Inspection on 13/12/05 for The Andover 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

The Andover Nursing Home 13/05/10

The Andover Nursing Home 06/07/09

The Andover Nursing Home 08/07/08

The Andover Nursing Home 25/04/06

The Andover Nursing Home 04/07/05

The Andover Nursing Home 14/02/05

The Andover Nursing Home 26/05/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Winton House

Newbeech House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE The Andover Nursing Home Weyhill Road Andover Hampshire SP10 3AN Lead Inspector Pat Griffiths Unannounced Inspection 13th December 2005 10:00 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 The Andover Nursing Home DS0000012147.V258677.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. The Andover Nursing Home DS0000012147.V258677.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Andover Nursing Home Address Weyhill Road Andover Hampshire SP10 3AN 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) 01264 333324 01264 332063 Mr P J Puddepha Mr B J Puddepha Mr Martin Watt Care Home 79 Category(ies) of Dementia - over 65 years of age (41), Old age, registration, with number not falling within any other category (49), of places Physical disability (15), Physical disability over 65 years of age (15) The Andover Nursing Home DS0000012147.V258677.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. A maximum of 49 service users may be accommodated in the OP category. A maximum of 41 service users may be accommodated in DE(E) category. A total of 15 service users may be accommodated in the PD and PD(E) categories. 4th July 2005 Date of last inspection Brief Description of the Service: The Andover Nursing Home is a privately owned, purpose-built care home for service users over the age of 65. The home is registered to provide personal and nursing care to older persons, older persons who are physically disabled and older persons who have dementia. Conditions of registration also allow for 15 service users below the age of 65 with physical disabilities to be resident at any one time. The home provides accommodation for 79 residents over four floors. There are 55 single bedrooms and 12 double rooms, all with en-suite facilities. The home is divided into two units. Unit one is on the lower ground and ground floors and provides care for elderly residents. Unit two is on the first and second floors, providing care for residents with dementia. Each unit has sitting and dining areas and there is a large lounge off the front entrance. The home is in a residential area of Andover, on a main road and close to local amenities. The home has a large garden to the rear and a small seating area at the front; there is a car park at the front of the home. The Andover Nursing Home DS0000012147.V258677.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second of the two statutory unannounced inspections for the inspection year 2005/06. The key standards are inspected over the course of the two inspection visits. The inspection took place over one day and the inspector was able to tour the home, seeing some of the bedrooms and the communal areas. The inspector looked at a sample of staff files and residents care plans and read some policies and procedures. Several residents and visitors spoke with the inspector. What the service does well: What has improved since the last inspection? What they could do better: During the last inspection residents indicated, through comment cards and conversation with the inspector, that they would like more choice in their daily lives. The manager invited an independent visitor to speak to the residents and undertake a survey of their concerns, likes and dislikes. The results of this survey have not been evaluated yet. When complete, the results must be made available to all interested parties as well as any action that is needed to ensure that the home is run in the best interests of the residents. Please contact the provider for advice of actions taken in response to this The Andover Nursing Home DS0000012147.V258677.R01.S.doc Version 5.0 Page 6 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Andover Nursing Home DS0000012147.V258677.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 The Andover Nursing Home DS0000012147.V258677.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): EVIDENCE: These standards were not examined during this inspection The Andover Nursing Home DS0000012147.V258677.R01.S.doc Version 5.0 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): 10 Arrangements do not always ensure that residents are treated with respect and their privacy is protected. EVIDENCE: The inspector saw that all resident’s bedroom doors are fitted with locks. The manager said that none of the residents has chosen to keep a key, which is offered on admission. In double bedrooms there are curtains that can be pulled across the room to provide privacy for the residents. In some of the double rooms the inspector saw the curtains were too short to provide privacy. The manager said that he would arrange for the curtains to be lengthened with extra fabric by the next day. Staff were seen to ring the doorbells that are fixed to the bedroom doors before entering the residents rooms. The inspector also heard staff speaking to residents and visitors in a respectful manner. Some