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Inspection on 21/06/05 for Mavern House Nursing Home

Also see our care home review for Mavern House Nursing Home for more information

This inspection was carried out on 21st June 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Mavern House provides a good standard of nursing care. Care needs are closely monitored with weekly GP visits taking place. All care records are of a satisfactory standard and regular reviews take place. The medication procedure is safe and of a good standard. Service Users who were able to express an opinion of the care provided were all complimentary of the care and of the attitude of the staff. Service Users are supported to retain links with families and friends who can visit freely.

What has improved since the last inspection?

The environmental standards are improving due to the extensive refurbishment programme currently taking place. Many of the bedrooms have been nicely refurbished providing a good standard of accommodation. The communal/dining room, which has also recently been extended, provides an open and comfortable seating area for Service Users. This room has been tastefully furnished in a homely style.Mavern House Nursing HomeVersion 1.30 D51_D01_S15927_MavernHouse_V191946_210605_Stage4.docPage 6

What the care home could do better:

The care staff should more closely monitor the weights of all Service Users ensuring that all dietary needs are met. The wound care documentation should include the size of the wound to enable staff to assess that the healing process is taking place. The commode pans should be cleaned more effectively ensuring a good standard of hygiene is maintained. All adequate fire precautions must be in place at all times to ensure the safety of the Service Users and staff.

