Inspection on 08/07/08 for The Andover Nursing Home

This inspection was carried out on 8th July 2008.

CSCI found this care home to be providing an Adequate 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 06/07/09

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 09/11/2008.

CARE HOMES FOR OLDER PEOPLE The Andover Nursing Home Weyhill Road Andover Hampshire SP10 3AN Lead Inspector Beverley Rand Unannounced Inspection 8thJuly 2008 11:15 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.V367753.R01.S.doc Version 5.2 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.V367753.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.V367753.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 25th April 2006 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 £460 and £975 a week dependent on whether the resident is self-funding or, funded through social services. The fees do not include hairdressing/papers/magazines/telephone or chiropody. The Andover Nursing Home DS0000012147.V367753.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 1 star. This means the people who use this service experience adequate quality outcomes. This was a key unannounced inspection. Before we visited the home we looked at the last 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 manager. During the inspection, we were shown around the home by the registered manager. We spoke with care staff and nurses as we went around the home, but also spoke with a care worker and a nurse in more detail. We also spoke with a service user and a visitor. We looked at records such as care plans and staff recruitment records. Since this inspection a pharmacy inspection has been carried out. What the service does well: What has improved since the last inspection? We did not suggest any improvements in the last report, however, the environment continues to be improved. The Andover Nursing Home DS0000012147.V367753.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. The Andover Nursing Home DS0000012147.V367753.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.V367753.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 does not apply to the home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager ensures that all new service users only move in after an assessment of their need has been completed. EVIDENCE: We looked at an assessment for a new service user. The format used was mainly a tick box one but did identify mental health needs. The AQAA states that, ‘all viewings are conducted at a time convenient to the visitors. We determine the needs of the prospective resident in question so The Andover Nursing Home DS0000012147.V367753.R01.S.doc Version 5.2 Page 9 that the viewing can be personalised. A copy of our brochure and newsletter are given. A copy of the Hampshire County Council Questions to ask when you visit a care home is made available. Further visits, if required, are supported. A full needs assessment is obtained prior to admission. For the more complex cases a second senior nurse would be included to ensure we can meet the needs. An initial care plan is written so that all staff are aware of the residents needs on admission. Pre-admission visits are welcomed and lunch provided if required. All admissions are on a trial basis for the first four weeks’. The Andover Nursing Home DS0000012147.V367753.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All service users have care plans in place but are not followed in practice which means service users are not supported as they would wish or in a consistent way. Healthcare professionals are involved where necessary. Shortfalls in the medication systems mean that some service users may be at risk. Staff support service users in a way which maintains their privacy. EVIDENCE: The last inspection report noted that care plans were not individually detailed, stating, for example, that staff were to, ‘ensure appropriate oral hygiene to be maintained’. During this inspection we looked at three care plans for service users with dementia. The areas covered were mobility, hygiene, elimination, The Andover Nursing Home DS0000012147.V367753.R01.S.doc Version 5.2 Page 11 eating/drinking and communication. The plans were not person centred and were general, for example, ‘use correct pads’, ‘wear correct footwear’ and, ‘encourage oral hygiene’. One of the plans stated that staff were to encourage the service user to, ‘choose his/her own clothes’ thereby showing that the plan was a template. Care plans did not include any information about how staff were to support individuals with mental health needs such as dementia. We looked at a care plan which gave some brief information about how to manage a particular service user’s challenging behaviour and we spoke to two staff about the person’s needs. Neither described what was written in the care plan, or worked in the way that was written in the care plan. One said they always worked, ‘in twos’ but other staff did not say they did, thereby highlighting the inconsistencies in care provided to a confused person. We spoke with a nurse and a care worker about how they supported the service users whose file we looked at. One of the service users was given different continence pads depending on which staff member provided them. We asked a care worker how they worked with service users as two care workers had said that care plans were not really used by staff. The care worker said that they undertook personal care, ‘the way I do it’, working to their own routine. They agreed that all staff have their own way of supporting with personal care and that this would mean a different routine each time. This may be confusing for people with