residents needed help with eating their meals and this was seen to be done in an unhurried way. The Andover Nursing Home DS0000012147.V258677.R01.S.doc Version 5.0 Page 10 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 and 13 Residents experience a varied life at the home and their visitors are welcomed. EVIDENCE: Many of the residents lived in the Andover area before their admission to The Andover Nursing Home and have kept in touch with their friends and neighbours. The manager told the inspector that the residents are encouraged to maintain contact with friends and family and the home has an open visiting policy. The residents can entertain their visitors in the communal rooms or in the privacy of their bedrooms. The home has an activities room with full and part time activities organisers that are available for group and individual activities. Information about activities is sent out to all residents as part of the monthly newsletter. The inspector saw the December Newsletter and the activities for the month included visiting musical entertainers, a theatre group with a pantomime, carols with church groups, crossword and quiz sessions, Bingo and knitting and sewing. One resident told the inspector that she enjoyed going to do flowerarranging in the activities room, but did not take part in the bingo sessions. Once individual interests and preferences have been identified the activities organisers arrange more individual activities for the residents with dementia, such as knitting and doing crosswords. The Andover Nursing Home DS0000012147.V258677.R01.S.doc Version 5.0 Page 11 None of the residents are able to attend church but the local ministers and a fellowship group visit the home for services and individual pastoral care. The Andover Nursing Home DS0000012147.V258677.R01.S.doc Version 5.0 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 the following standard(s): 16 and 18 Arrangements are in place to ensure that complaints will be listened to, taken seriously and acted upon. Arrangements in the home ensure that the staff and residents are protected from abuse. EVIDENCE: The home has a complaints procedure, which is available to all staff, residents and their relatives and visitors. This policy contains all relevant information such as who deals with complaints and the timescales involved. The home has received two complaints about the home since the last inspection. One complaint has been resolved and the other is on going. The home has an adult protection procedure in place and all staff, except the kitchen staff, have undertaken training on adult protection. The manager told the inspector that he has done a ‘train the trainers’ course in Adult Protection and is now doing the training in-house for all staff. The manager told the inspector that staff will be doing training in ‘break away’ techniques to give them further skills in coping with residents who are occasionally verbally or physically aggressive. The Andover Nursing Home DS0000012147.V258677.R01.S.doc Version 5.0 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 the following standard(s): 19 and 21 The arrangements in place for maintaining the home ensure that the residents live in a safe and comfortable environment with sufficient lavatories and washing facilities. EVIDENCE: The home was bright and homely on the day of inspection and had been decorated for Christmas. The home is large with many communal areas, large and small sitting rooms and a large dining room. The residents are free to wander in the home and the grounds. The manager told the inspector that residents who want to walk in the gardens are given nurse-call pendants to wear, so that they can call for help if necessary. The front door is not locked during the day, but there are usually staff available in this area during office hours. The manager told the inspector that the doors on the unit for residents with dementia have been made more secure, with keypads, for the protection of all The Andover Nursing Home DS0000012147.V258677.R01.S.doc Version 5.0 Page 14 residents and staff, but especially the more vulnerable residents. Some areas of the home have been decorated and new carpets laid as part of the rolling programme for repair and redecoration. The home owners plan to build an extension to the home, which will provide extra single rooms and reduce the number of double rooms. It was noted during the last inspection that some lavatories were being used as storage areas for broken and unused equipment and furniture. The manager said that the residents did not use these lavatories and the inspector saw that the signs on the doors have now been changed to indicate the different use of the rooms. The bathrooms in unit 2 have had the wall tiles replaced, have been decorated and had matching roller blinds fitted. There are also pictures and mirrors on the walls, making the bathrooms more homely and less clinical. The Andover Nursing Home DS0000012147.V258677.R01.S.doc Version 5.0 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 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, 29 and 30 Resident’s needs are met by the skill mix of the appropriately recruited and trained staff group. EVIDENCE: The staff skill mix includes qualified nurses, carers and ancillary staff for cleaning, catering and laundry