Inspection on 13/12/05 for Foxleigh Grove Nursing Home

This inspection was carried out on 13th December 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

Foxleigh Grove Nursing Home 23/08/06

Foxleigh Grove Nursing Home 30/06/05

Foxleigh Grove Nursing Home 18/01/05

Foxleigh Grove Nursing Home 26/08/04

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 Foxleigh Grove Nursing Home Forest Green Road Holyport Maidenhead Berkshire SL6 3LQ Lead Inspector Mrs Rhian Williams-Flew Unannounced Inspection 13th December 2005 11:00 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 Foxleigh Grove Nursing Home DS0000010985.V273450.R01.S.doc Version 5.0 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. Foxleigh Grove Nursing Home DS0000010985.V273450.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Foxleigh Grove Nursing Home Address Forest Green Road Holyport Maidenhead Berkshire SL6 3LQ 01628 673332 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) Mr Robert Anthony Aram Mr Mark Andrew Robert Aram, Miss Gillian Jane Aram, Mr Simon Michael James Aram, Mrs Gina Sanderson Aram Mrs Elizabeth Moxon Care Home 39 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (1), Old age, not falling within any of places other category (39), Physical disability (5) Foxleigh Grove Nursing Home DS0000010985.V273450.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The room known as `Goring` situated on the first floor of the home may only be used by service users if a documented risk assessment of their mobility capabilities has been undertaken and placed on record. 30th June 2005 Date of last inspection Brief Description of the Service: Foxleigh Grove is a care home with nursing. It provides care to older people who do not suffer from a diagnosis of dementia and younger people with physical disabilities. A General Manager, Mr Mark Aram, manages the home. There are also two Care Managers, Mrs Plant and Mrs Moxon. They share the responsibilities of the Registered Manager position. In addition, they are responsible for the clinical care provided at the home. The home provides its accommodation over two floors that are serviced by a passenger lift. The majority of the rooms available are for single occupancy. The home is situated in the village of Holyport on the outskirts of Maidenhead. It has extensive gardens that are much appreciated by the residents in the home. The train station is approximately 2 miles away. A bus service runs near to the care home. The home also has its own transport which residents can utilise for appointments and visits to the local amenities. Foxleigh Grove Nursing Home DS0000010985.V273450.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection occurring on a weekday between 11.00 17.30 hours. The General Manager, Mr Mark Aram, was present throughout the inspection and the two Registered Managers were present for the latter part of the day. This report should be read alongside the previous inspection report of 30 June 2005. This will give a complete overview of the key standards inspected over the two inspections. On this occasion only eight key standards were inspected. During the inspection various records kept in a care home were randomly sampled. These included the care and health records of the residents. Procedures and practices with regard to the storage, administration and recording of medication were also inspected. Some members of staff were spoken with. What the service does well: What has improved since the last inspection? There were no requirements from the previous inspection. The home is very committed to ensuring that they meet the needs of the residents who live in the home and deliver good care. They always strive to improve on their already high standards. Foxleigh Grove Nursing Home DS0000010985.V273450.R01.S.doc Version 5.0 Page 6 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. Foxleigh Grove Nursing Home DS0000010985.V273450.R01.S.doc Version 5.0 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 Foxleigh Grove Nursing Home DS0000010985.V273450.R01.S.doc Version 5.0 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): 3 & 4 (standard 6 is not applicable) The home ensures that full pre-admission assessments are completed before any prospective resident is admitted. The people admitted to the home can therefore have confidence that the home is prepared and ready to meet their needs. EVIDENCE: The care records of two recently admitted residents were reviewed in full. There was good evidence to demonstrate that one of the Registered Managers had conducted a full assessment of the peoples needs. These assessments were supported by additional information from health and social services professionals. As the Registered Managers are both registered nurses they had been able to determine whether the home had the correct equipment and level of skills to meet the peoples needs. There was evidence to demonstrate that the General Manager had been able to identify to the people/authority who are funding the care whether there were going to be any additional care needs. He had been able to do this based on the assessments of the Registered Managers. This practice should ensure that Foxleigh Grove Nursing Home DS0000010985.V273450.R01.S.doc Version 5.0 Page 9 when people are admitted to the home they can have confidence that their needs will be met. Foxleigh Grove Nursing Home DS0000010985.V273450.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, 9 & 10 The care and health needs of the residents in the home are well met and care plans reflect their current needs. The storage, administration and recording of medicines that are not controlled drugs met the standard. It was necessary to issue an immediate requirement with regard to the storage, administration and recording of controlled drugs. The home has subsequently submitted an action plan to address the serious concerns found in a timely manner. EVIDENCE: Care plans for residents of the home are developed from the pre-admission assessment. 4 care plans were reviewed (this included 2 newly admitted residents). The care plans detailed the peoples needs with regard to their health; personal and social care needs and defined the actions to be taken by staff to ensure that their needs were met. The care plans are reviewed monthly and any changes are detailed. Wherever possible the residents are fully included in their care plans. Throughout the care plans it was noted that references are made to ensure that when care is being delivered, residents are treated with respect and dignity. Foxleigh Grove Nursing Home DS0000010985.V273450.R01.S.doc Version 5.0 Page 11 The health care needs of the people who live in the home are well met. There are a number of experienced and qualified registered nurses on the staff who regularly attend continuing professional development courses to ensure that their practice is up-to-date. Care of a person’s psychological as well as physical health is addressed and regularly reviewed. The home is well supported by a local GP (who is contracted with by the care home) however; residents do have the choice to continue to use their previous GP if they are still within their catchment area. Evidence was seen of residents accessing specialist services at local hospitals and clinics. A review of the homes procedures for the receipt, recording, storage, handling, administration and disposals of medicines was conducted. This included the management of Controlled Drugs. A review of the medicines (other than the Controlled Drugs) evidenced that the home has clear procedures and practice with regard to the safekeeping and administration of medication. The medicines administration records (MAR) are clear and are regularly reviewed and updated. There was clear evidence that members of staff monitor the medical conditions of residents in the home and seek advice from the GP if there are changes in their condition that may result in medication being prescribed. The staff spoken with also demonstrated good knowledge of specific drugs and their interaction with other medication. During the inspection evidence was seen of residents taking alternative medicines. The specific advice of the Pharmacist Inspector was sought (after the inspection) and the home has been advised of the following information as a recommendation of good practice. Residents who wish to use alternative medicines and supplements have the choice to do so, if a registered practitioner does not prescribe them. If they are not prescribed the members of staff in the home should not administer the medicines unless they are in the original containers. The persons registered practitioner should be made aware of the preparations the person is taking and this should be reviewed regularly. Ideally, in these instances, selfadministration of these medicines and preparations is preferred. The home should have a policy and procedure with regard to this issue to safeguard the resident and themselves. During the review of the Controlled Drugs stored in the home it was revealed that errors had occurred in the recording of these medicines for individual residents. In addition, individual medicines for residents who had been prescribed Controlled Drugs were not available to be administered. This had resulted in the medicines for one person being used for another. This practice should not occur. It was necessary to issue an immediate requirement to comply with the appropriate legislation and guidance (from the Royal Pharmaceutical Society) with regard to Controlled Drugs. The Registered Managers accepted that deficits and deficiencies had occurred. Subsequent to Foxleigh Grove Nursing Home DS0000010985.V273450.R01.S.doc Version 5.0 Page 12 the immediate requirement the home has responded by providing an action plan as to how they intend to address the deficiencies and deficits. The CSCI is satisfied that this action plan is appropriate to address the immediate requirement. The home also accepted the advice of the Pharmacist Inspector from CSCI. Foxleigh Grove Nursing Home DS0000010985.V273450.R01.S.doc Version 5.0 Page 13 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): None of these standards were inspected on this occasion. EVIDENCE: None of these standards were inspected on this occasion. Foxleigh Grove Nursing Home DS0000010985.V273450.R01.S.doc Version 5.0 Page 14 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): None of these standards were inspected on this occasion. EVIDENCE: None of these standards were inspected on this occasion. Foxleigh Grove Nursing Home DS0000010985.V273450.R01.S.doc Version 5.0 Page 15 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): None of these standards were inspected on this occasion. EVIDENCE: None of these standards were inspected on this occasion. Foxleigh Grove Nursing Home DS0000010985.V273450.R01.S.doc Version 5.0 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 This home does see training and continuing professional development as an important part of staff development thus ensuring that staff have up-to-date knowledge of care practices. EVIDENCE: The home is committed to ensuring the care staff in the home do receive recognised training. All members of staff receive induction training and subsequent to this they receive additional training within the first six months of employment. Staff are encouraged to attend vocational training courses. In addition, a small number of staff have gone on to qualify as trainers themselves for specific courses in manual handling and infection control. The registered nurses also attend continuing professional development courses to ensure their practice is up-to-date. The General Manager of the home is very supportive of staff receiving training. Foxleigh Grove Nursing Home DS0000010985.V273450.R01.S.doc Version 5.0 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, 35 & 38 This home has a good management team with clear lines of accountability. The home is managed to safeguard the health and safety of the residents and staff. The homes quality assurance audit of residents and their carers revealed a very high satisfaction rating of the services and care provided by the home. EVIDENCE: This home encourages all residents to manage their own financial affairs or have family members and independent advocates assisting them. The home does not handle any monies on behalf of the residents in the home. A random sample of records and documents were reviewed to ensure that the home employs safe working practices for its staff and maintains a safe environment for the residents to live within. The home has clear procedures in place to ensure that the correct checks are carried out. The General Manager was advised to ensure that if a member of staff has a particular role with regard to these checks then it is his responsibility to ensure that if this person Foxleigh Grove Nursing Home DS0000010985.V273450.R01.S.doc Version 5.0 Page 18 is absent from work then someone else carries out the checks. Up-to-date risk assessments for all safe working practices could be evidenced and action plans were seen with regard to actions required by the Health and Safety Executive and the Fire Authority following their visits in the past year. The analysis of a recent survey of residents and carers with regard to their opinions of the care and services they receive was reviewed. It was clear that there are very high satisfaction levels. Foxleigh Grove Nursing Home DS0000010985.V273450.R01.S.doc Version 5.0 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 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X 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 X X N/A X X 3 Foxleigh Grove Nursing Home DS0000010985.V273450.R01.S.doc Version 5.0 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. 1 Standard OP9 Regulation 13(2) Requirement When residents are prescribed Controlled Drugs they must have their own prescription for the nurse to administer from. There must be an accurate record of “wasted” Controlled Drugs. The Responsible Individual should review the provision of pharmacy support to the home and be satisfied that it is sufficient to meet the needs of the people in the home. The nursing staff in the home must follow all relevant legislation and guidance with regard to Controlled Drugs. Timescale for action 13/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Foxleigh Grove Nursing Home DS0000010985.V273450.R01.S.doc Version 5.0 Page 21 No. 1 Refer to Standard OP9 Good Practice Recommendations The Registered Managers act on the advise given by the Pharmacist Inspector with regard to alternative medicines. Foxleigh Grove Nursing Home DS0000010985.V273450.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA 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. Extracts may not be used or reproduced without the express permission of CSCI Foxleigh Grove Nursing Home DS0000010985.V273450.R01.S.doc Version 5.0 Page 23 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!