some younger adults. At any time, there could be 2 people with physical disability, or 2 who are terminally ill. Some short-term care places are offered. The home is privately operated. The owners, Mr and Mrs Adey, live nearby, and have regular contact with the service. The registered manager is Mr Guy Montezuma and he is supported by the homes depuy matron, Wendy Sheen. Registered nurses are on duty at all times, supported by care assistants. Catering, domestic, laundry, maintenance and administration services are also available. The home was purpose built in 1988 and has since been further extended. It is set in its own grounds in the village of Aldbourne, which offers various local amenities and is an attractive location. The large town of Swindon is only 10 miles away. Market towns such as Marlborough, Hungerford, Newbury and Wantage are all within driving distance and there are also easy connections to the M4 motorway. Aldbourne Nursing Home DD51_D01_S15884_ALDBOURNE_V245783_070905_STAGE4.doc Version 1.40 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. Service users are known as residents in this home and will be referred to as such throughout this report. This unannounced inspection took place between 9.45am and 3.30pm on the 7th September and 11.15am and 12.30pm on the 8th September 2005. There were 35 residents in the home. The findings from this inspection are based on a tour of the premises, speaking to residents, staff and relatives; and visiting frail residents, some of who were unable to communicate. A number of records were inspected, including care plans and staff files. The findings were discussed with Mr Montezuma, the registered manager and Mrs Sheen, the deputy matron, at the end of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Not all care plans had been regularly reviewed and resident’s nutritional status needs to be assessed on admission. Staff need to ensure that they sign for any medication that they administer. Fire escape routes and exits need to be checked at least monthly. Aldbourne Nursing Home DD51_D01_S15884_ALDBOURNE_V245783_070905_STAGE4.doc Version 1.40 Page 7 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. Aldbourne Nursing Home DD51_D01_S15884_ALDBOURNE_V245783_070905_STAGE4.doc Version 1.40 Page 8 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 Aldbourne Nursing Home DD51_D01_S15884_ALDBOURNE_V245783_070905_STAGE4.doc Version 1.40 Page 9 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) 1,3,4 and 5 Residents have the information and opportunity to make an informed choice about the home, their needs are assessed before admission and the home has the capability to meet their needs. EVIDENCE: The statement of purpose and service users guide were available along with a copy of the previous CSCI inspection report. None of the residents spoken to had been physically able to visit the home prior to admission but some stated that their relatives had done so. None regretted their move to the home. Care plans indicated that pre admission assessments had been undertaken by a registered nurse to ensure any prospective residents needs can be met. Two residents confirmed this. Other pre admission documents, such as social services care reviews were also available. The home is currently providing nursing care for the elderly and people with a terminal illness. The findings of this inspection and the comments of residents, relatives and staff, indicate that the home has the capacity to meet the needs of this client group. Residents are given appropriate support, the environment is suitable, equipment is available and staff receive relevant training. Aldbourne Nursing Home DD51_D01_S15884_ALDBOURNE_V245783_070905_STAGE4.doc Version 1.40 Page 10 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 and 9. The standard of personal and health care delivered was good and met the assessed needs of residents, however residents nutritional needs are not always assessed. The systems for the handling of medication ensure that the residents are protected but administration recording needs to be improved. EVIDENCE: The care plans reviewed were mainly a good reflection of assessed needs, but one had not been regularly updated. Tissue viability and manual handling assessments are undertaken but nutritional assessments were not carried out and this was discussed with the manager and the matron. Visits to residents confirmed that appropriate action was being taken to meet their assessed needs and pressure relief equipment was in place as required. Residents appeared well looked after and to be having their personal hygiene needs met. Records indicated prompt response by staff to residents’ health care needs. The GP visits weekly and also sees all new residents on admission. A podiatrist was visiting residents’ during the inspection and records indicated other health care professionals, such as a tissue viability nurse and an ophthalmologist had visited the home. Aldbourne Nursing Home DD51_D01_S15884_ALDBOURNE_V245783_070905_STAGE4.doc Version 1.40 Page 11 Residents spoken with