Inspection on 06/07/09 for The Andover Nursing Home

This inspection was carried out on 6th July 2009.

CQC found this care home to be providing an Good service.

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 08/07/08

The Andover Nursing Home 25/04/06

The Andover Nursing Home 13/12/05

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 17/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE The Andover Nursing Home Weyhill Road Andover Hampshire SP10 3AN Lead Inspector Laurie Stride Key Unannounced Inspection 6th July 2009 11:25 DS0000012147.V376352.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. The Andover Nursing Home DS0000012147.V376352.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address The Andover Nursing Home DS0000012147.V376352.R01.S.doc Version 5.2 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 87 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0), Physical disability (0) of places The Andover Nursing Home DS0000012147.V376352.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Physical Disability (PD) Old age, not falling within any other category - (OP) 2. Dementia (DE) The maximum number of service users to be accommodated is 87. Date of last inspection 9th September 2008 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 service users who are physically disabled or who have dementia. The home is divided into two units. One unit is on the lower ground and ground floors and provides care for older people with physical disabilities. The second unit 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 current scale of charges range between £483 and £995 a week dependent on whether the person using the service is self-funding or, funded through social services. The fees do not include hairdressing/papers/magazines/telephone or chiropody. The Andover Nursing Home DS0000012147.V376352.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was an unannounced key unannounced inspection. Before we (the commission) visited the home we looked at the previous inspection report and other information we had received from the home or other parties. We received the Annual Quality Assurance Assessment which had been completed by the registered manager. During the inspection, we were shown around the home by the registered manager. We spoke with two care workers and two nurses in detail and also spoke with two of the people who use the service. We looked at records such as care plans and staff recruitment records. What the service does well: The manager ensures that prospective new people who use the service have their needs assessed before they move into the home. People who live in the home have access to healthcare specialists when they need them. Staff members respect and uphold the privacy and dignity of service users. There is a variety of activities offered and people who use the service have a choice at mealtimes. Visitors are welcome to the home and can spend time with the people they come to visit in various areas around the home. People who live in the home have personalised their rooms and can bring their own furniture in. The home is spacious with larger than standard bedrooms and communal areas which include a room which can be used for family parties. The gardens are well designed and maintained. New staff members have been recruited after the appropriate checks have been completed and all staff members receive ongoing training, with some staff obtaining qualifications in care. The home has a quality assurance system in place which seeks and acts upon the views of people who use the service. What has improved since the last inspection? Care plans now reflect individual needs and wishes in a more personal way. Some reorganisation of the plans has taken place to make them easier for staff to understand and access information. Further training for staff around deprivation of liberty and mental capacity has taken place. The home continues to make ongoing improvements to the environment. The Andover Nursing Home DS0000012147.V376352.R01.S.doc Version 5.2 Page 6 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. The Andover Nursing Home DS0000012147.V376352.R01.S.doc Version 5.2 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.V376352.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 & 3. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who are interested in using the service have the information they need to help them to make a decision. Each individual has their needs assessed before admission to the home, so that the home can be sure of meeting these. Standard 6 does not apply to this service. EVIDENCE: The home’s annual quality assurance assessment (AQAA) told us that in the last twelve months a more comprehensive information pack had been developed to help people enquiring about the home. During this visit we saw that the home has an up to date Service User Guide that gives information about the service that can be provided to people. Individual care plans also contained details about additional costs such as chiropody and hairdressing, a copy of the home’s complaints procedure, names and photographs of staff members and further information about the home. The Andover Nursing Home DS0000012147.V376352.R01.S.doc Version 5.2 Page 9 The AQAA also told us that care records are now organised in a way that places the relevant assessment and care plan consecutively in the care plan folder. We saw the records held in relation to a person who had recently been admitted to the home. These records included hospital discharge notes and an assessment for residential care completed by the home’s manager. Daily observation records referred to the individual’s wellbeing and progress from the time of admission. Specialist support from a physiotherapist had been obtained and there were risk assessments in place including one for falls. Further care plans had been generated from the initial assessment of the individual’s needs. The Andover Nursing Home DS0000012147.V376352.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 & 10. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Changes in care planning mean that peoples’ needs and wishes are reflected more fully. Further work is needed to ensure that records of the care given are maintained. EVIDENCE: We looked at the care plans of four people who use the service and spoke with two of the nurses who are responsible for updating the records. Since the last inspection the home has reorganised the care plans and these are now more personalised, for example one person’s care plan gave guidelines for staff supporting the individual’s emotional needs at that time. The plan also noted that, while the person likes to spend time in their room, they also like to go to the dining room for meals and to the hairdresser. Another person’s care plan indicated that the individual does not wish to take part much in the home’s daily activities. This plan also informed staff that the person prefers a shower to a bath and how to provide support for this. Another plan recorded the time The Andover Nursing Home DS0000012147.V376352.R01.S.doc Version 5.2 Page 11 when the person likes to have a bath. We also saw that more work has been done in recording individual’s life histories so that staff members have a fuller picture of each person. We saw that the care plans had been reviewed on a monthly basis and that the individual and/or their relatives are invited to attend the review meetings. Detailed moving and handling plans were in place, which meets a previous requirement. We spoke with two care workers who were the named key workers for two of the people whose records we saw. Both staff members demonstrated a good knowledge of the individual’s needs and the agreed ways of meeting these, as reflected in the care plans. For example, they told us about the individual’s assessed mobility requirements including the correct equipment to use and number of staff needed. They also talked about the best ways to communicate with the individuals and what each person’s preferences are in relation to how they are supported with personal care. We asked the staff members if they thought that care plans had improved and both said they did. One told us that the plans are now easier to understand and are more personalised. The other said that care staff members are instructed to read care plans when there are quieter moments in the home and that senior carers attend the handovers to ensure that relevant information is passed between staff. One of the nurses told us about the training she had given to care staff about the care planning system and showed us the signatures of staff who had attended the training. Some of the care plan guidance lacked specific detail, for example stating that a person likes to have a bath in the afternoon but not indicating what support is required for this. We discussed this with the nurse, who amended the plan to include the number of staff and type of equipment to use. A chart is kept of when people have baths but one care worker stated she did not know about this, although she had recorded in the daily record sheet when the individual had a bath. The nurse told us she would give the care staff some further guidance about writing daily records. Another person’s care plan stated that the individual, whose condition meant they spend a lot of the time in bed, was to be repositioned “at regular intervals” but did not specify any timescale. The nurse said that the person will use the call alarm when wishing to be moved and amended the care plan to show this. Some of the daily care records we saw gave a clear indication of the personal care tasks that individuals had been supported with, so that it was easy to see that all parts of the care plan had been carried out. Other entries, such as “all care given”, did not and this may lead to inconsistency in the care provided. For example, a person’s plan gave specific guidance for staff on providing mouth care, but it was not possible to see if this had been carried out daily in line with the guidance. The manager has subsequently commented that “we do have some staff who writing ‘all care given’ is an achievement and reflects our inclusiveness and equal opportunities.” It is the providers’ responsibility to ensure that the care staff have the necessary skills and competency to complete records to the required standard. The Andover Nursing Home DS0000012147.V376352.R01.S.doc Version 5.2 Page 12 A nurse showed us a referral form indicating that the person had seen a dentist in February and told us that the condition had improved and the individual was now able to eat without discomfort. Other sections of people’s care plans were clear and detailed, such as monitoring an individuals’ skin condition. The daily records indicated that care staff were checking and applying the prescribed treatment. Another person had a wound care chart showing regular monitoring and continuing risk assessment. We also saw records showing that people who use the service have access to a range of healthcare specialists when needed. On the first floor unit, we saw that an individuals’ personal handling profile identified that there can be a problem with aggression. The daily records referred to the individual being aggressive. There was a care plan in relation to communication but no guidance on how staff members manage such situations. The manager has since informed us that the records we were given were from 2005 rather than 2009 and that action would be taken to make the dates on the records clearer. However at the time of the visit, the nurse acknowledged the need for a specific strategy for the individual in relation to aggression and had drawn up a plan by the end of our visit, which we discussed with the manager. The draft care plan stated that staff members were to release the individuals’ grip “using the least restrictive/minimum force necessary”. The manager said he would contact the individual’s placing authority and discuss with them the need for a clear intervention strategy. Trained nurses give medication to people who use the service. We looked at samples of the medication systems in both units. Medication was stored appropriately and the Medication Administration Records (MAR) had photographs of the service users to aid recognition. The MAR were completed correctly, with the exception of one gap. The nurse said she would look into this. The home now carries out medication audits, with nurses from each unit checking the other’s records. The nurse we spoke with said these had started on a weekly basis and were now carried out once a month. The Andover Nursing Home DS0000012147.V376352.