dementia and means that service users have not had the opportunity to say how they would like to be supported with personal care. We also found differences between identified needs in moving and handling assessments and the care plan, for example, someone needing a hoist to bath, but the care plan saying they have a bed bath. Since this inspection, we have been informed by the manager as to what steps he has taken to improve the care planning systems. Staff did not know any personal history of the service users we discussed with them. We spoke to the manager about this who said there were personal profiles on some service users and that relatives were asked to assist with information when new service users moved in. Personal profiles are a useful tool when working with people with dementia as knowledge of peoples’ lives can provide information which enables staff to better meet service users’ needs. The AQAA states that, ‘all residents have a continence assessment on admission and reviewed annually or when their need changes. The appropriate care and product is then supplied. We directly employ a physiotherapist on a part time basis who assesses residents soon after admission and for those with a need provides treatment. External appointments are planned and transport coordinated. We send a carer to assist/act as advocate for residents’. We saw evidence of service users seeing healthcare professionals when needed. The Andover Nursing Home DS0000012147.V367753.R01.S.doc Version 5.2 Page 12 Trained nurses give medication to service users. We looked at the medication systems in Rooksbury unit which is for people with dementia. Medication was stored appropriately and the Medication Administration Record (MAR) had photographs of the service users to aid recognition. The MARs were not completed correctly, with general gaps throughout so it was not clear if the service users had received their medication as prescribed. This was also the case in the other unit, Danebury. There were no care plans in place for service users who had medication prescribed to be given, ‘when needed’, (PRN). Some medication was prescribed as being variable in the dose, for example, 1.25ml-2.5ml. There were no guidelines about how to determine the dose to give and one of the nursing staff said, ‘I would know, it depends on how much the service user had last time and the level of agitation.’ However, the records were unclear how much had been given and when, seemingly due to lack of space to record on the MAR and the nursing staff were unable to determine how much the previous doses had been. One nurse described an intervention which she used before administering sedation but this was not written down anywhere, which meant other staff may not have access to the strategy which could have reduced the need for medication. An inspection has since been carried out by a CSCI pharmacy inspector. We found that improvements in medication had been made and a separate report is available. Staff told us how they supported service users with regard to privacy and dignity. Staff always knock on service users’ doors before entering, or use the doorbell if there is one. Shared rooms have screen curtains in place. The Andover Nursing Home DS0000012147.V367753.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A programme of varied activities is offered to service users. Visitors are welcome and service users can personalise their rooms. Service users have a choice at mealtimes and have been involved in the menu planning. EVIDENCE: The home employs two full time activities co-ordinators and there is a designated activities room, where we saw art and craft created by service users. The manager has recently started a relatives support group to seek suggestions for specific activities for people with dementia. Examples of specific activities he plans to provide are discussing newspapers articles and reminiscence about service users’ lives, holidays and so on. Musical entertainment is available at least once a month and trips out every other week. In house activities include craft, floor games, visiting animals and The Andover Nursing Home DS0000012147.V367753.R01.S.doc Version 5.2 Page 14 cooking and activities co-ordinators can also provide one to one support, for example, letter writing. There is a hairdressing salon adjoining the craft room and service users can sit and have a cup of coffee and a chat whilst having their hair done. The AQAA says that, ‘residents are able to pursue their religious beliefs. We offer a monthly communion service and a separate monthly hymn service for the residents. Those of other faiths have visiting priests etc as they require. We have a weekly fellowship group with members of a local church and residents socializing and discuss religious and other topics.’ We saw visitors in the home on the day of the inspection and spoke with one who said they were made welcome. Family and friends are able to take lunch with service users. They also organise a, ‘Gourmet Evening’ every other month where service users can dine with family and friends in a, ‘restaurant’ style environment with a three course meal with wine and served by waitresses. Families can also hold parties and get togethers in a newly built room. Personalisation of rooms is encouraged and service users are able to bring their own furniture. Staff told us that they asked service users what they would like from the menus. They could also have something else such as salads, sausages, poached fish or omelettes. Service users can have a cooked breakfast and tea include food like scones with jam and cream or sponge cakes. Soft diets are created in moulds and served so that ground chicken looks like a chicken thigh, making the meal more appetising. Staff also said they could request special diets from the kitchen on a daily basis, for example, for chicken to be minced, and food was pureed seperately if necessary. The home employs three chefs to cover the week and the food provided is recorded. The home liaises with the dietician to ensure adequate nutrition for residents. We spoke with a visitor who said their relative liked the food. We also spoke to a service user who said they did not like the food and did not eat it but staff told us this person ate all their food. The Andover Nursing Home DS0000012147.V367753.