Inspection on 15/02/06 for The Albany Nursing Home

This inspection was carried out on 15th February 2006.

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

The Albany Nursing Home 24/02/09

The Albany Nursing Home 21/02/08

The Albany Nursing Home 20/04/06

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Albany Nursing Home 7 London Road Headington Oxford OX3 7SN Lead Inspector Philippa MacMahon Unannounced Inspection 15th February 2006 11:25 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 The Albany Nursing Home DS0000065923.V276520.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. The Albany Nursing Home DS0000065923.V276520.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Albany Nursing Home Address 7 London Road Headington Oxford OX3 7SN 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) 01865 744444 01865 744485 albany@schealthcare.co.uk Trinity Care (Crown) Limited Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48), Terminally ill over 65 years of age (3) of places The Albany Nursing Home DS0000065923.V276520.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Condition 1 On admission persons should be aged 60 years and over Condition 2 The total number of persons that may be accommodated at any one times must not exceed 48. Condition 3 Eight beds are for the provision of intermediate care within a separate unit in the home. Condition 4 CSCI has agreed to the use of two rooms as double rooms within this unit due to the circumstances at the time of the commissioning of the unit by the local authority. Condition 5 Admission to the Intermediate Care Unit is for people aged 55 years and over. Condition 6 The Intermediate Care Unit is staffed separately from the rest of the home, with one registered nurse covering the hours of 8am to 6pm, and two care assistants from 7am to 8pm. Night cover is one care assistant, from 8pm to 7am, with support provided from the homes establishment. Condition 7 The home has two registered nurses on duty from 8am to 8pm each day. 25 August 2005 5. 6. 7. Date of last inspection Brief Description of the Service: The Albany Nursing Home is a purpose built home that is registered to care for 40 older people. It is situated in the Headington area of Oxford, close to shops and amenities. The Albany is part of Crown Homes, which has a number of similar homes in Oxfordshire. Accommodation is on two floors, accessed by a lift or stairs, and all the bedrooms overlook the attractive gardens. There is a spacious conservatory that opens onto the gardens and a safe walkway through the garden for service users. A programme of reordering of the building to provide a discrete six bedded intermediate care unit has recently been completed. There are four single rooms and two large shared rooms, all with en-suite facilities. The Albany Nursing Home DS0000065923.V276520.R01.S.doc Version 5.1 Page 5 The unit provides a sitting room with a kitchen area that is designed to enable the service users to build up confidence in being independent and safe before being discharged home. A further communal sitting room has been provided on the ground floor, which provides an opportunity for socialisation. The Albany Nursing Home DS0000065923.V276520.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and the second to be carried out in the inspection year. The inspector was made very welcome by the staff and all co-operation was given throughout this inspection. Much of the time was spent in observing the residents and staff as they went about their daily activities. Residents relatives and visitors were spoken to, and the Commission for Social Care Inspection comment cards for residents and professionals that had been returned to the inspector were included in this report. A tour of the building was undertaken. Lunch was taken with the residents and the inspector met with the cook. What the service does well: What has improved since the last inspection? What they could do better: Ensure that all consultations with a GP are carried out in private. Arrangement must be made to cover the domestic staff member who is on maternity leave to ensure that the standards of cleanliness are maintained. The Albany Nursing Home DS0000065923.V276520.R01.S.doc Version 5.1 Page 7 Records of the participation of residents in social activities need to be documented. Care staff should be made aware of the need to offer different flavours and textures when they are assisting residents with their meals. 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. The Albany Nursing Home DS0000065923.V276520.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection The Albany Nursing Home DS0000065923.V276520.R01.S.doc Version 5.1 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 the following standard(s): None of these outcomes were addressed at this inspection as they were dealt with earlier in the inspection year. EVIDENCE: The Albany Nursing Home DS0000065923.V276520.R01.S.doc Version 5.1 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): None of these outcomes were addressed on this occasion. EVIDENCE: The Albany Nursing Home DS0000065923.V276520.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): 12, 13, 14, 15 A varied and interesting programme of activities is being developed, and there is good opportunity for 1-1 time for each resident. Recording of activities undertaken needs to be addressed. Residents are encouraged to maintain contract with family, friends and the local community. The residents receive a wholesome and nutritious diet. Issues around care staff assisting residents to eat need to be addressed. It is not acceptable for a GP to carry out a consultation with a resident within sight and earshot of the people in the dining room having lunch. EVIDENCE: The inspector met with the activities co-ordinator who works three days a week on Mondays, Wednesdays and Fridays. She has not been in post very long and is making good progress in developing an interesting and varied programme of activities that include outings, quizzes, 1-1 time and chair exercises. The Albany Nursing Home DS0000065923.V276520.R01.S.doc Version 5.1 Page 12 Records of individual participation in the activities need to be included in the care plans and it is recommended that the activities co-ordinator discusses with the manager how the record of activities undertaken can best be documented. It was apparent to the