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home supports people who use the service to exercise choice in relation to daily activities, maintaining social and familial contacts and at mealtimes. EVIDENCE: The home employs two full time activities co-ordinators and there is a designated activities room, where we saw people who use the service doing art and craft work. There is a hairdressing salon adjoining the craft room and residents can sit and have a cup of coffee and a chat whilst having their hair done. The AQAA told us that the co-ordinators also provide one-to-one activities, cooking and games and operate the bar for ‘happy hour’. Care staff will, weather permitting, organise spontaneous outings to the local pub for residents at lunchtime. They also organise entertainers to come to the home on a monthly basis and trips out. The AQAA told us that since the last inspection specific activities for residents with different stages of dementia have been introduced. We saw that a ‘work and play’ care plan was in place to encourage a person who has dementia to The Andover Nursing Home DS0000012147.V376352.R01.S.doc Version 5.2 Page 14 attend group activities. We also saw that sensory objects were used to help provide stimulation for the individual. The AQAA said that the home has enhanced the life-story questionnaire so that the staff members get a fuller picture of a resident’s life. This information is used to inform the activities coordinators. We were shown booklets that contained the personal histories of two people who use the service. The home welcomes visitors at any time, with family and friends being able to take lunch with the resident for a notional sum. The home also organise a Gourmet Evening every other month where people who use the service can dine with family and/or friends in a restaurant style environment with three course meal and wine served by waitresses. There is a monthly newsletter and an active Friends group that includes residents and relatives, who participate in fundraising for the home. The AQAA states that people who use the service are able to pursue their religious beliefs. The home offers a monthly communion service and a separate monthly hymn service. Those of other faiths have visiting priests as they require. There is a weekly fellowship group made up of members of a local church and residents. There is also a couple who visit weekly and spend time with a different group of residents talking about topics that are happening in the world and locally. The AQAA also told us that the home has policies designed to promote equality of opportunity and minimise social exclusion. A person who uses the service confirmed that people are encouraged to personalise their rooms and are able to bring items of their own furniture. A wide range of meals are offered and two residents we spoke to indicated that they liked the food provided. The AQAA told us that soft diets are created in moulds and served so that ground chicken looks like a chicken thigh, making the meal more appetising. Afternoon tea is accompanied by homemade cakes. The service has links with the dietician to ensure adequate nutrition for people who use the service and we saw records showing that individual nutritional assessments are undertaken. Al fresco dining is avialable, subject to the weather. We observed lunch being served in one of the units. This was carried out at a relaxed pace with five staff members on hand to give assistance where needed. The Andover Nursing Home DS0000012147.V376352.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service can be confident that any concerns they have will be listened to and acted on by the home. People are protected by the home’s policies and procedures backed up by staff training. EVIDENCE: The AQAA told us that the home had received one complaint in the last 12 months, which had been responded to within 28 days in line with the complaints procedure. During our visit we saw the complaints logbook, which gave the details of the complaint and the actions taken by the home in response to the matter. We spoke with two care workers who were both clear about what to do if someone made a complaint about the service, for example if the complaint was not something the care workers could rectify themselves then they would report the matter to the senior on duty or the manager. We spoke with a person who uses the service who told us they had no complaints about the home and felt able to raise any concerns about the service with staff. We had been notified of one safeguarding matter since the last inspection and the service had worked with Adult Services to ensure the protection of an individual living in the home. The manager told us that the individual had since moved on to another service. The AQAA told us that new staff receive adult The Andover Nursing Home DS0000012147.V376352.R01.S.doc Version 5.2 Page 16 protection training as part of their induction course. All staff undertake annual update training to ensure that they are current with regards to the policy and procedures about identifying, reporting and subsequent actions. This training has been further enhanced by including the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards 2009. The Andover Nursing Home DS0000012147.V376352.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 & 26. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service benefit from living in a clean, well-maintained environment that is suited to their individual needs. EVIDENCE: The previous inspection report identified that the home provides an excellent environment for people who use the service. During our visit we saw the main communal areas and some of the bedrooms and that the high standard of accommodation had been maintained and further improved upon, as stated in the AQAA. For example, since the last inspection, the visitors toilets have been upgraded to include non-touch facilities, patio lighting has been replaced with low energy fittings, the home has increased the number of parking spaces available and an additional storage area has been created. The Andover Nursing Home DS0000012147.V376352.R01.S.doc Version 5.2 Page 18 The home is spacious and well lit. All the bedrooms are ensuite and exceed the minimum standards in terms of size. There is also more communal space than set by the minimum standards and this includes six lounges and two dining rooms. People who use the service are encouraged to furnish their rooms to their personal choice and this was confirmed by a person who lives in the home. Each unit has a snack area which can be used by staff and visitors to make drinks. All bedrooms have a call bell available and lockable storage. Upper floor windows have restrictors. The standard of furnishings and fittings and decoration is good with an ongoing programme of maintenance and redecoration. The home was clean and there are infection control procedures, for example protective gloves and aprons are available and used by staff. The home has suitable laundry facilities including large washing and drying machines. The garden is laid to lawn and patio with a sensory garden. A large gazebo is set on the lawn so that people who live in the home can enjoy the garden in shade from the sun. The grounds of the home are wheelchair friendly with a choice of locations to sit. All radiators and hot pipes are covered or are low surface temperature. All hot water outlets for washing in resident areas are thermostatically controlled. The AQAA also told us that the home has contracted the use of a back up generator which will maintain electrical supplies in the event of a power cut. Aids or adaptations are provided according to individual need. The Andover Nursing Home DS0000012147.V376352.