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users feel able to complain and procedures are in place to protect people. EVIDENCE: The home has a compliments, comments and complaints procedure which is available for anyone. Alternative formats are available. The procedure is on display near the entrance and the service users have a copy in their room. The manager told us that the procedure is explained when prospective service users visit the home. We looked at the computer record which details all the compliments and complaints. There had been one complaint and we discussed what action the home had taken. Adult protection update training was provided to all staff in 2007. New staff receive adult protection training as part of their induction course. There has been an adult protection investigation by the local authority adult services but this has now been concluded. The home has taken on board the issues The Andover Nursing Home DS0000012147.V367753.R01.S.doc Version 5.2 Page 16 highlighted through the process and has amended practice to improve outcomes. The Andover Nursing Home DS0000012147.V367753.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The provider and manager have continued to improve the standard of the living environment so that service users have more space. The home was clean and staff work within guidelines to ensure the risk of infection is minimised. EVIDENCE: Since the last key inspection building and refurbishment work has been undertaken to provide 26 new bedrooms. The home can now accommodate 87 service users and the number of double rooms has been reduced from twelve to four. A conservatory, training room, sensory room and office have also The Andover Nursing Home DS0000012147.V367753.R01.S.doc Version 5.2 Page 18 been provided. The training room can, and has, been used for family parties and can be decorated accordingly. All of the new rooms have en-suite wet rooms and all are appropriately furnished. The manager told us that due to listening to relatives all the light fittings in the new rooms have individual switches so that service users can choose how much lighting they need. Specialist profiling beds have been bought for the new rooms. Some of the bedrooms are 18m square which is larger than the size suggested by the National Minimum Standards. 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 redecoration. The home was clean. Most of the home was free from unpleasant odours although in the areas accommodating residents with complex needs and dementia there were some odours. We spoke to staff about this who agreed there were odours but explained that there is an ongoing cleaning programme and that carpets are cleaned frequently. The garden is laid to lawn and patio with a sensory garden, which has been completed since the last inspection. A large gazebo sits on the lawn so that service users can enjoy the garden in shade from the sun. Some of the bedrooms have a part of the patio attached and service users can access this from the patio doors. The home has recently invested in a new, larger washing machine and two new tumble driers. The home is mindful of the need to minimise the risk of infection and protective gloves and aprons are available. The Andover Nursing Home DS0000012147.V367753.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by a range of staff, who have undergone induction training and ongoing training. The recruitment procedure is robust which protects service users. EVIDENCE: The staffing levels 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 five cleaners, (one who is also responsible for housekeeping), three chefs, three kitchen assistants, a full time maintenance person, two full time activities co-ordinators, the manager and deputy manager, a receptionist and an administrator. Staff told us that the rota included enough staff. If staff are suddenly unable to work agency staff are used and they are allocated to a senior carer who supervises them. The manager said that he used agency staff when necessary The Andover Nursing Home DS0000012147.V367753.R01.S.doc Version 5.2 Page 20 as service users were paying for a certain level of service to meet their needs. Familiar agency staff were used where possible. Out of 70 care staff, 28 have achieved the National Vocational Qualification in care, level 2 or higher. A further eight are currently working towards it. When these staff have completed the course, slightly more than 50 of staff will have achieved the qualification. We looked at the recruitment files for three new staff who had started work within the last three weeks. We found they contained application forms, two written references, a Criminal Records Bureau check and a Protection of Vulnerable Adults check. The references were dated when they were written but not when they were received. We advised the manager that the received date must be recorded so that he can fully evidence that the references were received before the person started work. However, one of the staff had started work the previous day and their references were in place. All new staff undergo a two day induction course which includes infection control, food hygiene, death and dying, adult protection and dementia. Two of the nursing staff have responsibility for ensuring the training plan is completed. These staff are qualified to undertake the training of staff in moving and handling. We looked at the training records and found this and other training was up to date. The Andover Nursing Home DS0000012147.V367753.