were complimentary about the home, saying that staff are kind and that they felt safe. Some described the staff as ’wonderful’ and ‘nice people’ another said he was ‘being well looked after’. Some residents reported difficulty communicating with some staff members and this was discussed with the manager. Visiting relatives were happy with the standard of care and support provided. The arrangements regarding medications were generally satisfactory, but there were some gaps on medicine administration records. Aldbourne Nursing Home DD51_D01_S15884_ALDBOURNE_V245783_070905_STAGE4.doc Version 1.40 Page 12 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) 12,14 and 15. The social, recreational and nutritional needs of the residents are met and they are able to maintain contact with friends, relatives and the local community. EVIDENCE: Information regarding social and recreational interests is obtained in the form of a ‘personal profile’, which is kept in residents care plans. These contain details of previous occupations, achievements, interests, and general information about life history. The Friends of Aldbourne Nursing Home group provides activities in the home. They come in and arrange sessions, usually once a week. A religious service was held in the home during the inspection. From the residents comments it was apparent that there was flexibility in the homes routine to allow for personal choice and preferences, some enjoyed the activities organised, others did not wish to partake. Residents were able to maintain contact with friends and relatives and there were no restrictions on visiting, unless at the request of the resident. Visitors can be received in private or in one of the communal areas. The food served at lunchtime appeared well cooked and nutritious and there was a choice. Residents were generally complimentary about the meals available and they are asked to choose from the menu in advance. The home has a large dining room and tables are attractively laid. Residents can eat in their own rooms if they wish. Aldbourne Nursing Home DD51_D01_S15884_ALDBOURNE_V245783_070905_STAGE4.doc Version 1.40 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 and 18 Complaints are taken seriously and investigated appropriately. The homes policies, recruitment procedures and staff training ensure residents are, as far as possible, protected from abuse. EVIDENCE: Residents spoken too knew whom to complain to if they had a problem, as did two relatives who were visiting the home. Three complaints had been recorded in the past year; none of these were serious or related to care issues. The manager had dealt with complaints promptly. No complaints have been received by the CSCI this year and there were no complaints from residents or relatives during the inspection. A complaints procedure is available and referred to in the homes statement of purpose. The homes adult protection policy follows the local guidelines issued by Wiltshire County Council. Staff have abuse awareness training and those spoken to demonstrated an awareness of procedures for reporting suspected abuse. POVA checks are obtained before staff commence working in the home and CRB checks are also carried out. Where a resident requires bedrails to be fitted for their safety, then consent is sought. Aldbourne Nursing Home DD51_D01_S15884_ALDBOURNE_V245783_070905_STAGE4.doc Version 1.40 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) 19,20,21,24and 26 The home and its surrounds are accessible, safe and well maintained and there are adequate and suitable toilet and washing facilities. Residents’ bedrooms are suitable and the home is very clean and hygienic. EVIDENCE: All service user accommodation is on the ground floor. Some offices and staff facilities are upstairs. The environment is pleasant and homely and furniture, fixtures and fittings are of a good standard. There are well kept grounds including an enclosed courtyard garden, which is wheelchair accessible. New corridor carpeting has been laid throughout and this has enhanced the overall appearance. New flooring has also been laid in the dining room area. The call bell system has been upgraded. The home appeared well decorated and maintained. There is a large communal area in the central part of the building. This offers both lounge and dining room facilities. Also on the ground floor are a separate quiet lounge, and a conservatory. All service users’ rooms have an en suite toilet, along with either a bath or shower. An assisted bathroom is also Aldbourne Nursing Home DD51_D01_S15884_ALDBOURNE_V245783_070905_STAGE4.doc Version 1.40 Page 15 available, if required. Further toilets for general use are provided close to the main communal area. There are separate sluice facilities available. The bedrooms provide a comfortable amount of space, and full en-suite facilities. Telephone points are available in each. Those seen were decorated to a satisfactory standard and carpeted. Occupants were able to personalise their rooms as they wish. Adjustable beds were available. The home was very clean