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Inspection on 03/01/06 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 3rd January 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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 homely environment for service users to live in with many of the bedrooms now refurbished. The home benefits from a stable staff group many of which have worked at the home for many years and have a good understanding of the care needs of the service users. Good interaction between the staff and the service users was observed and care needs well attended. All service users who were able to communicate were complimentary of the care provided. The food is home cooked and of a good quality with a varied menu.

What has improved since the last inspection?

Documentation relating to wound care has improved providing a detailed evaluation of a wound and progress being made to heal the wound. An unrestricted window is now safe as identified at the previous inspection. Some progress has been made to improve environmental standards through the home.

What the care home could do better:

The care plans will need to be more closely monitored in line with service users changing needs and monthly reviews should take place. A nutritional risk assessment should be implemented to ensure that all nutritional needs of the service users are being met. All staff should receive training in the local vulnerable adults procedure and infection control as not all measures were in place. The home had to much equipment stored in corridors which should be disposed of if not used or a storage area will need to be found in the home as this poses a risk to 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 Inspection 3rd January 2006 9:50am 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 Mavern House Nursing Home DS0000015927.V275236.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Mavern House Nursing Home DS0000015927.V275236.R01.S.doc Version 5.1 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 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) Mavern Care Limited Mrs Yvonne Cambridge Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29), Terminally ill (3) of places Mavern House Nursing Home DS0000015927.V275236.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Residents in rooms 4a, 5, 6 and 7 must be independently mobile until a ramp is provided 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 21st June 2005 Date of last inspection 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 DS0000015927.V275236.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection commenced at 9.50am and was completed at 1.55pm. The Registered Manager was not available at the time of the inspection. However the inspector was assisted by, the qualified nurse’s on duty Maggie Preston RGN and Sara Young RGN both of which, were open to the inspection process and were helpful through out the inspection. The home was calm and well organised. Mavern House is currently under going extensive building work within the home to improve environmental standards and building work has now commenced to the rear of the home to increase the amount of bedrooms provided. What the service does well: What has improved since the last inspection? Documentation relating to wound care has improved providing a detailed evaluation of a wound and progress being made to heal the wound. An unrestricted window is now safe as identified at the previous inspection. Some progress has been made to improve environmental standards through the home. Mavern House Nursing Home DS0000015927.V275236.R01.S.doc Version 5.1 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 DS0000015927.V275236.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mavern House Nursing Home DS0000015927.V275236.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 5 were assessed and met at the previous inspection. EVIDENCE: Mavern House Nursing Home DS0000015927.V275236.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, and 10 Health care needs are monitored and appropriate action taken when health care needs change. Not all care records were reviewed monthly and therefore did not fully relate to the changing needs of the individual service user. All care is provided in the privacy of the service users’ bedroom or bathroom. EVIDENCE: Each service user is provided with a care plan. The inspector reviewed 5 care plans following visits with service users. The frequency of care plan reviews taking place varied and not all care plans had been reviewed monthly. A pressure area risk assessment for a service user at high risk of breakdown had not been reviewed on a monthly basis, with the last review, taking place in October 2005, however the service user was being nursed on appropriate pressure relieving equipment whilst in bed. Another care plan did not fully address the care needs of a service user who suffers with Dementia. A daily statement is recorded in a kardex system, which provided limited information relating to how the service user spent their day. Nutritional risk assessments are not in place to ensure that all nutritional needs of the service users are Mavern House Nursing Home DS0000015927.V275236.R01.S.doc Version 5.1 Page 10 being met. Wound assessment charts were more detailed providing the size of the wound as required from the previous inspection. All service users are registered with a local GP who visits the home weekly. Evidence of the visits was recorded in the kardex. Service users who were able to communicate with the inspector were complimentary of the standard of care provided. The medications were not reviewed as standard 9 was met at the previous inspection. However glycerine suppositories were seen stored inappropriately around the home, which were prescribed generally and not to an individual service user. This is acceptable if a clear policy is in place to support the use of suppositories in line with the homely remedy policy as the home is registered to provide nursing care. 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 DS0000015927.V275236.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 and 15 Service users are supported by the home to maintain links with friends and family. Service users enjoyed the food with a varied well balanced diet provided by the home. EVIDENCE: Service users confirmed that they receive visits from friends and family when they wish, in the privacy of their bedroom or in the communal area. The visitors signing in book provided evidence of this taking place. All service users the inspector spoke with were complimentary of the standard of the food provided. A comfortable dining area is provided on the ground floor where 8 service users were seen having lunch together. Service users can by choice have their meals in the privacy of their bedroom. 9 service users were requiring assistance with their meals, which was conducted on a one to one basis by the staff. The inspector visited the kitchen, which was clean and organised. However the temperatures of two fridges had not being recorded, as both of the door seals were broken which could pose a risk of food not being stored at the correct temperature. The preparation room, which is situated to the rear of the kitchen, is in a poor state and is now only used for washing up. Mavern House Nursing Home DS0000015927.V275236.R01.S.doc Version 5.1 Page 12 Plans are in place to install a new kitchen and preparation room. This should be considered as a priority within the refurbishment plans of the home. Mavern House Nursing Home DS0000015927.V275236.