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is experienced and provides an excellent environment, however, he needs to pay further attention to other outcome areas. The home’s health and safety practices and risk assessments need developing further to ensure the safety of all service users. EVIDENCE: The Andover Nursing Home DS0000012147.V367753.R01.S.doc Version 5.2 Page 22 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 and this was detailed. Whilst the home provides good and excellent outcomes for service users, there are also some adequate outcomes. The areas of concern regarding care plans were highlighted at the previous key inspection and have not been addressed. The home has a quality assurance system in place which includes various monthly audits, service users’ meetings, relatives meetings and annual surveys. The manager showed us the results of a service users’ survey and the analysis showed year on year improvement. The manager told us there had been one issue which service users appeared less satisfied with than before but closer study showed the figures were skewed because of the way the question was written. The provider visits monthly to monitor quality and gives a copy of the Regulation 26 report to the manager. The home looks after money on behalf of some service users. We looked at the money and records for three service users. Two were accurate but one had more money than the record showed there should be. The manager said he would investigate this. 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. During the inspection we saw two service users being taken to the toilet, using the armchairs they were sitting in. The chairs had wheels and were fitted with a footrest. However, both service users were moved in the chairs without the footrests being used. This meant that the service users had to raise their legs and feet off the floor whilst in transit. We spoke to the manager about this who agreed that the footrests should have been in use. We spoke with a nurse and a care worker about the use of hoisting equipment. One said that two staff should always use the, ‘stand aid’, whereas another one said they almost always used this equipment on their own. We looked at moving and handling assessments for two service users: one said two staff, one said one. One of the staff also said that they, ‘always used a hoist’ for transfers because they felt it was safer for both the service user and staff. This means that staff are not following care plans which means inconsistency for service users, puts service users and staff at risk and may mean that service users’ are hoisted when they do not need to be, which may reduce their abilities over time. The Andover Nursing Home DS0000012147.V367753.R01.S.doc Version 5.2 Page 23 The garden can be accessed from different floors of the home, due to being built on a slope. To access the garden from the dining room means service users have to go down a flight of steep steps. A small gate was fixed to the top of the steps which the manager said was to protect service users. The gate was open when we saw it. The manager said there was a risk assessment in place for the gate but when we asked to see it, he found it was not included in the other environmental risk assessments as he thought. He added the gate to the risk assessments but when we looked at them they did not sufficiently detail the risk assessment process. For example, the steps were the risk and the gate was the way of reducing the risk. However, the gate itself posed a risk to service users but this was not identified. We advised the manager to look at, ‘Five steps to risk assessment’ published by the Health and Safety Executive which provides guidance and a model for risk assessment. The Andover Nursing Home DS0000012147.V367753.R01.S.doc Version 5.2 Page 24 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 3 3 2 The Andover Nursing Home DS0000012147.V367753.R01.S.doc Version 5.2 Page 25 N/A Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement Timescale for action 30/09/08 2 OP9 13 (2) Service users’ plans must identify individual needs and include mental health needs and strategies so that staff can support them consistently and in a way which meets all of their needs. 31/07/08 Care plans must be in place for medication which is prescribed to be ‘given when needed’, to ensure that staff use medication, (particularly sedation) consistently and appropriately. Records must be completed to show whether service users have received their medication or not. 3 OP38 13 (5) 4 OP38 13 (4) Service users’ plans must accurately detail the method of moving and handling to be used and staff must follow the plans to ensure the safety of service users and staff. Risk assessments must fully identify all risks so that service users are better protected against harm. 31/07/08 31/07/08 The Andover Nursing Home DS0000012147.V367753.R01.S.doc Version 5.2 Page 26 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.V367753.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V367753.R01.S.doc Version 5.2 Page 28 - 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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