throughout and there were no unpleasant odours. Infection control procedures were in place in the laundry, which was clean and tidy. Food hygiene procedures were in place in the kitchen. Aldbourne Nursing Home DD51_D01_S15884_ALDBOURNE_V245783_070905_STAGE4.doc Version 1.40 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) 27,28,29 and 30 The numbers and skill mix of staff met the residents’ needs and staff are trained and competent. The homes recruitment procedures support and protect the residents. EVIDENCE: Service users felt that there were enough care staff available and reported minimal delays in answering call bells. Staff were observed dealing with residents as promptly as possible. The care staffing levels on the day of the inspection appeared appropriate and review of duty rotas indicated that the home was meeting the minimum staffing notice and that registered nurses were on duty at all times. Staff and relatives spoken to had no concerns regarding staffing levels. The housekeeper and two cleaning staff were also on duty, there was a person in the laundry, one cook, one catering assistant and a maintenance person. Individual staff training records are kept. These indicated that regular mandatory training was being undertaken and that induction training is provided. Of the twelve care assistants employed, eight had achieved NVQ 2 or above. The remaining were currently undertaking NVQ2. The recruitment files of new staff members were reviewed. Recruitment procedure was satisfactory and all appropriate documentation was in place. Aldbourne Nursing Home DD51_D01_S15884_ALDBOURNE_V245783_070905_STAGE4.doc Version 1.40 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) 31,36 and 38 The registered manager is fit to run the home and is supported to do so effectively. Staff are appropriately supervised and the health safety and welfare of the residents and staff is promoted. EVIDENCE: The homes registered manager is Mr Guy Montezuma. Mr Montezuma’s previous role was as the homes general manager and he had also undertaken the registered managers role in the past. He is a registered general nurse who has a district nursing certificate, and a degree in business administration. Mrs Wendy Sheen, who is also registered nurse and the homes deputy matron, supports Mr Montezuma in his role. Mrs Sheen is shortly to start an NVQ4 in management. It was evident from the comments of residents and staff that both the manager and matron frequently work alongside staff, and monitor standards of work. Monthly staff meetings are held and a formal supervision system is in Aldbourne Nursing Home DD51_D01_S15884_ALDBOURNE_V245783_070905_STAGE4.doc Version 1.40 Page 18 place, care needs to be taken to ensure all staff receive supervision at least 6 times a year. Review of the fire log indicated that all fire safety checks were undertaken at the required intervals apart from the monthly check of ‘means of escape’. Fire exits were clear from obstruction. Maintenance records indicated that essential equipment and services were regularly maintained. Fire extinguishers, PAT testing and gas boilers were due to be serviced during the month of the inspection. Accidents are recorded and reviewed. Manual handling equipment is available and staff are trained in its use. Generic and individual risk assessments are in place. A tour of the building showed that it was free from obvious hazards to health and safety. Aldbourne Nursing Home DD51_D01_S15884_ALDBOURNE_V245783_070905_STAGE4.doc Version 1.40 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 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 x x 3 x 4 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 Standard No 16 17 18 Score 3 x 3 3 x x x x 3 x 3 Aldbourne Nursing Home DD51_D01_S15884_ALDBOURNE_V245783_070905_STAGE4.doc Version 1.40 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 OP7 Regulation 15 (2,b,c) Requirement The registered manager is required to ensure that residents care plans are reviewed at least once a month, updated to reflect changing needs and actioned accordingly. The registered manager is required to ensure that a nutritional assessment is undertaken on admission and reviewed at least once a month. The registered manager is required to ensure that persons administering medicines sign as having done so, or enter the appropriate code for non administration. The registered person is required to ensure that fire escape routes are checked monthly. Timescale for action 8/9/05 2. OP8 14 (1,a) (2,a,b) 8/9/05 3. OP9 17 (1,a) 8/9/05 4. OP38 23 (4,c,v) 8/9/05 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. Aldbourne Nursing Home DD51_D01_S15884_ALDBOURNE_V245783_070905_STAGE4.doc Version 1.40 Page 21 Refer to Standard Good Practice Recommendations Aldbourne Nursing Home DD51_D01_S15884_ALDBOURNE_V245783_070905_STAGE4.doc Version 1.40 Page 22 Commission for Social Care Inspection Suite C, Avonbridge House Bath Road Chippenham Wiltshire SN15 2BB 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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