inspector that the families who were visiting the home during the inspection related very well to the co-ordinator, and she has a good rapport with staff, relatives and the residents. The inspector met with relatives who were going shopping with one of the residents. This was a regular event and they spoke very highly of the care provided and said that they were “very happy with Mum’s care”. Another relative had previously had some concerns but the manager had dealt with these issues and she was now very satisfied with the care provided. The inspector joined the residents at lunch and enjoyed a meal of roast lamb and vegetables, followed by a delicious pineapple upside down pudding and custard. Discussion with the cook and examination of the planned menus that are on a four week cycle showed that a wholesome and nutritious diet is provided. The inspector observed staff assisting two residents with their lunch, and both residents required food to be liquidised. The meal had been correctly served with the vegetables and meat separately liquidised on the plate. The care staff both mixed all the food together before offering it to the residents. It is recommended that the manager should inform all the care staff of the need to offer different flavours and textures to the residents at mealtimes, even if the resident is not able to communicate with them. A GP came to visit one of the residents who was having her lunch. She was wheeled into the adjoining sitting room and the doctor carried out his consultation in view of the residents having lunch and the conversation was overheard. This is not good practice and it is a requirement that any resident must have any consultation with a GP carried out in private. The Albany Nursing Home DS0000065923.V276520.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, 17, 18 The home has a complaints system in place. Residents are able to take part in the civic process. Every effort is made by the manager to protect the residents from any form of abuse. EVIDENCE: The home has a complaints procedure and the inspector saw that it was posted in the main entrance lobby of the home. It is also contained in the service users’ guide. Southern Cross carries out a monthly audit of any complaints. At election time any resident wishing to vote is enabled to do so and this is usually by postal vote. All staff are given training in the protection of vulnerable adults as part of the induction programme, and further updates are given on an ongoing basis. The Albany Nursing Home DS0000065923.V276520.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, 26 The home is well maintained but there is room for improvement in the overall cleanliness of the home. EVIDENCE: The inspector toured the building and found overall that the home was clean and well maintained throughout. However, it was noted that in one of the sluice rooms there was a spillage of body fluids on the hopper that had not been cleaned up and the flooring was in need of cleaning. It is a requirement that all areas of the sluice must be kept clean and free from any possible source of cross infection. A visitor pointed out a flooded shower room floor in one of the en-suite facilities. The maintenance man was contacted and he explained that this was an error by the staff who had not activated the pump mechanism when operating the shower. The manager said that she would speak to the staff concerned to avoid a recurrence of this issue. The Albany Nursing Home DS0000065923.V276520.R01.S.doc Version 5.1 Page 15 The manager informed the inspector that one of the domestic staff was on maternity leave and this was leaving them short staffed on some occasions. It is recommended that the manager should look into ways of covering the shortfall in domestic staff to ensure that the standards of cleanliness do not fall. The Albany Nursing Home DS0000065923.V276520.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): None of these outcomes were addressed on this occasion. EVIDENCE: The Albany Nursing Home DS0000065923.V276520.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 The manager is managing the home well but as this is a new role to her she needs support to enable her to gain the necessary knowledge and skills to develop in this position. EVIDENCE: The manager has not yet been registered with the Commission for Social Care Inspection. An application has been made but there has been a delay in receiving references. It is hoped that this will be progressed quite quickly. The manager told the inspector that she is undertaking the Registered Manager’s Award and still has a number of units to complete. This is being hampered by not having a deputy manager in the home to allow some supernumerary time to complete the necessary documentation, as well as manage the home. The Albany Nursing Home DS0000065923.V276520.R01.S.doc Version 5.1 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 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 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X X X X The Albany Nursing Home DS0000065923.V276520.R01.S.doc Version 5.1 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 OP14 Regulation 12(4)(a) Requirement It is a requirement that any resident must have any consultation with a GP carried out in private. It is a requirement that all areas of the sluice must be kept clean and free from any possible source of cross infection. Timescale for action 15/02/06 2 OP26 13(3) 15/02/06 The Albany Nursing Home DS0000065923.V276520.R01.S.doc Version 5.1 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 OP12 Good Practice Recommendations It is recommended that the activities co-ordinator discusses with the manager how the record of activities undertaken can best be documented. It is recommended that the manager inform all the care staff of the need to offer different flavours and textures to the residents at mealtimes, even if the resident is not able to communicate with them. It is recommended that the manager should look into ways of covering the shortfall in domestic staff to ensure that the standards of cleanliness do not fall. 2 OP15 3 OP26 The Albany Nursing Home DS0000065923.V276520.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 The Albany Nursing Home DS0000065923.V276520.R01.S.doc Version 5.1 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. 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