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 A complaints policy and procedure is in place. The staff was not fully informed of the local vulnerable adults procedure ensuring as far as possible that service users are protected from abuse. EVIDENCE: A complaints policy and procedure is in place, which is available in the entrance hall to the home available to service users and visitors. The nurse in charge was not aware that any formal complaints had been received. The CSCI have not received any formal complaints regarding the service provided by Mavern House. A policy and procedure is in place for dealing with any allegations of abuse along with a copy of the local vulnerable adults procedure. However with speaking to staff it was evident that further training should be provided ensuring that the staff are fully informed of the local vulnerable adults procedure. Mavern House Nursing Home DS0000015927.V275236.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24, and 26 Mavern House provides a homely environment for service users to live in. However the environmental standards through the home do vary. The bedrooms are homely and personalised. Infection control practices were not satisfactory ensuring that service users were not at risk of cross infection. EVIDENCE: Mavern House is currently being refurbished through out and building work is now taking place to extend the accommodation provided at the home. Many of the bedrooms have now been refurbished to a good standard. However the communal bathrooms and the corridors upstairs remain in a poor condition. The communal room and dining room provide a comfortable area for service users to spend time during the day. The inspector visited many of the bedrooms, which were homely and personalised and well furnished. Several service users expressed how much they liked their bedrooms. Mavern House Nursing Home DS0000015927.V275236.R01.S.doc Version 5.1 Page 15 The home was clean through out. However not all infection control measures were in place to prevent cross infection occurring from one service user to another. The storage of wound dressings was seen in two communal bathrooms, which is not considered a clean area to store unused dressings. A member of staff was observed handling dirty laundry without wearing a disposable apron or gloves. The staff did not wear blue plastic aprons when handling food in accordance with local infection control guidelines. Body creams such as Sudocrem and Aqueous cream did not have the name of the service user the cream was being used for clearly labelled on the container. A bandage was seen on a bath hoist, which could not possibly be cleaned appropriately between service users’ baths. Mavern House Nursing Home DS0000015927.V275236.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 The service users’ nursing needs and personal care needs are fully supported by the number of staff provided. EVIDENCE: At the time of the inspection two trained nurses were on duty supported by a team of 5 carers. A cook and kitchen assistant was available as was a cleaner and maintenance person. Service users’ nursing and personal care was provided within an appropriate amount of time during the morning, without service users waiting for a long period of time before being provided with care and assistance. Call bells were observed being answered within a reasonable amount of time. Mavern House benefits from a stable staff group who know the service users well and the homes’ routine. The home was calm and well organised during the inspection with staff clearly being directed. Positive interaction was heard between the staff and the service users. Mavern House Nursing Home DS0000015927.V275236.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 and 38 The Registered Manager understands her responsibilities towards the service users and staff. Health and Safety issues are generally addressed. EVIDENCE: The Registered Manager Mrs Yvonne Cambridge has worked at Mavern House for many years and has been the Registered Manager for approximately two and a half years. Mrs Cambridge has many years experience in nursing older people and fully understands her responsibility as the manager. Health and safety issues are generally addressed, with electrical equipment tested annually and accidents recorded. However the emergency lighting had not been tested monthly and the entrance to the loft space had been left open which in the event of a fire could pose a risk to the service users. The inspector asked the maintenance person to secure the loft opening before leaving the building, which was done. Equipment continues to be stored in the corridors, Mavern House Nursing Home DS0000015927.V275236.R01.S.doc Version 5.1 Page 18 which was identified at the previous inspection posing a risk to service users and staff. Mavern House Nursing Home DS0000015927.V275236.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 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 3 X X X X X X 2 Mavern House Nursing Home DS0000015927.V275236.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? YES 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. 2 Standard OP7 OP7 Regulation 15 15 Requirement The Registered Manager will ensure that the care plans are reviewed monthly. The Registered Person will ensure that all service users are provided with a nutritional risk assessment. The Registered Person will ensure that all adequate fire precautions are in place at all times. The Registered Person will ensure that the pressure area risk assessment is kept up to date for all service users. The Registered Person will ensure corridors are kept clear and not used as a storage area. The Registered Person will ensure a policy is in place to support the use of suppositories, which are not prescribed to an individual and that they are stored correctly. The Registered Person will ensure that all the staff receives training in the local vulnerable adults procedure. The Registered Person will DS0000015927.V275236.R01.S.doc Timescale for action 10/02/06 10/02/06 3. OP38 23(4,a) 03/01/06 4. OP7 15 03/02/06 5. 6. OP38 OP9 23(2,I) 13(2) 03/01/06 10/02/06 7. OP18 18(C,I) 15/02/06 8. OP26 13(3) 03/02/06 Page 21 Mavern House Nursing Home Version 5.1 9. 10. OP26 OP26 13(3) 13(3) 11. 12. OP26 OP7 13(3) 15 ensure that all creams are labelled with the appropriate service users’ name. The Registered Person will ensure that all staff receives infection control training. The Registered Person will ensure that the staff will wear disposable aprons and gloves when dealing with soiled laundry and blue plastic aprons when dealing with food. The Registered Person will ensure that dressings are stored correctly. The Registered Person will ensure that the care plan of a service users suffering from Dementia clearly provides information of how the person is supported with the dementia care need. 15/02/06 03/02/06 03/01/06 03/02/06 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. The Registered Person should consider that a more detailed daily statement is recorded for each service user. 2 OP7 Mavern House Nursing Home DS0000015927.V275236.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham 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 DS0000015927.V275236.R01.S.doc Version 5.1 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. 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