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 & 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are supported by a trained staff team and are protected by the home’s staff recruitment procedures. EVIDENCE: Staffing levels at the home include care workers and nurses. There are two nurses on duty during the day in each unit and one in each at night. Care staff and nurses are supported by a team of cleaners and a housekeeper, chefs and kitchen assistants, a maintenance person, two full-time activities coordinators, the manager and deputy manager, a receptionist and an administrator. A record of staffing levels for each day is now kept on the home’s upgraded computer software. Throughout our visit we observed that people who use the service were being attended to by staff as and when needed. A person who uses the service told us that “staff members are very helpful”. The previous inspection report identified that the home operated a thorough staff recruitment process in order to protect people who use the service. During this visit we looked at the recruitment files for two staff members who had started work in the time since the last inspection. The files contained The Andover Nursing Home DS0000012147.V376352.R01.S.doc Version 5.2 Page 20 application forms with the dates of employment, two written references and Criminal Records Bureau checks. The AQAA stated that 36 out of 68 permanent care staff are qualified to NVQ 2 level 2 or above in health and social care. New staff members have an induction programme that uses the Common Induction Standards as the base and the service augments this by including fire, infection control, adult protection, dementia awareness and food handling in the process. Moving and handling training is provided in house and is updated annually in the month that individual staff members started work. The home’s training records were being updated and those we saw indicated that staff are being given the training. The two care workers we spoke to confirmed they had recently had training updates, such as infection control. The home’s computer system now flags up when an individual is due for training, which allows for better monitoring. The Andover Nursing Home DS0000012147.V376352.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 & 38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The views of people who use the service and their representatives are sought to ensure the service is run in their best interests. EVIDENCE: The registered manager is a Registered Mental Nurse and has achieved the Registered Manager’s Award. He has many years experience of managing the home. The manager completed the Annual Quality Assurance Assessment prior to our visit. The Andover Nursing Home DS0000012147.V376352.R01.S.doc Version 5.2 Page 22 Whilst changes have been made in the documentation to support staff in providing care for the people using the service, there continues to be areas identified that need further attention. The manager has worked with the staff to improve the detail within the care plans, but there are omissions in the support needed and monitoring of care given. The home has a quality assurance system in place which includes various monthly audits, service users’ meetings, relatives meetings and annual surveys. The manager has subsequently given us more detail on the auditing of care plans. This involves reviews by the Matron or Deputy, monthly reviews by unit staff with the person using the service or their relative and a system of quarterly and annual reviews. The manager showed us the results of a service users’ survey and the responses had been largely positive. The manager informs the service provider of the survey results and a newsletter including a year on year comparison report is sent to people who are interested in the service. The provider visits monthly to monitor quality and gives a copy of the Regulation 26 report to the manager. The AQAA stated that people who use the service are encouraged to maintain their own finances. All internal transactions involving a fee, for example hairdressing and chiropody, are invoiced monthly in arrears. A monitored procedure is available for those individuals wishing for the home to manage their personal allowances. The manager said that he checks theses records every six weeks and an external company carries out an audit every three months. Environmental risk assessments were in place and these are checked as part of the home’s monitoring processes. During our visit the parts of the premises we observed were free from visible obstructions or hazards. Records regarding fire safety are kept and the fire alarms are tested weekly. Other equipment such as hoists are regularly tested and certificates are available. Training records showed that staff members receive mandatory training such as fire safety, infection control, moving and handling, food hygiene and first aid. The home was given a satisfactory food hygiene award by the local authority food safety officer in March 2009. The Andover Nursing Home DS0000012147.V376352.R01.S.doc Version 5.2 Page 23 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 3 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 2 X 3 X 3 X X 2 The Andover Nursing Home DS0000012147.V376352.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15 Requirement Daily records must clearly show the actions taken to meet the assessed needs of individuals so that people can be assured that individuals’ needs are being fully met Timescale for action 07/09/09 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.V376352.R01.S.doc Version 5.2 Page 25 Care Quality Commission South East Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. The Andover Nursing Home DS0000012147.V376352.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!