CARE HOMES FOR OLDER PEOPLE Mavern House Nursing Home Corsham Road Shaw Melksham Wiltshire, SN12 8EH Lead Inspector Karen Mandle Unannounced 21st June 2005 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. Mavern House Nursing Home Version 1.30 D51_D01_S15927_MavernHouse_V191946_210605_Stage4.doc Page 3 SERVICE INFORMATION Name of service Mavern House Nursing Home Address Corsham Road Shaw Melksham Wiltshire SN12 8EH 01225 708168 01225 793372 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) Mavern Care Limited Mrs Yvonne Cambridge Care Home with Nursing 29 Category(ies) of OP Old Age (29) registration, with number TI Terminally ill (3) of places Mavern House Nursing Home Version 1.30 D51_D01_S15927_MavernHouse_V191946_210605_Stage4.doc Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents in room 4a, 5, 6 and 7 must be independently mobile until a ramp is provided. 2. No more than 29 persons in receipt of nursing care of which no more than 3 persons in receipt of terminal care at any one time only accommodated on the ground floor. Date of last inspection 10th February 2005 Brief Description of the Service: Mavern House Nursing Home is registered to provide nursing care for 29 older people aged 65 years and older. The home is currently under going a large refurbishment programme to improve the environmental standards for Service Users. The home provides single room accommodation and shared rooms with a recently extended communal/dining area. The home is situated in the village of Shaw just a few miles from the town of Melksham in Wiltshire. The home is owned by Mavern Care Limited, which is a family run business. The Registered Manager is Mrs Yvonne Cambridge who is a qualifed nurse and has worked at the home for many years who has a clear understanding of the care the home is able to provide. Mavern House Nursing Home Version 1.30 D51_D01_S15927_MavernHouse_V191946_210605_Stage4.doc Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection commenced at 10.10am and was completed at 1.30pm. The inspection was carried out due to the major building work in progress and to ensure that the building work was not interrupting the Service Users care or daily life in anyway. The inspector was freely able to tour the home and visit with many Service Users. Several members of staff were spoken to and care records were inspected, as were the medications. What the service does well: What has improved since the last inspection? The environmental standards are improving due to the extensive refurbishment programme currently taking place. Many of the bedrooms have been nicely refurbished providing a good standard of accommodation. The communal/dining room, which has also recently been extended, provides an open and comfortable seating area for Service Users. This room has been tastefully furnished in a homely style. Mavern House Nursing Home Version 1.30 D51_D01_S15927_MavernHouse_V191946_210605_Stage4.doc 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. Mavern House Nursing Home Version 1.30 D51_D01_S15927_MavernHouse_V191946_210605_Stage4.doc 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 Mavern House Nursing Home D51_D01_S15927_MavernHouse_V191946_210605_Stage4.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 and 5 A clear admission procedure is in place and all needs are assessed during the pre admission assessment. Service Users and families can visit the home prior to admission. EVIDENCE: All Service Users are fully assessed by the Registered Manager prior to admission to Mavern House to ensure that through the assessment process the home is able to meet the nursing care needs and social needs of the individual Service User. The assessment is detailed providing information of all current health care needs and social needs. A record of the assessment is kept on the Service Users’ file. Service Users are encouraged and invited to visit the home prior to admission, to meet with staff and other Service Users and view the accommodation provided. However due to poor health care pre admission visits cannot always take place. Mavern House Nursing Home D51_D01_S15927_MavernHouse_V191946_210605_Stage4.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) 7,8,9 and 10 Health care needs of Service Users are closely monitored and appropriate action taken when health care needs change. The care plans fully address all aspects of care, apart from regular monitoring of Service Users weights. The privacy and dignity of Service Users is supported by the care team. EVIDENCE: Each Service User is provided with a plan of care. The care plans address current and long-term health care needs ensuring all care needs are fully identified and addressed. Monthly reviews take place or when care needs of the Service Users change. Service Users with high needs are provided with daily care charts providing evidence of close monitoring by the care staff ensuring that all needs are fully met. The care charts were up to date and detailed during the inspection. The monitoring of Service Users weights was not done on a regular basis ensuring that all dietary needs are being met. It was observed that whilst many Service Users were provided with a pressurerelieving mattress, several did not have a pressure relieving cushions in their armchair to ensure their was no risk of pressure breakdown whilst out of bed. A wound assessment chart is maintained to ensure any wounds are monitored and addressed correctly by the nursing staff, however the documentation Mavern House Nursing Home D51_D01_S15927_MavernHouse_V191946_210605_Stage4.doc Version 1.30 Page 10 should include the size of wound during assessment to provide evidence of the healing process. All Service Users are registered with a local GP who visits the home weekly. Service Users who were able to communicate were complimentary of the standard of care provided, as was a relative who frequently visits the home. The inspector observed two very frail Service Users who looked well cared for and comfortable. Service Users confirmed that any nursing or personal care always took place in the privacy of their bedroom or bathroom. This was also observed taking place during the inspection. Mavern House Nursing Home D51_D01_S15927_MavernHouse_V191946_210605_Stage4.