services. The number of staff is sufficient and appropriate to meet the need of the residents. The inspector looked at four staff personnel files and saw that they contained the appropriate information, such as proof of identity, written references, CRB disclosures (Criminal Records Bureau) and POVA checks (Protection of Vulnerable Adults). The file of a recently appointed registered nurse contained details of an NMC check, (Nurses and Midwives Council) which confirms that their professional qualifications are valid. New care staff undertake the TOPPS induction training as well as mandatory training such as fire safety and manual handling. The manager said that the new ‘Skills for Care’ induction training will be used next year. A record is kept on files of all staff training and the course trainers issue attendance certificates. The Andover Nursing Home DS0000012147.V258677.R01.S.doc Version 5.0 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 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, 33, 35, 36 and 38 The home is run by an experienced manager and has arrangements in place to promote and protect the resident’s rights, their interests and safeguard their financial interests. Arrangements are in place to ensure that staff receive appropriate, documented, supervision. The home ensures that staff training promotes the health, safety and welfares of the residents and staff. EVIDENCE: The manager is a registered nurse, who has been in post for several years. The home has a comprehensive set of policies and procedures, which include Health and Safety, Moving and Handling, Adult Protection and Record Keeping. The manager told the inspector that the policies and procedures will be reviewed in January 2006. The home does seek the views of the residents, their relatives and friends. A service user survey is done quarterly and the manager said that the results are The Andover Nursing Home DS0000012147.V258677.R01.S.doc Version 5.0 Page 17 displayed on a notice board in the home. Residents that spoke with the inspector said that they generally felt comfortable in the home and the food was usually satisfactory. One resident said that they had moved to new room which would provide access to the garden, so she was looking forward to the summer months and better weather. During the last inspection residents indicated through comment cards and conversations with the inspector, that they would like more choice in their daily lives. The manager invited an experienced, independent, visitor to speak to the residents and undertake a survey of their concerns, likes and dislikes. The results of this survey have not been evaluated yet. When complete, the results must be made available to all interested parties as well as any action that is needed to ensure that the home is run in the best interests of the residents. The administrator showed the inspector the account balances of the money held for residents. It is kept in a bank account that does not attract interest and does not incur any charges. The residents are unable or unwilling to open their own separate accounts and money is drawn on their behalf to pay any bills or provide day-today pocket money. The company accountant was in the home during the inspection and told the inspector that he had audited the account and it was satisfactory. The manager said that more of the registered nurses had completed training in ‘supervisory skills’ and regular staff supervision had started. All sessions are documented, the records are confidential and kept separately by the supervisors, and only the date of the supervision session is entered in the staff files. The manager said that all staff have completed training in moving and handling and fire safety. The manager said that Infection Control training is done in-house and it is planned that First Aid, Food Hygiene and Health and Safety training will be done in the new year. The home has a maintenance man on site for day-to-day repairs and local contractors undertake the larger repairs. The inspector was able to see the service contracts for systems such as the boilers, the fire safety equipment and the lift, all of which were up-to-date. The record of the weekly fire alarm tests was seen to be up-to-date and staff receive regular fire training, the last fire safety training and drill was done in October. The Andover Nursing Home DS0000012147.V258677.R01.S.doc Version 5.0 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 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X X X X X STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 3 The Andover Nursing Home DS0000012147.V258677.R01.S.doc Version 5.0 Page 19 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 OP33 Regulation 24 Requirement The results of a recent service user survey must be evaluated and made available to all interested parties. A plan of any action that is needed to ensure that the home is run in the best interests of the residents must also be included. Timescale for action 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Andover Nursing Home DS0000012147.V258677.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Andover Nursing Home DS0000012147.V258677.R01.S.doc Version 5.0 Page 21 - 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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