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 and 13 The activities provided are appropriate for the Service Users group. Service Users are supported by the home to retain links with families and friends. EVIDENCE: Activities are provided two to three afternoons a week. Service Users when asked were satisfied with the amount of activities provided and were looking forward to the entertainment and Barbeque that was taking place on the day of the unannounced inspection. Service Users who do not wish to attend activities reported they can do as they like and that the staff respect this. Service Users can receive visitors at anytime in the privacy of their bedroom or the communal room. The visitors signing in book confirmed this. Mavern House Nursing Home D51_D01_S15927_MavernHouse_V191946_210605_Stage4.doc Version 1.30 Page 12 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 There is a complaints policy and procedure in place. A vulnerable adults procedure is also in place and staff are aware of the local procedure and how to use it. EVIDENCE: A complaints policy and procedure is in place, which is available in the entrance hall to the home for Service Users and visitors to obtain. The home has not received any formal complaints. Two Service Users confirmed that they would talk to the Manager if they had any issues or problems, as she is always helpful. A procedure is in place for dealing with any allegations of abuse and a copy of the local vulnerable adults procedure is available to all staff. The Manager confirmed that she had recently provided training to all staff on how to use the vulnerable adults procedure. Mavern House Nursing Home D51_D01_S15927_MavernHouse_V191946_210605_Stage4.doc Version 1.30 Page 13 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, 24 and 26 Mavern House provides a homely environment. The standard of accommodation has recently much improved for Service Users to live in. The home is clean and infection control practices observed, apart from the commode pans. EVIDENCE: Mavern House is currently being refurbished throughout to improve all environmental standards for Service Users. The refurbishment programme has been extensive but good progress is now being made, with the communal/dining area now completed providing a light and spacious room for Service Users to enjoy during the day. Many of the bedrooms have been refurbished to a good standard. The bedrooms are homely, with many personal items and furnishings around. Two Service Users confirmed that the building work, which was being carried out did not disturb them in anyway. The home was clean throughout. Infection control measures are in place and staff were seen changing disposable gloves and aprons between Service Users reducing the risk of cross infection form one Service Users to another. However Mavern House Nursing Home D51_D01_S15927_MavernHouse_V191946_210605_Stage4.doc Version 1.30 Page 14 many of the commode pans were not suitably clean enough for Service Users to use. Mavern House Nursing Home D51_D01_S15927_MavernHouse_V191946_210605_Stage4.doc Version 1.30 Page 15 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 The number of staff available is sufficient to meet the nursing and personal needs of the Service Users. EVIDENCE: Mavern House benefits from a stable staff group, some of which have worked at the home for many years and have a clear understanding of the Service Users’ groups care and social needs. The staffing rotas seen provided evidence that a trained nurse is on duty day and night ensuring all nursing care needs can be met or assessed by a qualified nurse. The qualified nurse is supported by, a team of carers who provide personal care to the Service Users. Care staff were observed during the inspection as calm and well organised and Service Users care needs were being met. Service Users call bells were answered promptly. Good verbal interaction between staff and Service Users was heard. Several Service Users expressed satisfaction with conduct of the staff and commented how helpful the staff always were. Mavern House Nursing Home D51_D01_S15927_MavernHouse_V191946_210605_Stage4.doc Version 1.30 Page 16 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) 33 and 38 Quality assurance procedures are in place, which gain the views and opinions of the Service Users and families. Health and Safety issues are not being fully addressed ensuring the safety of the Service Users and staff. EVIDENCE: The home conducts an annual survey based on gaining the views of the Service Users and families of the service that Mavern House provides. The Registered Manager had just recently sent out the surveys but had not yet received any replies. Health and safety issues are addressed, with all accidents being recorded and fully audited monthly by the Manager. Electrical equipment is tested annually and servicing of hoists was taking place. The fire records indicated that the weekly testing of the fire alarm was taking place. However due to building work being carried out an entrance to the loft space of the home had been left open which was situated above an electrical sluicing machine which in the Mavern House Nursing Home D51_D01_S15927_MavernHouse_V191946_210605_Stage4.doc Version 1.30 Page 17 event of an undetected fire would cause increased risk to Service Users safety. A window in Room 5 had no restrictor applied and open freely posing a risk to the Service User occupying the room. The corridor in the Burrows wing is used for storage of wheel chairs and other equipment again posing risk to Service Users and staff in the event of a fire. Mavern House Nursing Home D51_D01_S15927_MavernHouse_V191946_210605_Stage4.doc Version 1.30 Page 18 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 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x 3 x 2 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x x x 2 Mavern House Nursing Home D51_D01_S15927_MavernHouse_V191946_210605_Stage4.doc Version 1.30 Page 19 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 Requirement The Registered Manager will ensure the wound care documentation includes the size of the wound in detail. The Registered Person will ensure regular monitoring of Service Users weights takes place. The Registered Person will ensure that all commode pans are cleaned to a good standard of hygiene. The Registered Person will ensure that all adequate fire precautions are in place at all times. The Registered Person will ensure that the window in room 5 and any other unrestricted window in the home has a window restricting device placed on the window. The Registered Person will ensure corridors are kept clear and not used as a storage area. Timescale for action By 15th August 2005 By 15th August 2005 By 1st August 2005 From 21 st June 2005 By 15th August 2005 2. OP8 12(1,a) 3. OP26 13(3) 4. OP38 23(4,a) 5. OP38 13(4,a) 6. OP38 23(2,I) By 1st August 2005 Mavern House Nursing Home D51_D01_S15927_MavernHouse_V191946_210605_Stage4.doc Version 1.30 Page 20 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 OP8 Good Practice Recommendations The Registered Manager should ensure that the pressure relieving equipment used for Service Users when not in bed is appropriate to meeting the needs of the Service Users. Mavern House Nursing Home D51_D01_S15927_MavernHouse_V191946_210605_Stage4.doc Version 1.30 Page 21 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI Mavern House Nursing Home D51_D01_S15927_MavernHouse_V191946_210605_Stage4.doc Version 1.30 Page 22 - 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. 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